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HKCAD Medical Report Form

This medical report form collects personal and medical information from an applicant for an aviation medical certificate. It includes sections on the applicant's identifying information, medical history, current medications, last medical exam, and results of the current physical exam. The examining physician provides comments and recommendations. If found medically fit, the physician will issue a medical certificate for the appropriate aviation class.

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636 views

HKCAD Medical Report Form

This medical report form collects personal and medical information from an applicant for an aviation medical certificate. It includes sections on the applicant's identifying information, medical history, current medications, last medical exam, and results of the current physical exam. The examining physician provides comments and recommendations. If found medically fit, the physician will issue a medical certificate for the appropriate aviation class.

Uploaded by

HelloWorld
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Medical Report Form

Initial

Renewal
1 SURNAME

CIVIL AVIATION DEPARTMENT, HONG KONG, CHINA

Medical Examination

Name of AME

Date (dd/mmm/yyyy) (e.g. 01/Jan/2012):

OTHER NAMES

Title

Mr / Mrs / Ms / Other

Gender

M/F

2 CORRESPONDENCE ADDRESS

3 PLACE OF BIRTH

MEDICAL IN CONFIDENCE (when completed)

Telephone No

Email

4 DATE OF BIRTH

5 AGE

6 EMPLOYER (if applicable)

7 OCCUPATION

(dd/mmm/yyyy)
(e.g. 01/Jan/1960)

8 DETAILS OF HK LICENCE AND MEDICAL CERTIFICATE HELD OR APPLIED FOR


ATPL
Single Crew
Multi Crew
Expiry Date(s) of last Medical Certificate(s)
(dd/mmm/yyyy) (e.g. 01/Jan/2012)
CPL
Single Crew
Multi Crew
PPL
PPL Inst Rating
Student Pilot
FE
ATCO
Others
Please specify:

Licence Number(s)
Hours flown since
last medical

Total hours flown

9 Any aircraft/incident since last medical? YES/NO (if yes, please give details)
Date (dd/mmm/yyyy) (e.g. 01/Jan/2012)

Place

Details
10 LAST HKCAD MEDICAL EXAMINATION

Date (dd/mmm/yyyy) (e.g. 01/Jan/2012)

City and Country

HK / UK / AUS / SG / Other (please specify)

AMEs Name
11 Name and Address of own Medical Practitioner

Telephone No
Email

12 List ALL MEDICATIONS CURRENTLY TAKEN whether prescribed by a doctor or over-the-counter. (Please indicate vitamins, supplements and herbal medicines)
Name (Generic)

Dose

Date started

Purpose

By Whom Prescribed

(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
13 Do you smoke? YES/NO/NEVER. If yes or no, give details

14 State weekly alcohol intake in units:

15 Since last medical, have you had any illness, accident, admission to hospital or started long term medication?

YES/NO

If YES describe in Para 20

16 MEDICAL HISTORY Have you EVER had any of the following? Please tick YES or NO. If YES describe in the REMARKS column or in Para 20
Yes

No

Remarks

(a) Eye disorders, eye surgery including refractive surgery


(b) Ear disease or deafness
(c) Motion sickness requiring medication
(d) Hayfever or allergy
(e) Frequent or severe headaches
(f) Dizziness, fainting or unconsciousness
(g) Epilepsy or fits
(h) Head injury or concussion
(i) Psychiatric or nervous trouble of any sort
(j) Asthma or other lung disorder
(k) Heart trouble or high/low blood pressure
(l) Anaemia or other blood disorder
(m) Stomach, liver or intestinal disorder
(n) Diabetes, thyroid or other hormone disease
(o) Sugar or protein in urine
(p) Kidney stone or blood in the urine
DCA 153 (Dec 2011)

Page 1

Applicants Name :
16 MEDICAL HISTORY (Continued)
Yes

No

Remarks

(q) Musculo-skeletal disorder


(r) Malaria or other tropical disease
(s) A positive HIV test
(t) Alcohol/substance abuse or related problem
(u) Use of opioids, cannabinoids, sedatives, cocaine, hallucinogens,
solvents, recreational drugs or other psychoactive substances
(v) Admission to hospital overnight
(w) Any other illness or injury

17 Have you ever been: Please tick YES or NO. If YES describe in the Remarks column or in Para 20
Yes

No

Remarks

(a) Refused life insurance


(b) Denied, deferred or delayed in an application or renewal of an
aviation medical certificate by any licensing authority
(c) Convicted of civil or criminal offence in or outside Hong Kong

18 Have you a family history of: Please tick YES or NO. If YES describe in the Remarks column or in Para 20
Yes

No

Remarks

(a) Heart disease


(b) High/Low blood pressure
(c) Epilepsy
(d) Mental illness
(e) Diabetes

19 Females only: Please tick YES or NO. If YES describe in the Remarks column or in Para 20
Yes

No

Remarks

(a) Are you pregnant?


(b) Have you a history of gynaecological problems?

20 REMARKS - If no change since last report, so state. If insufficient room, use separate sheet of paper.

21 Declaration I hereby declare that I have carefully considered the statements made above and that to the best of my belief they are complete and
correct and that I have not withheld any relevant information or made any misleading statement. I understand that if I have, with intent to deceive,
made any false representation for the purpose of procuring for myself a medical certificate, I may be guilty of a criminal offence.
Consent to obtaining of medical information I hereby consent to the Civil Aviation Department (so long as I hold or am an applicant for a medical
certificate) obtaining information about my health from any medical adviser or hospital consulted by me.

