Military Flight Physical Note (Initial/Periodic)

Patient: [Name], [DoD ID], [DOB], [Rank/Grade], [Service/Branch], [Unit], [Duty Station]

Encounter: [Date], [Time], [Location], [Examiner name and credentials]

Exam Type: [Initial / Periodic / Recheck / Waiver Follow-up / Post-Event]

Duty Sought: [Aviation duty or special duty category] (If unknown, state: "Disposition deferred—duty/standard not specified. Clarification required from [source].")

Current Duty Status: [Current qualification status and any restrictions]

Aeromedical Class: [Class/category per service standards]

Standard Applied: [Governing directive/manual and chapter]

Submission System: [Official system where package is maintained] — [Key forms completed]

Purpose

[Purpose statement including exam type, duty sought, aeromedical class, and administrative intent]

Sources of Information

• [Patient interview date/time]
• [Standardized forms reviewed with dates]
• [Prior aeromedical determinations or waivers reviewed with condition and date]
• [Outside records reviewed with source and date range]
• [Testing reviewed with collection dates]
• Records Pending: [Expected records/tests not yet available and impact on disposition] (Omit if none pending.)

Aviation/Operational History

[Brief narrative overview of aviation/special duty experience or training status] (If exam is not for aviation or special duty, state: "Not applicable—exam not for aviation/special duty.")

• Platform/Role: [Aircraft/platform types and role]
• Flight/Operational Exposure: [Flight hours, mission sets, unique demands such as NVG, ejection seat, high-G, altitude exposure]
• Physiologic/Aeromedical Events: [Spatial disorientation, hypoxia symptoms, decompression symptoms, G-LOC, severe airsickness, panic in flight with dates and outcomes] (Omit if none.)
• Mishap Involvement: [Details and date if applicable] (Omit if none.)
• Grounding Episodes: [Prior DNIF/grounding with dates, reasons, and current status] (Omit if none.)

Medical History

Interval History

(Include for periodic exams; omit for initial exams.)

Since last flight physical on [date]: [New diagnoses, injuries, surgeries, hospitalizations, ER/urgent care visits, new or changed medications including PRN and supplements, and new symptoms relevant to aviation safety. Note any care received outside the military system and documentation status.]

Past Medical History

(Include comprehensive history for initial exams; for periodic exams, include only if significant baseline conditions exist.)

• Medical Conditions: [Aeromedically relevant conditions with diagnosis dates, current status, treatment, and functional impact]
• Surgical History: [Surgeries with dates; highlight aviation-relevant procedures and outcomes]
• Mental Health History: [Prior diagnoses, treatment modalities, timeline, current stability]

Medications

• [Medication name, dose, frequency, indication, stability]
• OTC/Supplements/Energy Products: [All products including caffeine/energy patterns]

Allergies

[Agent and reaction type/severity] (State "NKDA" if no known drug allergies.)

Family History

[Relevant positives: premature cardiac disease, sudden unexplained death, seizures, heritable eye disease] (Include only when relevant to aeromedical determination.)

Social History

• Tobacco/Nicotine: [Type, amount, duration, quit date if applicable]
• Alcohol: [Pattern, quantity, any problematic use]
• Cannabis/Other Substances: [Use status; last use date if relevant]
• Sleep/Shift Work: [Sleep duration/quality, shift schedules, fatigue concerns]
• Caffeine/Energy Products: [Type, quantity, timing]
• Physical Training: [Aerobic/strength activities; fitness testing status]

Review of Systems

(Targeted to disqualifying and safety-critical symptoms. Emphasize interval changes for periodic exams; use broader ROS for initial exams.)

• [General]
• [HEENT/ENT and Vestibular]
• [Ophthalmologic]
• [Cardiovascular]
• [Pulmonary]
• [Neurologic]
• [Psychiatric/Sleep]
• [Musculoskeletal]
• [Other systems as indicated]

Physical Examination

Vitals

• Height: [value]
• Weight: [value]
• BMI: [value]
• Blood Pressure: [value, position; repeat measurement if abnormal]
• Pulse: [value]
• SpO2: [value]
• Additional Anthropometrics: [Include if required by duty/platform]

Examination

(Document findings sufficient to support qualification decision. Note chaperone use for sensitive examinations per policy.)

