Index to Pilot Medical Application for Aviation Medical Certification FAA 8500-8

Applicants will Enter Values through FAA's MedXpress

Apr 2014

Abbreviated Briefing:

Sample Medical Application -- Know what to Expect
Errors may have Legal Ramifications
Study Instructions for MedXPress by Item Number
Use as Review prior to actual FAA Airman Medical Application
This is the First Section (Items 1 - 20) of the FAA Form 8500-8

Guidance is compiled and interpreted by professional pilots and physicians at FlightPhysical.com from the 2014 AME Guide pages 26-41, FAA and FDA web data (www.FAA.gov & www.FDA.gov), instructions specified in the Aeronautical Information Manual, Federal Air Surgeon Bulletins from 1999-2015, and 14 CFR Part 61 and Part 67 (the FARs).

- FlightPhysical.com Notice -

Below is a practice form for review and information in advance of the complex process of completing your FAA Form 8500-8 through MedXPress in advance of your AME appointment for your flight physical. This is a simulated form intended to reflect the content and spirit of the actual FAA form as closely as possible. Nothing on this page will be transmitted anywhere--instructions are for pilot applicant understanding prior to submitting the actual FAA Form 8500-8 which will be irrevocable except through your actual AME. When ready, you must proceed to the real FAA MedXpress Form prior to your actual FlightPhysical with an AME.

- FAA Warning -
(This is a practice form - no fines or imprisonment at FlightPhysical.com)

Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or who makes any false, fictitious or fraudulent statements or representations, or entry, may be fined up to $250,000 or imprisoned not more than 5 years, or both" (Title 18 U.S. Code. Secs. 1001; 3571).

1. Application For (Specify Which Type): Airman Medical Cert. Airman Medical & Student Pilot Cert.

2. Class of Medical Cert.: 1st2nd3rd

3. Last Name: First Name: Middle Name: Suffix:

4. SSN: International/Declined to Submit (An SSN will be generated by the system)

5. Address: City:
State: Country: Zip Code:
Telephone Number:

12. Employer:

13. Has Your FAA Airman Medical Certificate Ever Been Denied, Suspended, or Revoked? Yes No If yes, give date:

14. Total Pilot Time To Date: (Civilian Only)

15. Total Pilot Time Past 6 months: (Civilian Only)

16. Date of Last FAA Medical Application: No Prior Application

17.a. Do You Currently Use Any Medication (Prescription or Nonprescription)? YesNo

**Medication Name* :**
Med Name required, other fields optional

Dosage:

Dosage Unit:

Frequency:

Sequentially enter medications clicking "Add" button for each
Continue Until Your List is Complete.
These actions will generate a reviewable table similar to the example below:

(Reminder Practice Only - Entries do not Go anywhere)

This is what the MedXPress Medical Entry Table will look like
Medication	Dosage Amount	Dosage Unit	Frequency	Previously Reported
IBUPROFEN	200	mg	As Needed	Y	Delete
LOSARTAN	25	mg	Daily	Y	Delete
--- ETC --- (Keep Adding Until All Your Meds Are Listed)

17.b. Do You Ever Use Near Vision Contact Lens(es) While Flying? Yes No

19. Have you visited any health professionals within the last 3 years?: YesNo

20. Applicant's National Driver Register and Certifying Declarations:
I hereby authorize the National Driver Register (NDR), through a designated State Department of Motor Vehicles, to furnish to the FAA information pertaining to my driving record. This consent constitutes authorization for a single access to the information contained in the NDR to verify information provided in this application. Upon my request, the FAA shall make the information received from the NDR, if any, available for my review and written comment. Authority: 23 U.S. Code 401, Note.

NOTE: ALL persons using this form must sign it. NDR consent, however, does not apply unless this form is used as an
application for Medical Certificate or Medical Certificate and Student Pilot Certificate.

