Health declaration - Flygmedicinskt Centrum

Fill in your health declaration with care. Make sure you answer all the questions.

1. State of licence issue

3. Surname

4. Previous surname(s)

5. Forenames

6. Date of birth (dd/mm/yyyy)

7. SexMaleFemale

8. Place and country of birth

9. Nationality

10. Permanent address

Street address

Zip

City

Country

Telephone No

Mobile No

11. Temporary address

Street address

Zip

City

Country

Telephone No

12. Application:InitialRevalidation/Renewal

15. Occupation (principal)

16. Employer

17. Last medical examinationDateDoctor and Place

18. Licence(s) held

If Other above

18b. License number

18c. State of issue

19. Any Limitations on Licence(s)/Medical Certificate heldNoYesDetails

20. Have you ever had a medical certificate denied, suspended or revoked by any licensing authority?NoYesDateCountryDetails

21. Flight time total

22. Flight time since last medical

24. Any aviation accident or reported incident since the last medical examination?NoYesDatePlaceDetails

25. Type of flying intended

26. Present flying activitySingle pilotMultipilot

27. Do you drink Alcohol?NoYes, weekly amount

28. Do you currently use any medicationNoYes
State medication, dose, date stated and why

29. Do you smoke tobacco?
No, never
No, date stopped
Yes, state type and amount

General and medical history: Do you have, or have you ever had, any of the following? YES or NO (or has indicated) must be ticked after each question. Elaborate YES answers in remarks section (30).

101. Eye trouble/eye operationYesNo

102. Spectacles and/or contact lenses ever wornYesNo

103. Spectacles/contact lens precriptions change since last medical exam.YesNo

104. Hay fever, other allergyYesNo

105. Asthma, lung diseaseYesNo

106. Heart or vascular troubleYesNo

107. High or low blood pressureYesNo

108. Kidney stone or blood in urineYesNo

109. Diabetes, hormone disorderYesNo

110. Stomach, liver or intertinal troubleYesNo

111. Deafness, ear disorderYesNo

112. Nose, throat or speech disorderYesNo

113. Head injury or concussionYesNo

114. Frequent or severe headachesYesNo

115. Dixxiness or fanting spellsYesNo

116. Unconsciouness for any reasonYesNo

117. Neurological disorders: stroke, epilepsy, seizure, paralysis etc.YesNo

118. Psychological/psychiatric trouble of any sortYesNo

119. Alcohol/drug/substance abuseYesNo

120. Attempted suicideYesNo

121. Motion sickness requiring medicationYesNo

122. Anaemia / Sickle cell trait / other blood disordersYesNo

123. Malaria or other tropical diseaseYesNo

124. A positive HIV testYesNo

125. Sexually transmitted diseaseYesNo

126. Sleep disorder/apnoea syndromeYesNo

127. Musculoskeletal illness/impairmentYesNo

128. Any other illness or injuryYesNo

129. Admission to hospitalYesNo

130. Visit to medical practitioner since last medical examinationYesNo

131. Refusal of life insuranceYesNo

132. Refusal of flying licenceYesNo

133. Medical rejection from or for military serviceYesNo

134. Award of pension or compensation for injury or illnessYesNo

Family history of

170. Heart diseaseYesNo

171. High blood pressureYesNo

172. High cholesterol levelYesNo

173. EpilepsyYesNo

174. Mental illnessYesNo

175. DiabetesYesNo

176. TuberculosisYesNo

177. Allergy/asthma/eczemaYesNo

178. Inherited disordersYesNo

179. Inherited disordersYesNo

Females only

150. Gynaecological, mentrual problems?YesNoNA

151. Are you pregnant?YesNoNA

30. Remarks

Are there any changes since the last medical check?YesNo

After you clicked the Send button you will recieve a confirmation message next to the button within a few seconds. If you don´t get at message you proboly havent answered all the questions so please scroll up and check for validation errors.

Telefon	040 - 20 81 25
Fax	040 - 684 91 25
E-post	mottagning@flygmedc.se