caaf-667-mcc-medical - Civil Aviation Authority

CIVIL AVIATION AUTHORITYPAKISTANRef No.CAAF - 667MEDICAL ASSESSMENT REPORT(For Operation of Micro-light)Name (Block Letters)Father NameAddress & Tel No.Date of Birth Place of Birth Date of Examπ MaleMartial Height Weight B.P Temp. Colour of Heir/Eyesπ FemaleHave you ever had or have you now any of the following(For each yes, describe the condition in remarks below)Yes No Yes No1. Eye Trouble 12. Back Ache Sciatica, Slipped Disc2. Ear Trouble 13. Motion or Travel Sickness3. Nose Trouble4. Throat Trouble14. Fainting, Giddiness, Blackout, FitsEpilepsy, Convulsions5. Heart Trouble 15. Nervous Illness, Anxiety-State6. Rheumatic Fever, Rheumatism 16. Skin Disease, Dermatitis Eczema7. Pneumonia, Pleurisy 17. Allergy, Migraine8. Chronic Bronchitis, Asthma otherLung Disorders18. Diabetes, Hypertension19. Dysentery, Typhoid, Malaria9. Stomach Trouble, Severe Indigestion 20. Severe Menstrual Disorders10. Kidney or Bladder Disorders 21. Gynaecological Problems11. Venereal Diseases 22.Additional Remarks:Have you ever undergone investigations or Treatment in the Hospitals if so give detail:Have you had a Serious Injury or Accident if so give details:Is there any family H/O Heart Trouble Diabetes, Allergies, Mental Disorders etc. If so give details:PhotoI declare that all the information given is true and thereby give consent to any Doctor tocommunicate confidentially with my Medical AttendantsDateSignature & Stamp

VISUAL ACUITYCOLOUR VISIONFIELD OF VISIONDISTANT VISION/NEAR(ISHIHARA)Uncorrected Corrected VISIONSafe Unsafe Normal AbnormalR L R LPrescription of Glasses / Lenses if any:Hearing Performance: Normal AbnormalClinical Examination Normal Abnormal Clinical Examination Normal Abnormal1. Skin, Lymphatic, Glands 9. Heart, Blood Vessels2. Head, Neck, Face 10. Abdomen3. Ears, Drums 11. Extremities4. Eyes including Funds copy 12. Psychological Disorders5. Nose, Throat & Nasal Passages 13. Neurological Disorders6. Chest / Breasts 14. Genitalia7. Respiratory System 15. Rectal Examination8. Vaginal Examination 16.a) COMMENTS ON CLINICAL EXAMINATIONb) Investigationc) X-ray Chest (if indicated)c) ECG (above 40 years)d) FBS (if indicated, D.M. requiring oral Medication is acceptable)e) Other Tests (if indicated)f) Defects /RestrictionsRECOMMENDATIONS:Medically Fit / Unfit for “MICROLIGHT CERTIFICATE COMPETENCY”DateSignature & Stamp(Authorised Medical Officer)For Official use:Fit / Unfit / Referred to CAM for Accredited Medical Conclusion (AMC)DateSignature & Stamp(Authorised Medical Officer)