I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge, and I agree that they are to be considered part of the basis for issuance of any FAA certificate to me. I have also read and understand the Privacy Act statement that accompanies this form.
YesNo

- Save and Review Options -

You can save or review your application here but it is not complete until you enter your password and press the "Submit" button at the bottom of this page.

I'm not done yet. Save my application so I can finish it later.

FlightPhysical.com note: This preserves your work without officially submitting form.

Show me any errors I have made on my application.

FlightPhysical.com note: This button also saves your work and in addition will attempt to validate your entries against FAA algorithms (without submitting)

- Final Submission and Password Step -

I understand that by entering my password, I certify that I agree with the National Driver Register and Certifying Declarations. I further understand that I will not be able to change my application after I submit the information (only your AME will be able to change the application at the time of the physical exam).
I'm done. Send my application to the FAA. Password:

Commentary:

- FlightPhysical.com Reminder -

The above example was a practice form to faciliate review and for your information only. This is a simulated form meant to reflect the content and spirit of the actual FAA form as closely as possible. Material is reproduced as accurately as possible to allow applicants to prepare for actual application with advanced understanding of these complex requirements. Nothing on this page will be transmitted anywhere--instructions are for pilot applicant understanding prior to submitting the actual FAA Form 8500-8 which will be irrevocable except through your actual AME. When ready, you must proceed to the real FAA MedXpress Form prior to your actual FlightPhysical with an AME.

- FAA Warning -
(The above was a practice form - no fines or imprisonment at FlightPhysical.com)

The FAA Warns: Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or who makes any false, fictitious or fraudulent statements or representations, or entry, may be fined up to $250,000 or imprisoned not more than 5 years, or both" (Title 18 U.S. Code. Secs. 1001; 3571).

If you're tired of all of this talk about jail and fraud and are done with e-copies for today, you can see the paper version of the FAA Form 8500-8 from 2008. Of course, you'll still have to come back later and submit electronically through MedXpress, but as of 2014 the item numbers still match. Some pilots find the paper version a useful reference.

This page discussed Index to Pilot Medical Application for Aviation Medical Certification FAA 8500-8

Reminder: use FlightPhysical.com to familiarize yourself with aviation medical regulations and guidelines, but always discuss your specific situation with one or more AMEs before dedicating resources toward expensive clinical workups. Find an AME now

18. a Yes No	Frequent or severe headaches
18. b Yes No	Dizziness or fainting spell
18. c Yes No	Unconsciousness for any reason
18. d Yes No	Eye or vision trouble except glasses
18. e Yes No	Hay fever or allergy
18. f Yes No	Asthma or lung disease
18. g Yes No	Heart or vascular trouble
18. h Yes No	High or low blood pressure
18. i Yes No	Stomach, liver, or intestinal trouble
18. j Yes No	Kidney stone or blood in urine
18. k Yes No	Diabetes
18. l Yes No	Neurological disorders: epilepsy, seizures, stroke, paralysis, etc.
18.m Yes No	Mental disorders of any sort: depression, anxiety, etc.
18. n Yes No	Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years.
18. o Yes No	Alcohol dependence or abuse
18. p Yes No	Suicide attempt
18.q Yes No	Motion sickness requiring medication
18. r Yes No	Military medical discharge
18.s Yes No	Medical rejection by military service
18. t Yes No	Rejection for life or health insurance
18.u Yes No	Admission to hospital
18. v Yes No	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.
18.w Yes No	History of nontraffic conviction(s) (misdemeanors or felonies).
18. x Yes No	Other illness, disability, or surgery
18.y Yes No	Medical disability benefits

Index to Pilot Medical Application for Aviation Medical Certification FAA 8500-8

Applicants will Enter Values through FAA's MedXpress

Abbreviated Briefing:

- FlightPhysical.com Notice -

- FAA Warning - (This is a practice form - no fines or imprisonment at FlightPhysical.com)

Medication Name* : Med Name required, other fields optional

This is what the MedXPress Medical Entry Table will look like