Comprehensive Medical Examination Checklist BasicMed

SECTION 1 – Instructions to the Individual and State-Licensed Physician     
This checklist is to be used by individuals seeking to operate certain small aircraft in accordance with
Title14 of Code of the Federal Regulations (14 CFR), § 61.113(i). This rule (BasicMed) allows pilots to
use this checklist, and other requirements, in lieu of holding a third-class FAA Airman Medical Certificate.
Under BasicMed, an individual may only act as pilot-in-command (PIC) of an aircraft that is authorized to
carry not more than 6 occupants, and that has a maximum certificated takeoff weight of not more than
6,000 pounds.
1. The individual must complete SECTION 2 of this checklist and provide the checklist in its entirety (including
the completed SECTION 2) to the state-licensed physician performing the medical examination.
2. The state-licensed physician must perform a comprehensive medical examination addressing all items in
SECTION 3 of this checklist. The physician completes the “Physician’s Signature and Declaration” if the
physician determines that he/she is not aware of any medical condition that, as presently treated, could
interfere with the individual’s ability to safely operate an aircraft.
3. The completed checklist shall be retained in the individual’s logbook (in any legible paper or electronic
format) and made available on request.
4. In order to act as PIC under BasicMed, an individual must receive a comprehensive medical examination
by a state-licensed physician during the previous 48 months in accordance with 14 CFR 61.23(c)(3)(i).
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Comprehensive Medical Examination Checklist
NOTICE: Whoever in any matter within the jurisdiction of any department or agency of the United States
knowingly and willingly 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. (18 U.S.C Secs. 1001; 3571)
Paperwork Reduction Act Statement:
The information collection is conducted in accordance with the requirements of 44 USC § 3507, as amended
by section 2 of the Paperwork Reduction Act of 1995. The information collected on this form is necessary to
determine eligibility to exercise pilot privileges under BasicMed and is consistent with the FAA’s authority to
regulate and promote safety in air commerce under 49 USC 44701; see also the Federal Aviation
Administration Extension, Safety, and Security Act of 2016, Pub. L. 114-190 § 2307, Medical Certification of
Certain Small Aircraft Pilots. The FAA estimated that it will take each user 0.5 hours per user to complete the
BasicMed Comprehensive Medical Examination Checklist. The information is required to be eligible to
exercise pilot privileges under BasicMed. Note that an agency may not conduct or sponsor, and a person is
not required to respond to a collection of information unless it displays a currently valid OMB control number.
The control number for this collection of information is 2120-0770.
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Comprehensive Medical Examination Checklist
SECTION 2 – Information to be completed by the Airman
To operate an aircraft under BasicMed, you may only use this checklist to comply with 14 CFR 61.113(i) if you:
• Hold or have held a valid first-, second-, or third-class medical certificate issued by the FAA at

any time after July 14, 2006; and

• The most recent medical certificate held (including an authorization for a special issuance

certificate) must have not been denied, suspended, revoked, or withdrawn.

INSTRUCTIONS: After completing all mandatory fields in SECTION 2, provide both SECTION 2 and
SECTION 3 to the state-licensed physician who will perform your medical examination.
1. OMITTED: Leave blank
2. OMITTED: Leave blank
3. FULL NAME: List current name. List any former name(s) in the “additional comments or explanation” box
found in #18 of the checklist form.
4. SOCIAL SECURITY NUMBER: Entry is optional.
5. ADDRESS: Enter permanent mailing address and country of residence. Include the nine digit ZIP code, if
known. (e.g., 20003-3230). Provide your current telephone number, including area code.
6. DATE OF BIRTH: List month, day, and year (e.g., 01/31/1960). COUNTRY OF CITIZENSHIP: Enter
citizenship (e.g., USA).
7. COLOR OF HAIR: Specify as black, blond, brown, gray, red, or bald.
8. COLOR OF EYES: Specify actual (not contact lenses) eye color as black, blue, brown, green, gray, or
hazel.
9. SEX: Indicate male or female.
10. TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD: Select the checkboxes that apply. If “Other” is selected,
write in the name of the type of certificate.
11. OCCUPATION: Enter major employment. Entry is optional.
12. EMPLOYER: Enter your employer. Entry is optional.
13. HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED, REVOKED,
OR WITHDRAWN: Select “Yes” or “No.” If “Yes” is selected, list the month and year (e.g., 01/1999) of the
action.
