Motion Sickness/Spatial Disorientation Evaluation Note

Date/Time: [Date and time of encounter]

Location: [Clinic or operational setting]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Aviation Role: [student pilot / rated aviator / aircrew / ATC / UAS operator / other safety-sensitive duty]

Aircraft/Platform: [Aircraft type, simulator, or platform relevant to evaluation] (Enter N/A if not applicable)

Encounter Type: [initial evaluation / follow-up / post-event / return-to-duty]

Reason for Evaluation

[Chief concern in patient's words; concise description of primary issue] (Format as 1–3 sentences. State the referral question explicitly: fitness to fly, differential diagnosis, training countermeasures, medication review, and/or restriction recommendations. Include operational significance such as training attrition risk, recent in-flight event, safety report, or upcoming checkride/deployment.)

Immediate Safety Status

Current Symptom Status: [asymptomatic now / symptomatic now]

Red Flags Screened: [Focal neurologic deficits, new unilateral hearing loss, syncope, severe headache or neck pain, persistent vertigo, chest pain or palpitations] (List positives and pertinent negatives.)

Current Duty Status Recommendation: [DNIF/no-fly / dual-only / day-VMC only / no IMC/night/NVG / simulator-only / ground duties only / no restrictions] (If no acute concerns, state: No acute safety concerns; see Restrictions and Duty Status in Plan.)

History of Present Illness

[1–2 sentence summary identifying predominant presentation: motion sickness/airsickness, simulator/VR sickness, spatial disorientation/illusion, true vertigo, or mixed]

• Onset and Trajectory: [First episode date and context; improving / stable / worsening]
• Frequency: [Episodes per week/month; proportion of symptomatic sorties or simulator sessions]
• Latency: [Time from exposure to symptom onset]
• Duration and Recovery: [Typical episode length; time to recovery; residual effects]
• Severity and Functional Impact: [Required transfer of controls / vomiting / premature sortie termination / near-loss of control / none]
• Prodromal Symptoms: [Warmth, sweating, stomach awareness, pallor, yawning, or none]
• Associated Symptoms:
  • GI/Autonomic: [Nausea, vomiting, diaphoresis, salivation]
  • Vestibular: [Vertigo, disequilibrium, oscillopsia]
  • Neurologic: [Headache, aura, photophobia, phonophobia, paresthesias]
  • ENT: [Tinnitus, aural fullness, hearing change]
  • Visual/Cognitive: [Eyestrain, difficulty concentrating, visual fatigue]
• Aggravating Factors: [Head movements, reading/head-down tasks, sleep deprivation, meal timing, dehydration, turbulence]
• Mitigating Factors: [Horizon reference, fresh air/ventilation, posture changes, controlled breathing, medications tried]

Spatial Disorientation Event Reconstruction (Include only when evaluating a spatial disorientation or illusion event; otherwise omit this block.)

• Event Details: [Date/time; aircraft or simulator type]
• Environment: [IMC / VMC; night / day; NVG use; terrain features; over-water]
• Trigger Maneuver/Phase: [Takeoff, turns, aerobatics, unusual attitudes, instrument approach, hovering, formation]
• Perception vs Instruments: [Brief patient quote for perceived illusion vs actual instrument indications] (Do not infer a specific illusion type; if unclear, document "illusion type unclear.")
• Crew Actions and Outcome: [Transfer of controls, level-off, go-around, termination; result and recovery]
• Reproducibility: [Whether similar conditions reliably provoke symptoms]

Motion/Simulator/VR Sickness Details (Include only when motion sickness, simulator sickness, or VR sickness is a primary concern; otherwise omit this block.)

• Provoking Modes: [Car, boat, air, simulator, VR] (Include non-aviation motion sensitivity.)
• Specific Aggravators: [Head movements, visual-vestibular mismatch, display characteristics, oscillatory vs sustained motion, G-load]
• Aircraft/Conditions Involved: [Type, seat position, canopy/window, ventilation, turbulence, mission profile]
• Treatments Tried: [Behavioral strategies and medications with effectiveness and side effects]

Trigger Profile

• Environmental: [IMC vs VMC, night, NVG, featureless terrain, over-water, turbulence, shipboard, formation]
• Flight Phase/Maneuver: [Takeoff, turns, aerobatics, unusual attitudes, instrument approaches, hovering, NVG transitions]
• Visual Factors: [Head-down time, display scanning demands, visual-vestibular mismatch, false horizon cues]
• Motion Factors: [Sustained vs oscillatory motion, cross-coupled head movements, acceleration/deceleration, G-load]
• Non-Aviation Motion Sensitivity: [Car, boat, train, reading while passenger, amusement rides]

(If triggers are unclear, document what was asked and note that a symptom diary or instructor debrief was requested.)

Past Medical History

• Headache/Migraine: [Migraine with/without aura; vestibular migraine features; treatment history]
• Vestibular Disorders: [BPPV, vestibular neuritis, Ménière spectrum, chronic dizziness]
• ENT: [Ear surgery, barotrauma, chronic sinus disease, recurrent otitis]
• Neurologic: [Concussion/TBI, seizure, neuropathy]
• Psychophysiologic: [Anxiety, panic, hyperventilation episodes] (Document neutrally.)
• Other Relevant: [Cardiovascular/autonomic issues, sleep disorders]

Medications

• Current Medications: [Rx, OTC, supplements with name, dose, frequency] (Note sedating agents, vestibular suppressants, stimulants.)
• Operationally Significant Timing: [Last dose date/time for medications with potential impairment] (If unknown, document reason.)
• Substances: [Caffeine, nicotine, alcohol use and timing relative to symptoms]
• Prior Motion Sickness Medication Trials: [Agent, dose, effectiveness, side effects]

Aviation History

• Certification/Medical Class: [Status and any existing restrictions]
• Flight Hours: [Total time; hours in last 30/90 days]
• Training Stage: [Current phase; upcoming checkride/evaluation/deployment]
• Prior Aeromedical History: [DNIF/no-fly periods or aeromedical consults with dates and reasons]
• Simulator vs In-Flight Symptoms: [Distinguish clearly between environments]

Records Reviewed

• [Instructor notes/debriefs with dates]
• [Safety reports or mishap notes with dates]
• [ENT/audiology/neurology consults with dates]
• [Vestibular testing results with dates]
• [Imaging or labs with dates]

(If collateral was requested but is pending, document what was requested and when.)

