APPLICATION FOR – Check the appropriate box.

CLASS OF AIRMAN MEDICAL CERTIFICATE APPLIED FOR – Check the appropriate box for the class of airman medical certificate for which you are making application.

FULL NAME If your name has changed for any reason, list current name on the application and list any former name(s) in the EXPLANATIONS box of number 18 on the application.

SOCIAL SECURITY NUMBER – The social security number is optional; however, its use as a unique identifier does eliminate mistakes.

ADDRESS – Give permanent mailing address and country. Include your complete nine digit ZIP code if known. Provide your current area code and telephone number.

DATE OF BIRTH – Specify month (MM), day (DD), and year (YYYY) in numerals; e.g., 01/31/1950. Indicate citizenship; e.g., U.S.A.

COLOR OF HAIR – Specify as brown, black, blond, gray or red. If bald, so state. Do not abbreviate.

COLOR OF EYES – Specify actual eye color as brown, black, blue, hazel, gray or green. Do not abbreviate.

SEX – Indicate male or female.

TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD – Check applicable block(s). If “Other” is checked, provide name of certificate.

OCCUPATION – Indicate major employment. “Pilot” will be used only for those gaining their livelihood by flying.

EMPLOYER – Provide your employer’s full name. If self-employed, so state.

HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED, OR REVOKED – If “yes” is checked, give month and year of action in numerals.

TOTAL PILOT TIME TO DATE – Give total number of civilian flight hours. Indicate whether logged or estimated. Abbreviate as Log. or Est.

TOTAL PILOT TIME PAST 6 MONTHS – Give number of civilian flight hours in the 6-month period immediately preceding date of this application. Indicate whether logged or estimated. Abbreviate as Log. or Est.

MONTH AND YEAR OF LAST FAA MEDICAL EXAMINATION – Give month and year in numerals. If none, so state.

DO YOU CURRENTLY USE ANY MEDICATION (Prescription or Nonprescription) – Check “yes” or “no.” If “yes” is checked, give name of medication(s) and indicate if the medication was listed in a previous FAA medical examination. See NOTE below.

Indicate whether you use near vision contact lens(es) while flying.

MEDICAL HISTORY – Each item under this heading must be checked either “yes” or “no.” You must answer “yes” for every condition you have ever been diagnosed with, had, or presently have and describe the condition and approximate date in the EXPLANATIONS block. If information has been reported on a previous application for airman medical certificate and there has been no change in your condition, you may note “PREVIOUSLY REPORTED, NO CHANGE” in the EXPLANATIONS box, but you must still check “yes” to the condition. Do not report occasional common illnesses such as colds or sore throats. “Substance dependence” is defined by any of the following: increased tolerance; withdrawal symptoms; impaired control of use; or continued use despite damage to health or impairment of social, personal, or occupational functioning. “Substance abuse” includes the following: use of an illegal substance; use of a substance or substances in situations in which such use is physically hazardous; or misuse of a substance when such misuse has impaired health or social or occupational functioning. “Substances” include alcohol, PCP, marijuana, cocaine, amphetamines, barbiturates, opiates, and other psychoactive chemicals. Arrest, Conviction and/or Administrative Action History – Letter (v) of this subheading asks if you have ever been: (1) arrested and/or convicted (which may include paying a fine, or forfeiting bond or collateral) of an offense involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; or (2) arrested, convicted and/or subject to an administrative action by a state or other jurisdiction for an offense for which your license was denied, suspended, cancelled, or revoked or which resulted in attendance at an educational or rehabilitation program. Individual traffic arrests and/or convictions are not required to be reported if they did not involve: alcohol or a drug; suspension, revocation, cancellation, or denial of driving privileges; or attendance at an educational or rehabilitation program. If “yes” is checked, a description of the arrest(s), and/or conviction(s), and/or administrative action(s) must be given in the EXPLANATIONS box. The description must include: (1) the alcohol or drug offense for which you were arrested and/or convicted or the type of administrative action involved (e.g., attendance at an alcohol treatment program in lieu of conviction; license denial, suspension, cancellation, or revocation for refusal to be tested; educational safe driving program for multiple speeding arrests and/or convictions, etc.); (2) the name of the state or other jurisdiction involved; and (3) the date of the arrest(s), and/or convictions and/or administrative action(s). The FAA may check state motor vehicle driving licensing records to verify your responses. Letter (w) of this subheading asks if you have ever had any other (nontraffic) convictions (e.g., assault, battery, public intoxication, robbery, etc.). If so, name the charge for which you were convicted and the date of the conviction in the EXPLANATIONS box. See NOTE below

VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS – List all visits in the last 3 years to a physician, physician assistant, nurse practitioner, psychologist, clinical social worker, or substance abuse specialist for treatment, examination, or medical/mental evaluation. List visits for counseling only if related to a personal substance abuse or psychiatric condition. Give date, name, address, and type of health professional consulted and briefly state reason for consultation. Multiple visits to one health professional for the same condition may be aggregated on one line. Routine dental, eye and FAA periodic medical examinations and consultations with your employer-sponsored employee assistance program (EAP) may be excluded unless the consultations were for your substance abuse or unless the consultations resulted in referral for psychiatric evaluation or treatment. See NOTE below.

APPLICANT’S DECLARATION – Two declarations are contained under this heading. The first authorizes the National Driver Register to release adverse driver history information, if any, about the applicant to the FAA. The second certifies the completeness and truthfulness of the applicant’s responses on the medical application. The declaration section must be signed and dated by the applicant after the applicant has read it.

Additional Instructions.

These are available by expanding applicable 8500-8 Items within the application form.

1. Application For
Select Airman Medical Certificate. (Effective April 1, 2016, AAM is no longer authorized to issue Student Pilot Certificate.) 
2. Class of Medical Certificate Applied For
Select the appropriate class of medical certificate that you want to apply for. See 14 CFR §61.23 for the requirements for medical certificates.
3. Full Name
Enter your legal name. If your name changed for any reason since the date of your most recent medical examination, list your current legal name in the General Explanations Pertaining to Medical History comment box (in the Medical History section.) See 14 CFR § 61.25 for the requirements for change of name.
4. Social Security Number
Entering your SSN is optional. Enter your SSN in the box provided, or select the International/Declined to Submit checkbox if applicable.
5. Address
Enter your mailing address. Enter your telephone number. See 14 CFR § 61.60 for the requirements for change of address. Do not use punctuation.
6. Date of Birth
Select the month, day, and year of your date of birth. Select citizenship (e.g. United States).
7. Color of Hair
Specify hair color as bald, black, blond, brown, gray, or red by selecting the appropriate value from the drop down box.
8. Color of Eyes
Specify actual eye color as black, blue, brown, green, gray, or hazel by selecting the appropriate value from the drop down box.
9. Sex
Indicate male or female by selecting the appropriate radio button.
10. Type of Airman Certificate(s) You Hold
Select the boxes that apply. If you select None, that should be the only box you select. If you select Other, indicate an Airman Certificate (not represented) that you may hold (e.g. Aircraft dispatcher, Ground Instructor).
11. Occupation
Enter your primary means of employment (e.g. pilot, air traffic controller, flight instructor, teacher, etc.). Enter “pilot” only if you currently work as a pilot.
12. Employer
Enter your employer’s full name. Enter “self-employed” if applicable.
13. Has Your FAA Airman Medical Certificate Ever Been Denied, Suspended, or Revoked?
Select Yes or No. If you select Yes, enter the date your certificate was denied, suspended, or revoked.
14. Total Pilot Time (Civilian Only) to Date
Enter your total number of flight hours. The flight hours you enter can be logged or estimated.
15. Total Pilot Time (Civilian Only) Past 6 Months
Enter your total number of flight hours in the 6-month period immediately before the date of this application. The flight hours you enter can be logged or estimated.
16. Date of Last FAA Medical Application
Select the date of your most recent FAA medical examination. If this is your first-ever application, select “No Prior Application.”
17.a. Do You Currently Use Any Medication (Prescription or Nonprescription)?

• 1. Select Yes or No.
  
  • You are required to enter ALL prescription and nonprescription medication you take.
    
  • You must enter the medication name; all other fields are optional.
    
• 2. If you selected Yes
  
  • Enter the name of the first medication in the Medication Name box.
    
  • Enter the dosage amount in the Dosage box.
    