14. OMITTED: Leave blank
15. OMITTED: Leave blank
16. DATE OF LAST FAA MEDICAL APPLICATION: Enter month and year. If you have no prior application,
you cannot use BasicMed.
17. a. DO YOU CURRENTLY USE ANY MEDICATION (prescription or non-prescription): Select “Yes” or
“No.” If “Yes” is selected, enter the name of the medication(s), dosage, and frequency used.
b. DO YOU EVER USE NEAR VISION CONTACT LENSES WHILE FLYING: Select “Yes” or “No.”
Example: If you have one contact that is calibrated to give you near vision and one that is calibrated to give
you distant vision, check “Yes.” If you wear a contact in only one eye to correct for near vision, check “Yes.”
18. a – x. MEDICAL HISTORY: Select “Yes” or “No” for each item listed. For every condition you have ever
been diagnosed with, had, or presently have, you must answer “Yes.” Give the approximate date,
description of the condition, its severity, treatment, and any medication(s) you used or continue to use for
treatment. You must give an explanation for each item marked “Yes” in the “additional comments or
explanation” box.
• Do not report common, occasional illnesses such as colds or sore throats.
• “Substances” include alcohol, PCP, marijuana, cocaine, amphetamines, barbiturates, opiates, and
other psychoactive chemicals.
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Comprehensive Medical Examination Checklist
• “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” is defined as 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.
18. v. CONVICTION, AND/OR ADMINISTRATIVE ACTION HISTORY:
(1) Have you ever been 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) Have you ever been convicted, and/or subject to an administrative action by a state or other jurisdiction
for an offense for which your driver’s license was denied, suspended, cancelled, or revoked or which
resulted in attendance at an educational or rehabilitation program? Individual traffic convictions are not
required to be reported if they did not involve alcohol/drugs, suspension, revocation, cancellation, or denial
of driving privileges, or attendance at an educational or rehabilitation program. If “Yes” is checked, you
must give a description of the conviction(s) and/or administrative action(s) in the “additional comments or
explanation” box. The description must include:
• 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 convictions, etc.);
• The name of the state or other jurisdiction involved; and
• The date of the conviction(s) and/or administrative action(s). The FAA may check state motor
vehicle driving licensing records to verify your responses.
19. w. HISTORY OF NON-TRAFFIC CONVICTIONS(S) (MISDEANORS OR FELONIES): Have you
ever had any other (non-traffic) convictions (e.g., assault, battery, public intoxication, robbery,
etc.)? If so, name the charge for which you were convicted and the date of conviction in the
“additional comments or explanation” box.
20. 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 it was related to a personal substance abuse or psychiatric
condition.
Enter the date of visit as month and year (e.g., 01/1990), name, address, and type of health
professional consulted and briefly state reason for consultation. Repeat this process to add all
relevant visits to medical professionals in the past 3 years. Multiple visits to one health
professional for the same condition may be grouped together on one line. You do not need to
report:
o Occasional common illnesses such as colds or sore throats that resolved;
o Routine dental, eye, and FAA periodic medical examinations; or
o Consultations with your employer-sponsored employee assistance program (EAP) unless
the consultations were for substance abuse or unless the consultations resulted in referral
for psychiatric evaluation or treatment.
NOTE: After completing SECTION 2, carefully review and read the affirmation statements under the “Airman’s
Signature and Declarations.” If you agree with the statements, sign and date the document. Once you have
completed, signed, and dated SECTION 2, you must provide ALL sections (SECTION 1-3) of this checklist to
the state-licensed physician who will perform and complete the comprehensive medical examination, as
required by Section 2307(a)(7) of FESSA.
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Comprehensive Medical Examination Checklist
BASICMED SECTION 2: INDIVIDUAL INFORMATION
(To be completed by the airman) Form approved OMB No: 2120-0770
Expires: 04/30/2020
1-2 Omitted
3 Name: Last: First: Middle: 4 SS # (optional)
5 Address/street: Telephone:
City State/Country Zip Code:
6. Date of birth: Country of Citizenship:
7 Color of hair: 8 Color of eyes: 9 Sex:
10 Type of airman certificate(s) you hold: □ Airline Transport □ ATC Specialist □ Commercial □ Flight Engineer □ Flight Instructor
□ Flight Navigator □ Private □ Recreational □ Student □ None
□ Other _____________________
11 Occupation (optional): 12 Employer (optional):
13
Has your FAA Airman Medical
Certificate ever been denied,
suspended, revoked, or withdrawn?
