First Name
Last Name
Date of Birth
Crew Employee ID
FAA / Aviation Authority License #
Current Medical Class Held
Class 1
Class 2
Class 3
Assigned Aircraft Type / Fleet
Crew Position / Role
Captain
First Officer
Flight Engineer
Lead Cabin Crew
Corporate Email
Mobile Phone Number
Flight crew members operate under unique environmental and physiological stressors. Please review the operational demands below when evaluating your patient’s operational readiness:
Atmospheric & Barometric Stressors: Rapid altitude changes, cabin pressurization cycles, hypoxia potential, and micro-climate dehydration.
Circadian & Fatigue Factors: Multi-time-zone travel, night-duty windows, disrupted sleep cycles, and extended duty periods.
Cognitive & Vision Demands: High-speed spatial orientation, multi-instrument monitoring, color-critical displays, rapid decision-making under stress, and clear radio communication.
Physical & Ergonomic Demands: Prolonged seated posture in flight deck harnesses, manual flight control manipulation, emergency egress capability, and heavy flight kit handling.
(To be completed by the evaluating physician)
Please select the primary reason prompting this operational evaluation:
Routine Periodic Flight Duty Clearance
Post-Illness / Post-Surgical Return-to-Duty Evaluation
Prescription Medication / Pharmacological Review
Cardiovascular or Metabolic Screening Event
Neurological, Balance, or Vestibular Assessment
Vision / Hearing Threshold Changes
Fatigue / Circadian Recovery Assessment
Other Clinical Concern:
Cardiovascular Vitals
Resting Systolic BP (mmHg)
Resting Diastolic BP (mmHg)
Resting Heart Rate (BPM)
Cardiovascular Status
Normal
Flagged
Vision Screening (Distant Vision)
Uncorrected - Right Eye (20/___)
Uncorrected - Left Eye (20/___)
Corrected - Right Eye (20/___)
Corrected - Left Eye (20/___)
Vision Status
Normal
Flagged
Color Vision & Hearing Screening
Color Vision Screen (Ishihara Passed)
Audiometric Hearing Screen Passed
Sensory Screening Status
Normal
Flagged
Please select ONE of the following clearance levels based on your clinical assessment:
OPTION A: UNRESTRICTED FLIGHT CLEARANCE
The crew member is medically fit for full flight duty across all assigned aircraft types, routes, and duty schedules without limitations.
OPTION B: CONDITIONAL / RESTRICTED FLIGHT CLEARANCE
The crew member is cleared for flight duty ONLY under specific operational restrictions, aircraft limitations, or schedule modifications detailed in Section 5 below.
OPTION C: TEMPORARY GROUNDING / UNFIT FOR FLIGHT DUTY
The crew member is currently unfit for flight operations due to medical considerations.
Re-evaluation date scheduled
(Required if Option B is selected above)
Please check any specific flight parameters or schedule conditions required for this crew member:
Multi-Pilot Operations Only: Must fly with a qualified dual-pilot crew (No single-pilot operations).
Correctionive Lenses Required: Must wear corrective lenses and carry a spare set during flight duty.
Long-Haul / Time-Zone Restriction: Restricted from flights crossing more than 3 time zones.
Night Duty Restriction: Restricted from scheduled flight duty during local window-of-circadian-low (10:00 PM – 6:00 AM).
Aircraft Type Limitation
Restricted to specific fleet types
Approved Medications On Duty
Mandatory Pre-Flight Blood Glucose / Vital Checks
Required
Not Required
Follow-Up Clinical Re-Check Interval
3 Months
6 Months
12 Months
Other:
I certify that I have evaluated the flight crew member named above and that the medical findings provided herein reflect my professional judgment regarding their physiological and psychological fitness for flight operations.
Physician / Examiner Full Name
Medical Credentials / Designation
AME (Aviation Medical Examiner)
Occupational Health MD/DO
Specialist
Aviation Authority Examiner ID / License #
Medical Practice / Clinic Name
Clinic Address
Direct Office Phone Number
Emergency / Duty Contact Email
Physician Signature
Date
Operational Status
Pending
Approved / Accepted
Incomplete / Returned
Verified By (Initials)
Date Completed
Operational Status
Fit for Duty
Conditional / Restricted
Unfit / Grounded
Verified By (Initials)
Date Completed
Operational Status
Roster Updated / Active
Schedule Restrictions Applied
Removed from Roster
Verified By (Initials)
Date Completed
Operational Status
Access Activated
Access Restricted
Access Deactivated
Verified By (Initials)
Date Completed
Form Template Insights
Please remove this form template insights section before publishing.
Below is an in-depth breakdown explaining why each section and field exists, and what operational problems occur if they are removed.
Lacking accurate license and fleet details creates roster misassignments—such as assigning a pilot with flight restrictions to an incompatible single-pilot route or aircraft type.
Without clear operational context, non-aviation physicians might approve a pilot based on standard desk-job health benchmarks, missing hidden risks like subtle spatial disorientation or altitude-induced sinus blockages.
Skimping on sensory or cardiovascular testing risks placing a pilot on duty who cannot clearly hear emergency radio calls, distinguish warning indicators, or maintain consciousness during unexpected turbulence or pressure changes.
Ambiguous clearance terms leave flight dispatchers guessing about a pilot's true readiness, potentially resulting in grounded flights or dangerous situations where an unfit crew member enters the flight deck.
Without granular restrictions, flight schedulers cannot tailor routes to a pilot's specific health needs, forcing a binary choice between total grounding or exposing the flight to unnecessary risk.
Without verifiable credentials and contact channels, flight operations cannot confirm the validity of the medical clearance, creating severe operational integrity gaps.
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation section before publishing.
Here are the mandatory fields and questions on the Aviation & Commercial Pilot Flight Readiness Medical Evaluation Form, along with the operational, clinical, and safety reasons why flight operations departments must require them.
Required Fields: Legal First & Last Name, Date of Birth, Crew Employee ID, Aviation License Number, Current Medical Class, and Assigned Aircraft Fleet.
Why It Must Be Required:
Required Selection: Reason for evaluation (Routine, Return-to-Duty, Medication Review, Vision/Hearing Change, Post-Illness, etc.).
Why It Must Be Required:
Required Fields: Blood Pressure, Heart Rate, Distant Vision (Uncorrected & Corrected), Color Vision Screen (Ishihara), and Audiometric Hearing Threshold.
Why It Must Be Required:
Required Selection: Single-choice clearance status (Option A: Unrestricted, Option B: Conditional/Restricted, or Option C: Temporary Grounding).
Why It Must Be Required:
Required Fields (When Option B is selected): Operational restrictions (Multi-Pilot Only, Corrective Lenses Required, Time-Zone Limits, Night-Fly Restrictions, or Approved On-Duty Medications).
Why It Must Be Required:
Required Fields: AME/Physician Name, Medical License / Examiner ID, Practice Name, Direct Phone Number, Signature, Execution Date, and Clinic Stamp.
Why It Must Be Required:
Required Fields: Intake Status, System Log Confirmation, Crew Scheduling Restriction Update, and Staff Initials/Date.
Why It Must Be Required:
To configure an element, select it on the form.