  • Select a dosage unit for your medication from the Dosage Unit box.
    
  • Select how often you use the medication from the Frequency box.
    
  • Select Previously Reported if you have previously reported the medication on an FAA medical application.
    
  • Click the Add button
    
• 3. If an exact match for the medication does not appear, you will see an error message followed by a drop-down box of possible matches.
  
  • If you see the correct match, select it and click the Add button again.
    
  • If you do not see the correct match, select Could not Locate Medication and click the Add button again.
    
• 4. Repeat Steps 2 and 3 for each medication.
  

17.b. Do You Ever Use Near Vision Contact Lens(es) While Flying?
Do you use a contact lens in either eye for near vision? (for example: for reading or close up work)
18.a. Frequent or severe headaches
For example: Chronic (daily or weekly) headaches, headaches that have required medical treatment, migraine headaches, cluster headaches, or headaches associated with visual or neurological symptoms.
18.b. Dizziness or fainting spell
For example: Frequent spinning or lightheadedness; other factors associated with episodes of dizziness or fainting, such as headache, nausea, loss of consciousness, tingling, numbness, vertigo.
18.c. Unconsciousness for any reason
For example: Unconsciousness, no matter how short, whether explained or unexplained.
18.d. Eye or vision trouble except glasses
For example: Unusual visual experiences (halos, wavy lines, etc.), sensitivity to light, eye injury, loss of vision, vision discomfort, eye surgery.
18.e. Hay fever or allergy
For example: Chronic or seasonal allergies controlled by allergy shots and/or medication, nasal allergies, nasal obstruction, sinus block, sinusitis.
18.f. Asthma or lung disease
For example: Asthma attacks; use of an inhaler; COPD; chronic bronchitis; emphysema; fistula; fungal disease; pleurisy; pneumothorax; pulmonary embolism; pulmonary fibrosis; chest surgery; tumor(s).
18.g. Heart or vascular trouble
For example: Angina, heart pain, coronary heart disease, heart attack, myocardial infarction, abnormal rhythm, atrial fibrillation, cardioversion, cardiac failure, congestive heart failure, heart enlargement, cardiac decompensation, hypertrophy or dilation of the heart, pulmonary hypertension, heart valve disease, heart valve repair or replacement, pacemaker, anti-tachycardia device, implantable defibrillator, congenital heart disease, endocarditis, heart inflammation, pericarditis or heart transplant.
18.h. High or low blood pressure
For example: Diagnosis of high or low blood pressure, whether treated or not; use of blood pressure medication of any kind.
18.i. Stomach, liver, or intestinal trouble
For example: Appendicitis, bleeding ulcer, bowel obstruction, cancer, Crohn's disease, chronic hepatitis, cirrhosis, colostomy, irritable bowel syndrome, hernia, ulcerative colitis, any surgery.
18.j. Kidney stone or blood in urine
For example: Kidney stone, kidney cancer, kidney transplant, blood in urine, chronic recurrent urinary tract infections, urinating frequently at night.
18.k. Diabetes
For example: Pre-diabetes, type I diabetes, or type II diabetes treated with insulin, medication (oral or injectable), and/or diet and exercise.
18.l. Neurological disorders: epilepsy, seizures, stroke, paralysis, etc.
Also, muscle weakness, disturbance of sensation, disturbance of consciousness, loss of coordination, head injury, concussion.
18.m. Mental disorders of any sort: depression, anxiety, etc.
Also, attention deficit disorder, attention deficit hyperactivity disorder, bipolar disorder, obsessive compulsive disorder, panic attacks, personality disorder, post-traumatic stress disorder, psychosis.
18.n. Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years.
For example: Select Yes if you have been diagnosed and/or treated in an inpatient or outpatient setting for substance use. Select Yes if you ever had a diagnosis of substance use disorder. Select Yes for any and all positive drug tests whether administered at the federal, state, or local level, or by a private employer. For a detailed description of substance, substance dependence, substance abuse, and drug and alcohol testing, refer to 14 CFR §67.107, §67.207, and §67.307, paragraphs (a)(4) and (b).
18.o. Alcohol dependence or abuse
For example: Select Yes if you have been diagnosed and/or treated in an inpatient or outpatient setting for misuse of alcohol. Select Yes if you ever had a diagnosis of alcohol use disorder. Select Yes for any and all positive alcohol tests whether administered at the federal, state, or local level, or by a private employer. For a detailed description of substance, substance dependence, substance abuse, and drug and alcohol testing, refer to 14 CFR §67.107, §67.207, and §67.307, paragraphs (a)(4) and (b).