Review of Systems

(Targeted; include only findings that support clinical decision-making.)

• Neurologic: [Headache, aura, focal deficits, paresthesias, ataxia]
• ENT: [Hearing change, tinnitus, aural fullness, congestion]
• Visual: [Diplopia, photophobia, visual strain]
• Cardiovascular: [Palpitations, chest pain, syncope/presyncope]
• GI: [Nausea, vomiting]
• Sleep/Fatigue: [Sleep duration/quality, fatigue level]

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2] (Include orthostatic vitals when dizziness or near-syncope is suspected.)

Ear Exam: [Otoscopy findings; tympanic membrane appearance]

Eye Movements: [EOMI; spontaneous or gaze-evoked nystagmus; saccades; pursuit]

Neurologic: [Focused cranial nerves; Romberg; tandem gait; cerebellar testing as indicated]

Vestibular Maneuvers: [Dix-Hallpike right/left; supine roll test if horizontal canal BPPV suspected; head impulse test if trained] (If maneuvers were not performed, document reason and referral plan if appropriate.)

Diagnostics

(Summarize only tests obtained, reviewed, or ordered that are relevant to this evaluation. Include date, test name, key result, and interpretation. Do not copy full reports.)

• Audiogram/Tympanometry: [Key findings and interpretation]
• Vestibular Testing: [VNG, calorics, vHIT, VEMP findings and interpretation]
• Imaging: [CT/MRI findings and interpretation]
• Laboratory: [Key abnormalities and relevance]

(Omit categories where no testing was performed or ordered.)

Assessment

(Problem-oriented; order by operational/safety risk. Do not introduce new patient-reported data in this section.)

[Problem 1: Working diagnosis or primary concern]

• Key Supporting Features: [Concise list]
• Key Features Against: [Concise list]
• Differential: [Relevant considerations from: motion sickness/sensory conflict, spatial disorientation/illusions, peripheral vestibular disorders, vestibular migraine, central causes, systemic contributors, cardiovascular/autonomic causes, psychophysiologic factors]
• Aeromedical Significance: [Explicit linkage between findings and flight safety/mission impact]
• Uncertainty: [What is unclear and what will resolve it]

[Problem 2: Secondary diagnosis or concern]

(Include additional problems as needed, following same format.)

Plan

Restrictions and Duty Status

Current Recommendation: [DNIF/no-fly / dual-only / day-VMC only / no IMC/night/NVG / no aerobatics / simulator-only / ground duties only / no restrictions] effective [start date] for [anticipated duration]

• Return-to-Fly Criteria: [Objective criteria: symptom-free exposures, successful graded sorties, completion of desensitization program, off disqualifying medications for required interval, normal vestibular testing]
• Reassessment Triggers: [Recurrence, new red flags, completion of graded exposures]
• Notifications: [Training chain, safety office, flight medicine team notified on date]
• Counseling: Patient counseled on self-grounding responsibilities and verbalized understanding.

Countermeasures and Training

• Habituation/Desensitization: [Start / continue / avoid] [Graded exposure schedule, frequency, success measures] (If formal program exists, document referral and success criteria.)
• Behavioral Strategies: [Maximize horizon reference; minimize provocative head movements during critical phases; manage head-down time; controlled breathing; optimize sleep/hydration/meal timing; avoid alcohol/nicotine proximate to exposure] (Tailor to identified triggers.)
• SD-Specific Reinforcement: [Instrument reliance and cross-check discipline; transfer of controls when illusions occur; night currency; weather decision-making] (Include only when spatial disorientation is a concern.)

Medications

(Include only when medications are prescribed, requested, or under consideration.)

• [Medication name]: [Dose, timing, intended use (prophylaxis vs rescue), expected benefit, side effects relevant to flight, regulatory acceptability, duty restriction] (State explicitly: "No flight duties while taking [X]" with required no-fly interval.)

Patient counseled on medication use and flight restrictions; verbalized understanding.

Referrals

• ENT/Audiology: [Clinical question: hearing change, tinnitus, persistent vertigo, vestibular assessment]
• Neurology: [Clinical question: focal signs, atypical spells, central concern]
• Vestibular Rehabilitation: [Clinical question: persistent disequilibrium, BPPV management, desensitization]
• Aerospace Psychology/Human Factors: [Clinical question: anxiety, performance factors]

(Include only referrals being placed.)

Patient Education and Follow-up

• Urgent Return Precautions: [Symptoms requiring immediate evaluation]
• Self-Grounding: [When to self-restrict and how to notify chain]
• Episode Documentation: [Symptom diary, trigger log, instructor corroboration]
• Follow-up: [Timeframe or after specified number of graded exposures; objective targets for reassessment]

Attestation

Information Sources: [Patient, instructor/crew, records reviewed]

Limitations: [Incomplete information or pending collateral, if any]

Signature: [Clinician name, credentials, date/time]