Signed.. Date (dd/mmm/yyyy) (e.g. 01/Jan/2012).... AMEs (Witness) Signature.......


AMEs Name.. Telephone No.(s)..... Email Address...
AMEs Address...
22 AME please comment on Page 4 on all items answered YES above and detail your recommendations for further progress reports and specialist
consultations. All tests, reports and tracings should be securely attached to the examination report. You are advised to make photocopies of the
examination report and copies of other reports for future reference.

Page 2

REPORT OF MEDICAL EXAMINATION

Applicants Name :

23 Height (cm)

24 Weight (kg)

25 BMI

26 Waist Measurement

27 Identifying Marks, Scars, Tattoos, Deformities

28 Hair colour

29 Eye colour

30 Pulse

31 Blood pressure
(recumbent)

Please tick for each item.


32 Head
Neck
33 Eyes - Lids and Orbits
34 Eyes - Pupils, Lens, Media, Fundi
35 Eyes - Visual fields by confrontation
36 Eyes - Ocular Movements,
Nystagmus
37 Mouth
Throat
Teeth
38 Sinuses
Nose
39 Ears
Drums
Valsalva
40 Lungs
Chest incl Breast
41 Heart
Size, Auscultation
42 Vascular System
Varicose Veins
43 Abdomen, Hernia
44 Liver
Spleen
45 Anus
Rectum Only if indicated
46 Gebito-urinary System
47 Endocrine System
48 Upper, Lower Limbs
Joints
49 Spine, Spinal Movement
50 Neurological
(Reflexes, Equilibrium, etc.)
51 Skin
52 Psychiatric & Mental Status
53 Pelvic Examination (if applicable)
55 VISUAL ACUITY

Normal

Abnormal

st

nd

2 (if indicated)

rd

3 (if indicated)

Notes: Enter item number before each comment. Any abnormal finding should be
given in details. Attach additional sheet(s) if necessary

LEFT

RIGHT

54 Last Menstruation Date (Female only) (dd/mmm/yyyy) (e.g. 01/Jan/2012)


Does the candidate wear glasses
Right
Left
Binocular
or contact lenses: YES/NO
Without Glasses
Prescription of glasses or contact lenses if
Distant Vision (Standard Test Types)
applicable
With Glasses
Without
Glasses
S
C
A
Intermediate Vision (N type at 100 cm)
[Able to read N14 at 100cm]
With Glasses
Distant
Without Glasses
Near
Near Vision (N type at 30 to 50 cm)
[Able to read N5 in the range 30 to 50 cm]
With Glasses
Distant
Without Glasses
Accommodation in cm
(Near point 30 cm with or without lenses)
Near
With Glasses
56 MEASURE OF HETEROPHORIA
Exophoria
Esophoria
Hyperphoria
57 Power of convergence in cm
(by Maddox Rod at 6 M)
Result of cover test
Number Correct
Number Incorrect
58 COLOUR PERCEPTION (Initial medical examination only - ALL Licences)
Tested by pseudoisochromatic (Ishihara) plates - State number of correct and incorrect plates
Tested by an approved Colour Perception test (must be tested if plates test is abnormal)
- State name of test and result
59 AUDITORY ACUITY
Any hearing difficulty with Conversational voice at 2 metres with back to examiner?
YES/NO
At what distance from examiner can Forced Whisper be heard in each ear separately?
Right:
Left:
(when appropriate) Rinne: .. Weber: ..
61 ECG Report (Summary)
60 AUDIOMETRY
Frequency
Right
Left
Max Permitted Loss
3000
50
2000
35
1000
35
62 CXR Report (Summary) Initial exam only
500
35

Pass / Fail

Remarks
63 Date of last Special examinations (mmm/yyyy) (e.g. Jan/2012):
ECG
Audio
OPH
64 URINALYSIS

NOTES: ECG tracing and report, CXR report and ophthalmological report (DCA 153
(Oph) should be attached to this report. For frequency of ECG, audiogram and
ophthalmic examination, see the Guidance Notes for AME.
Albumin . Sugar . Blood . Other .

65 HIV TEST RESULTS (initial medical and when clinically indicated)


Test used:

Result:

66 DRUG SCREEN (when clinically indicated)


Alcohol.
Amphetamines...
Cannabinoids.
Comments: -

Cocaine
Opiates.
Other.

Page 3

Applicants Name :
67 Comments - Additional comments from AME on Items 12-20 and 23-66, including any items answered YES in Items 15-19 and your recommendations
for further progress reports and specialist consultations.

68 Medical Examiners declaration:


I hereby certify that I have personally examined the applicant named on this medical examination report and that this report with any attachments
embodies my findings completely and correctly.

Signature of AME

69 For use by AMA and CAD ONLY


Attained

NAME IN BLOCK CAPITALS

Annex 1 requirements
Not Attained

Medical Certificate issued : YES / NO

Class .

Date of next (mmm/yyyy) (e.g. Jan/2012):

ECG
AUDIO
OPH

Class One
Class Two

DATE COMPLETED
(dd/mmm/yyyy) (e.g. 01/Jan/2012)

Expiry Date of Medical Certificate (dd/mmm/yyyy) (e.g. 01/Jan/2012):

Class Three

Class 1 for single-crew commercial air transport


operations carrying passengers

..

Limitations:

Class 1 for commercial air transport operations other


than (i) above

..

Class 2

..

Class 3

..

Comments:

Signature of ASSESSOR

Date..
(dd/mmm/yyyy)
(e.g. 01/Jan/2012)

Page 4

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