18.p. Suicide attempt
For example: Thoughts of suicide, attempted suicide.
18.q. Motion sickness requiring medication
For example: Unresolved, chronic motion sickness (in flight while traveling by other vehicle) for which you must be medicated.
18.r. Military medical discharge
No Additional Instructions
18.s. Medical rejection by military service
No Additional Instructions
18.t. Rejection for life or health insurance
No Additional Instructions
18.u. Admission to hospital
List any hospitalization(s) not already reported in the APPLICANT EXPLANATION box in relation to items 18a-y.
18.v. History of (1) any arrest(s) and/or conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; or (2) history of any arrest(s), and/or conviction(s), and/or administrative action(s) involving an offense(s) which resulted in the denial, suspension, cancellation, or revocation of driving privileges or which resulted in attendance at an educational or a rehabilitation program.
For purposes of this application: "Arrest" means being detained or taken into custody by any law enforcement or military authority for any reason related to a driving stop for suspected driving while intoxicated by, while impaired by, or under the influence of drugs or alcohol. List, for each arrest, the place, date, and circumstance (s) of the arrest.  "Conviction" means any judgment of guilt based on a jury, court, or military verdict, a plea of guilty, or a plea of nolo contendere/no contest. Examples include, but are not limited to, assault, battery, disorderly conduct, domestic violence, driving under the influence, driving while intoxicated, murder, possession of drugs, public intoxication, reckless driving, etc. If you answer yes, you should report all misdemeanors and felony convictions regardless of the classification of the conviction and regardless of whether the conviction is pending on appeal to another court. List the charge(s) for which you were convicted, the date of the conviction, and the state, federal, military, or foreign court in which you were convicted. If a conviction has been reversed or vacated in a final judgment, state the date of the final judgment and the court that issued the final judgment. If the record of a conviction has been expunged, state the date that the record was expunged and the court that ordered the expunction.  List, for each denial, suspension, cancellation, or revocation of your driver's license or driving privileges, the U.S. state, U.S. military base, or foreign country where the action occurred, the specific type of action taken (for example, the driver's license was denied, suspended, cancelled, or revoked, the date each action was taken, and the basis for the action.) Examples of educational or rehabilitation programs include, but are not limited to, anger management program(s), drug or alcohol treatment program(s), safe driving course(s), etc. List the type of educational or rehabilitation program you were required to attend as part of a criminal, civil, or military action, the entity that required you to attend, and the date(s) and place(s) of your attendance.
18.w. History of nontraffic conviction(s) (misdemeanors or felonies).
No Additional Instructions
18.x. Other illness, disability, or surgery
List any illness/illnesses or disability/disabilities not provided for in 18a-y.
18.y. Medical disability benefits
For example: Veterans Affairs (VA), Social Security Disability Insurance (SSDI), workers' compensation, and any other disability benefits.
19. Have you visited any health professionals within the last 3 years?

• 1. Select Yes or No 
  • You are required to enter ALL visits to any health professionals (such as physician, physician assistant, nurse practitioner, psychologist, psychiatrist, chiropractor, clinical social worker, or substance abuse specialist, including an EAP employer-sponsored specialist) for treatment, examination, or medical/mental evaluation. 
  • Multiple visits to one health professional for the same condition may be aggregated on one line (you may use the most recent date in the date field). 
  • You do not need to enter routine dental and eye examinations or periodic FAA medical examinations and visits to health professionals related to an Authorization for Special Issuance. 
• 2. If you selected Yes 
  • Enter the month and year in the Date of Visit box 
  • Enter health professional’s name in the Name box 
  • Enter the type of professional in the Type of Professional box 
  • Enter the reason in the Reason box 
  • Enter the health professional’s address in the address boxes 
  • Click the Add button 
• 3. Repeat Step 2 to add all your visits to health professionals.

20. Applicant’s National Driver Register and Certifying Declarations
No Additional Instructions