Return-to-Flight Evaluation (Post-Illness/Injury)

Encounter date & time: [Date and time]

Location: [Clinic location / Telehealth originating site]

Visit type: [in-person / telehealth]

Author: [Name, credentials, role (e.g., PCP, surgeon, AME)]

Patient: [Full name]

Date of birth: [DOB]

MRN: [MRN]

Aircrew role: [pilot / flight instructor / other]

Crew configuration: [single-pilot / multi-crew]

Aircraft type/class: [Aircraft type/class and relevant physical demands]

Operational environment: [VFR / IFR capability] | [day / night] | [typical altitude or cabin pressure exposure] | [typical duty day length]

Regulatory context: [FAA Medical Class I / Class II / Class III / BasicMed / other]

Scope statement: [Acting as Aviation Medical Examiner (AME) / Acting as treating clinician providing clinical fitness assessment; pilot must comply with 14 CFR 61.53 self-grounding and applicable aeromedical certification requirements]

Clearance Question

[Reason for visit and explicit clearance question] (Include: index illness/injury/intervention with date, requested determination [fit for unrestricted flight / fit with restrictions / not fit / indeterminate], and operational context such as return to single-pilot IFR or multi-crew VFR operations.)

Event Summary & Current Status

[Index event narrative] (Include onset date, mechanism or trigger, initial severity, red flags such as loss of consciousness, syncope, hypoxia, severe pain, or seizure activity as applicable. Describe care received including ED, hospitalization, or surgery. List key diagnoses and treatment course.)

Current symptoms (Document presence or absence explicitly; do not infer from silence. Include frequency, severity, provoking factors, and functional impact. State whether symptoms occur at rest, with cognitive exertion, and with physical exertion. Include only relevant domains.)

• Neurologic/cognitive: [Presence/absence and details: headache, dizziness, mental fogging, slowed processing, visual disturbance, sleep disruption]
• Vestibular/ENT: [Presence/absence and details: barotrauma symptoms, tinnitus, imbalance]
• Cardiopulmonary: [Presence/absence and details: exertional dyspnea, wheeze, chest pain, palpitations, syncope/presyncope]
• Pain: [Location, severity, analgesic requirements]
• GI/GU: [Presence/absence and relevant symptoms if applicable]

Functional status since event: [Activities tolerated such as work, exercise, driving] | [Near-miss safety events: confusion, delayed reaction, imbalance] | [Duty status: grounded / modified duties / flying]

Pertinent history: [Prior similar events, relevant chronic conditions, baseline functional status, factors impacting incapacitation risk]

Flight & Operational Demands

[Operational profile and risk modifiers] (Include single-pilot vs multi-crew operations, passenger carriage, typical mission profile with day/night and VFR/IFR, altitude and cabin pressure exposure, duty day length, physical demands such as emergency egress or control manipulation, and upcoming check rides or training.)

Medications

(For each current medication, document all fields. If exact dosing is unknown and poses aeromedical risk, document that clearance is deferred. Do not infer absence of side effects—document explicit denial or that side effects were not assessed.)

• Name: [Medication name] | Dose/route/frequency: [Dose, route, frequency] | Indication: [Indication]

  Start date: [Date] [new / chronic] | Last dose: [Time/date]

  Side effects: [Denies sedation, dizziness, visual changes, cognitive effects / Reports specific effects / Not assessed] | Ground trial: [Duration and tolerance observed / None]

• (Repeat for additional medications)

Examination & Findings

(Document only examinations actually performed. If telehealth, note exam limitations.)

• Vital signs: [BP, HR, RR, Temp, SpO2] (Include orthostatics if dizziness or syncope is a concern.)
• General: [Appearance, distress level]
• Neurologic: [Mental status, cranial nerves, motor strength, coordination, gait, Romberg] (Include when relevant.)
• Cardiovascular: [Rate/rhythm, murmurs, edema] (Include when relevant.)
• Respiratory: [Effort, breath sounds, adventitious sounds] (Include when relevant.)
• Vestibular/ENT: [Ear exam, oculomotor screening, Dix-Hallpike if indicated] (Include when relevant.)
• Musculoskeletal: [Range of motion, strength, job-relevant movement capacity, operative site status] (Include when relevant.)