□ No □Yes If yes, give date ___________
MM/YYYY
14. Omitted
15. Omitted
16 Date of Last FAA Medical Application _________
MM/YYYY or □ No Prior Application (If no prior application, STOP. You cannot use BasicMed.)
17
Do You Currently Use Any Medication?
(Prescription or over-the-counter)
If additional space is needed,
check this box □
and list information on an
additional sheet of paper
□ No □Yes (If yes, list medication(s) and dosage used below.)
Medication Name Dosage
17b. Do you ever use near vision contact
lens(es) while flying
□ No □Yes Answer “Yes” if you wear a contact in one eye only to correct for near vision or if you have one
contact that adjusts for near vision and one in the other eye that adjusts for distant vision.
18
Medical History: Mark “Yes” if you have or had any of the following conditions at ANY TIME in your life. Explain when it occurred, the severity, how it was
treated, and if you are currently taking any medication or having treatment for the condition or have to see a physician for the condition. Discuss any “Yes”
responses with the physician doing this exam.
Additional comments or explanations
(Give details in the space below)
No Yes
a. Frequent or severe headaches:
b. Dizziness or fainting spell:
c. Unconsciousness for any reason:
d. Eye or vision trouble (except for glasses):
e. Hay fever or allergy:
f. Asthma or lung disease:
g. Heart or vascular trouble:
h. High or low blood pressure:
i. Stomach, liver, or intestinal trouble:
j. Kidney stone or blood in urine:
k. Diabetes:
l. Neurological disorders (epilepsy, seizures, stroke, paralysis, etc.):
No Yes
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Comprehensive Medical Examination Checklist
m. Mental disorders of any sort (depression, anxiety, etc.):
n. Substance dependence, failed a drug test ever, or substance abuse
or use of illegal substance in the last 2 years:
o. Alcohol dependence or abuse:
p. Suicide attempt:
q. Motion sickness requiring medication:
r. Military medical discharge:
s. Medical rejection by military service:
t. Rejection for life or health insurance:
u. Admitted to a hospital:
x. Other illness, disability, or surgery:
v.
History of (1) any 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 conviction(s) 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:
w. History of non-traffic conviction(s) (misdemeanors or felonies):
(e.g. battery, assault, public intoxication, robbery, etc.)
19.
Any visits to a health professional
within the last 3 years?
□ No □ Yes
If “Yes,” list the date, name, address,
type of provider and why you saw
them.
If additional space is needed,
check this box □
and list information on an additional
sheet of paper
Date Name Address Type of Provider Reason
Airman’s Signature and Declarations
In accordance with section 2307(b)(2)(A) of the FAA Extension, Safety, and Security Act of 2016 (Public Law 114-190), I affirm that:
□ The answers provided by me on this checklist, including my answers regarding my medical history, are true and complete;
□ I understand that I am prohibited under Federal Aviation Administration regulations from acting as pilot in command, or in any other
capacity as a required flight crewmember, if I know or have reason to know of any medical deficiency or medically disqualifying
condition that would make me unable to operate the aircraft in a safe manner; and
□ I am aware of the regulations pertaining to the prohibition on operations during medical deficiency and I have no medically
disqualifying conditions in accordance with applicable law.
Printed Name Airman Signature
NOTE: You must provide ALL sections (SECTION 1-3) of this checklist to your state-licensed physician who will perform and
complete the comprehensive medical examination as required by Section 2307(a)(7) of FESSA.
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BasicMed SECTION 3: Instructions for State-Licensed Physician
Comprehensive Medical Examination Checklist
This checklist is being submitted by an individual seeking to operate certain small aircraft in accordance with
14 CFR 61.113(i). This rule (BasicMed) allows pilots to use this checklist, and other requirements, in lieu of
holding a FAA Airman Medical Certificate. The examination checklist may only be completed by a statelicensed
physician. Under BasicMed, an individual may only act as pilot in command (PIC) of an aircraft that
is authorized to carry not more than 6 occupants, and that has a maximum certificated takeoff weight of not
more than 6,000 pounds.
