50{rru{r,tr{al South African Civil Aviation

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l%,rM APPLICATION FORM FOR A MEDICAL CERTIFICATE
Authorillv
wffi Physical address: lkhaya Lokundiza, '16 Treur Close, Waterfall Park, Bekker Street, lVidrand, Gauteng
",iit#fr#. Postal address : Private Bag X73, Halfway House 1685
South Africa Medical in Confidencer
(l) State applied to: (2)Classofmediffil certifcateappliedfor: fl I i], lt [ la l lc"ninCr"*[otn",.
(3) Surname: (4) Previous surname(s): (12) Application:

ld (7) Sex:
I tniti"t
(5) Forename(s): (6) Date of birth: Renewal/Revalidation
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f ltuate [lremate (1 3) Reference number: Social Security Number
(8) Place and country of birth: (9) Nationality:

(14) Type of licence applied for:

(10) Pemanent address: (1'1) Postal address (if ditferent):

( 15) Occupation (principal):

(16) Employer:
Telephone No,: Telephone No.:
[robile No.:
E-Mail: (17) Last medi€l examinatjon:
Date:
(18) Licence(s) held (type): Licence number: State of issue:
Place:

(19) Any limitations on licene(s)/medi€l certifi€te held:

(20) Have you ever had medical certificate denied, suspended or revoked by any licensing authority?
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Details:
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E *o [ves Date: country: (21) Flight time total: (22) Flight tim€ since last medical:

Delails:

(23) Aircraft class/type(s) presently flown:

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I24) Anv aviation accident or reported incident since the last medical examination?
[v"' Date: Plaee: (25) Type offlying intended:
Details:

(26) Curent flying aetivity: pilot pilot

(27) Do you drink alcohol? No Yes, amount

Curent ATCO activity: BPP
(29) Do you smoke tobacco?
(28) Do you curently use any medi€tion
State medi€tion, dose, date started and why:
L l*o f lv"" No, never I No, date stopped;
Yes, state type and amount:

General and medical history: Do you have, or have you ever had, any ofthe following? (Please tick). lf yes, give details in remarks section (30).
Yes No Yes No Yes No Yes Nc

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01) Eye trouble/ eye operation (1 12) Nose, throat or speech disorder (123) N4alaria or other tropical Family history of:
tr tr tr tr
(1
disease (170) Heart disease
tr T
TI
(102) Spectacles and/or contact ('l 13) Head injury or concussion (124) A positive HIV test
lenses everwom tr tr T tr (171) High blood pressure
tr T
(103) Spectacles/ contact lens
prescriptions change since last
tr I
(1 14) Frequent or severe headaches
TI
(1 25) Sexually transmitted disease
tr I
(172) High cholesterol level
tr I
I fl
mediml exam.
(173) Epilepsy

tr l
(104) Hay fever, other allergy
tr n
(115) Diziness orfainting spells (1 26) Sleep disorder/apnoea
syndrome T tr (174) Mental illness
T T
(105) Asthma, lung disease
u tr
(1 16) Unconsciousness for any
reason I I (127) Musculoskeletal
illness/impaiment l n (175) Diabetes
T T
(106) Heart or vascular trouble
tr tr
(1 17) Neurologiml disorders: stroke,
epilepsy, seizure, paralysis etc. tr tr
('128) Any other illness or injury
tr T (176) Tuberculosis
tr T
(1 07) High or low blood pressure (1 1 8) Psychological/psychiatr c
(129) Admission to hospital
tr u (l 77) Allergy/asthma/eaema
tr n
tr tr trouble of any sort T tr (130) Vlsit to mediml practitioner
tr tr
since last medical examination (1 78) lnherited disorders
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(1 08) Kidney stone or blood in urine
tr T
(1 1 9) Alcohol/drugisubstance abuse
I T (131) Refusal oflife insurance
tr T (179) Glaucoma
T I
(109) Diabetes, hormone disorder
tr tr
(120) Attempted suicide
tr tr
(132) Refusal of piIoUATCO licence
tr I Females only

(1 10) Stomach, liver or intestinal (121) lvlotion sickness requirjng (133) N4edical rejection from orfor
(150) GynaecologiGl, menstrual
problems tr E
trouble TT medimtion TT military service tr tr (151) Are you pregnant?
tr T
1122\ Anaemia / Sickle cell traiu other
tr I
(1'l 1) Deafness, ear disorder (134) Award of pension or
T tr blood disorders compensation for injury or illness T T
(30) Remarks: lf previously repo(ed and no change since, so state.

(3 1) Oeclaration by applicant : I hereby declare that I have carefully considered the statements I have made above and that to the best of my belief they are complete and

may withdraw any Medical Assessment granted, without prejudice to any other legal action applicable pursuant.
Consent to release of medical information: I hereby give my consent that all relevant medical information may be released and submitted to the Medical Assessor of the
Licensing Authoritiy. Note: Medical Confidentiality will be respected all times.

Examineis Name and Address:

Date Signature of applicant Signature of Al\4E / mediBl assessor