• General/Mental Status: [Appearance, orientation, affect, behavior]
• HEENT: [TMs, nasal patency, oropharynx, dentition]
• Eyes: [External exam, pupils, EOMs, any ocular findings]
• Cardiovascular: [Rate/rhythm, murmurs, pulses, edema]
• Pulmonary: [Effort, breath sounds, adventitious sounds]
• Abdomen: [Tenderness, masses, hernia]
• Neurologic: [Cranial nerves, strength, sensation, reflexes, gait/coordination]
• Musculoskeletal: [ROM, strength, stability, functional limitations]
• Skin: [Findings relevant to standards] (Omit if unremarkable.)

Required Testing

(For each test: document test name, date, method, result, interpretation relative to standard, and follow-up indicated. For tests not completed, state: "Not performed—required for disposition; ordered [date]" or "Pending results—disposition deferred" or "Not required for this class per [standard].")

Vision

• Visual Acuity: [Near and distance; uncorrected and corrected; date/method] — [Interpretation]
• Refraction: [Sphere/cylinder/axis; date] — [Interpretation] (Include if performed.)
• Color Vision: [Test type, result, date] — [Interpretation]
• Depth Perception/Stereo: [Test type, result, date] — [Interpretation] (Include if required.)
• Contact Lens Use: [Type, wear schedule, compliance] (Include if applicable.)

Hearing

• Audiogram: [Date; thresholds summary; significant threshold shift assessment] — [Interpretation]

Cardiovascular

• ECG: [Date; interpretation; reviewing clinician] — [Meets/does not meet standard]
• Additional Studies: [Echo, stress test, Holter as indicated; date; result] — [Interpretation] (Include only if required or clinically indicated.)

Pulmonary

• Spirometry/PFT: [Date; FEV1/FVC, bronchodilator response] — [Interpretation] (Include only if required or indicated.)

Laboratory

• [Required labs per standard with dates and results] — [Clinical significance and plan for abnormalities]

Additional Elements

• Dental Classification: [Class and date] — [Impact on duty] (Include if required.)
• Immunizations: [Status; missing vaccines and implications] (Include if required for duty.)
• Preventive Screenings: [Type; date; result] (Include as required.)

Assessment

(Problem-oriented list ordered by aeromedical and safety impact. Separate clinical diagnosis from qualification outcome.)

• [Problem 1]: [Diagnosis] — Status: [stable / unstable / resolved / active]; Aeromedical relevance: [potentially disqualifying / requires waiver consideration / no aeromedical impact]; [Supporting evidence with dates]
• [Problem 2]: [As above]
• [Additional problems as needed]

Aeromedical Determination

(Must always include an explicit qualification determination. If determination cannot be made, state: "Disposition deferred" with specific reasons and required actions.)

• Qualification Status: [PQ / PQ with Limitations / TNPQ / NPQ / NPQ—Waiver Recommended / Disposition deferred] for [duty] at [aeromedical class/category]
• Waiver Action: [Not required / Required and recommended / Already granted with date and authority / Submitted with date and package status] (Omit if no potentially disqualifying conditions.)
• Restrictions/Safety Actions: [Grounding status with effective date; scope of restriction; conditions for return to duty; notification issued to command] (Omit if PQ without restrictions.)
• Follow-up Plan: [Referrals with specialty, reason, and priority; tests ordered; re-evaluation timeline; required documentation for final certification; next periodic exam due date]

Attestation

[Examiner signature: name, rank/credentials, date/time]

[Reviewing clinician co-signature] (Include if required by policy.)

[Technician-performed testing attribution with interpreting clinician identified]

Addendum

(Add when results return after the visit. Identify new information, update disposition if changed, and sign/date separately.)

[New information received] — [Updated qualification status if changed] — [New restrictions or waiver actions if applicable]

[Addendum signature: name, credentials, date/time]