Online medical waiver app- fit for your mobile phone
First Landings Aviation Medical Questionnaire
Please give details where appropriate
First and Last Name:
*
Please enter your name.
Angina
*
Yes
No
Please select at least one choice above.
Coronary heart disease that has been treated or, if untreated, has been symptomatic or clinically significant
*
Yes
No
Please select at least one choice above.
Cardiac valve replacement
*
Yes
No
Please select at least one choice above.
Permanent cardiac pacemaker
*
Yes
No
Please select at least one choice above.
Cardiac replacement (heart transplant)
*
Yes
No
Please select at least one choice above.
Diabetes mellitus that requires hypoglycemic medication
*
Yes
No
Please select at least one choice above.
Psychosis
*
Yes
No
Please select at least one choice above.
Bipolar disorder
*
Yes
No
Please select at least one choice above.
Personality disorder that is severe enough to have repeatedly manifested itself by overt acts
*
Yes
No
Please select at least one choice above.
Substance abuse or dependence (drugs or alcohol)
*
Yes
No
Please select at least one choice above.
Epilepsy
*
Yes
No
Please select at least one choice above.
Disturbances of consciousness without satisfactory explanation of cause
*
Yes
No
Please select at least one choice above.
Transient loss of control of nervous system function without satisfactory explanation of cause.
*
Yes
No
Please select at least one choice above.
Other medical conditions
Please enter your answer here.
I declare that the information I have given is correct to the best of my knowledge
*
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Signature Date
*
Set Today
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