Diagnostic Data

• Records reviewed: [Source and date] — [Key results with aeromedical relevance]
• Tests performed today: [Test name] — [Results with aeromedical relevance]
• Pending/requested: [Specific items needed] — [Impact on clearance] (If clearance depends on missing items, state clearance is deferred pending receipt.)

Functional Assessment

• Cognitive readiness: [Symptom provocation with cognitive tasks, standardized screening results if performed, observations on processing speed or attention] (Include after concussion, CNS illness, or with sedating medications.)
• Vestibular/oculomotor readiness: [Balance and gait observations, symptom reproduction with head movement or visual tracking] (Include for dizziness, concussion, or ENT illness.)
• Physical exertion tolerance: [Walk/stair test results, heart rate and symptom response] (Include for cardiopulmonary illness, post-operative status, or deconditioning.)
• Condition-specific anchors: [e.g., PFT results and rescue inhaler frequency for asthma; pain-free interval for renal colic; ability to operate controls without narcotics for musculoskeletal injury] (Include only if applicable.)

Assessment & Plan

(Organize by problem, ordered by aviation risk: highest sudden incapacitation risk first. For each, state diagnosis with differential if uncertain, current status, supporting evidence, aeromedical concern, and explicit uncertainties.)

[Problem 1 – Highest aviation risk]: [Diagnosis]

Status: [resolved / improving / persistent] — Evidence: [Key findings] — Aeromedical concern: [Sudden incapacitation risk / Subtle impairment risk] — Uncertainty: [If present]

• Plan: [Medications, diagnostics, referrals, counseling, follow-up actions]

[Problem 2 – Moderate aviation risk]: [Diagnosis]

(Include only if applicable.)

• Plan: [Actions]

[Problem 3 – Low risk/administrative]: [Issue]

(Include only if applicable.)

• Plan: [Actions]

Return-to-Flight Determination

Disposition: [Not fit for flight duties / Fit with restrictions / Fit for unrestricted flight / Unable to determine]

Basis: [Concise rationale referencing symptoms, exam, functional assessment, diagnostic data, and medication tolerance]

Restrictions: (Include only if applicable. Make operationally specific with review or expiration criteria.)

• [Crew restriction: no solo / no PIC / dual-only with instructor]
• [Weather/conditions restriction: day VFR only / no night / no IFR]
• [Passenger restriction: no passenger carriage]
• [Altitude restriction: below specified altitude]
• [Medication restriction: no flying while using specific medications]
• [Symptom restriction: no flying if symptoms recur]
• [Review date or criteria for restriction expiration]

(If Unable to determine, specify what is pending and state clearance is deferred.)

Staged Return Plan

(Use progressive, criteria-based approach. Advance only if asymptomatic at rest and with exertion, no impairing medications, and stable objective findings.)

1. Stage 0 – Grounding: [Symptom stabilization and medication washout]
2. Stage 1 – Daily activities: [Normal non-flying activities while symptom-free]
3. Stage 2 – Aerobic and cognitive ramp-up: [Graded exercise and cognitive workload with symptom monitoring]
4. Stage 3 – Simulator/procedural training: [Targeted tasks if available; monitor tolerance]
5. Stage 4 – Supervised flight: [Dual with instructor or safety pilot; defined mission profile; no passengers]
6. Stage 5 – Restricted independent operations: [Day VFR at familiar airports; no IFR/night; no passengers]
7. Stage 6 – Unrestricted return: [Criteria met: symptom-free at rest and with exertion, no impairing medications, stable findings, required evaluations completed]

Progression rules: Advance after [specified symptom-free interval and task tolerance]. If symptoms recur or performance concerns arise at any stage, stop progression, return to prior asymptomatic stage, and reassess clinically.

Counseling & Follow-up

• Self-grounding counseling: Advised on 14 CFR 61.53 and 91.17 responsibilities. Do not fly with recurrent symptoms or medication effects that could impair performance. Reviewed warning signs requiring immediate grounding and medical evaluation.
• Patient acknowledgment: [Verbalized understanding / Questions answered / Education materials provided]
• Follow-up: [Timing and modality], [tests or records to obtain], [criteria to advance stages or clear restrictions]
• Records released: [Forms or results released to employer, flight school, or AME] | [Authorization on file]