As the examining physician, you are required to:
1. Review all sections of the checklist, particularly SECTION 2 completed by the airman.
2. Conduct a comprehensive medical examination in accordance with the checklist by:
a. Examining each item specified;
b. Exercising medical discretion, address, as medically appropriate, any medical conditions
identified; and
c. Exercising medical discretion, determine whether any medical tests are warranted as part of the
comprehensive medical examination.
3. Review and discuss all prescription and non-prescription medication(s) the individual reports taking and
any potential to interfere with the safe operation of an aircraft or motor vehicle.
4. Complete the Physician’s Signature and Declaration.
5. Complete the Physician’s Information.
You should consider consulting available aeromedical resources on the flight hazards associated with medical
conditions/medications, to include:
• The FAA Guide for Aviation Medical Examiners (AME Guide) at http://www.faa.gov/go/ameguide;
• The FAA Pharmaceuticals (Therapeutic Medications) Do Not Issue – Do Not Fly list at
http://www.faa.gov/go/dni;
• Chapter 8 of the FAA’s Aeronautical Information Manual (AIM 8-1-1), which addresses medical facts for
pilots and is available at http://www.faa.gov/air_traffic/publications/;
• www.faa.gov/go/basicmed.
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Comprehensive Medical Examination Checklist
BASICMED SECTION 3: MEDICAL EXAMINATION
(To be performed by state-licensed physician only)
Physician Use Only
Patient/Pilot name:
Patient/Pilot Date of Birth: Examined
1. Head, face, neck and scalp: □
2. Nose, sinuses, mouth, and throat: □
3. Ears, general:
(Internal and external (canals) and eardrums (perforation):
□
4. Eyes (general), ophthalmoscopic, pupils, (equality and reaction), and ocular motility (associated
parallel movement, nystagmus):
□
5. Lungs and chest:
(Not including breast examination):
□
6. Heart:
(precordial activity, rhythm, sounds, and murmurs):
□
7. Vascular system:
(pulse, amplitude, and character and arms, legs, and others):
□
8. Abdomen and viscera:
(including hernia):
□
9. Anus:
(not including digital examination):
□
10. Skin: □
11. G-U system:
(not including pelvic examination):
□
12. Upper and lower extremities:
(strength and range of motion):
□
13. Spine and other musculoskeletal: □
14. Identifying body marks, scars, and tattoos (size and location): □
15. Lymphatics: □
16. Neurologic:
(tendon reflexes, equilibrium, senses, cranial nerves, coordination, etc.):
□
17. Psychiatric:
(appearance, behavior, mood, communication, and memory):
□
18. General systemic: □
19. Hearing: □
20. Vision:
(distant, near, and intermediate vision, field of vision, color vision, and ocular alignment):
□
21. Blood pressure and pulse: □
22. Anything else the physician, in his or her medical judgment, considers necessary. □
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Comprehensive Medical Examination Checklist
In accordance with 14 CFR 68.5 and 68.7, the examining physician is instructed to:
• Exercise medical discretion to address, as medically appropriate, any medical conditions identified, and to exercise medical
discretion in determining whether any medical tests are warranted as part of the comprehensive medical examination; and
• Discuss all drugs the individual reports taking (prescription and nonprescription) and their potential to interfere with the safe
operation of an aircraft or motor vehicle.
Physician’s Signature and Declaration
□ In accordance with section 2307(b)(2)(C)(iv), of the FAA Extension, Safety, and Security Act of 2016 (Public Law 114-190), I certify
that I discussed all items on this checklist with the individual during my examination, discussed any medications the individual is taking
that could interfere with their ability to safely operate an aircraft or motor vehicle, and performed an examination that included all of the
items on this checklist. I certify that I am not aware of any medical condition that, as presently treated, could interfere with the
individual’s ability to safely operate an aircraft.
Patient/Pilot Name (printed) Patient/Pilot Date of Birth
Signature of Physician who performed the exam
Physician’s Information
1.
Full name of physician
who performed the
exam:
Printed or Stamp
Last : First: Middle Initial:
2. State license number: State Medical license number
3. Telephone number:
4.
Street address: Address:
City:
Suite:
State: Zip Code:
5.
Date of Examination:
_____________
(MM/DD/YYYY)
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