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Pilot Intake Form

FAA MEDICAL CERTIFICATION

Follow these steps to ensure a smooth pre-examination processing of your FAA medical certification. Completing this digital intake allows our clinical team to review your history before you arrive.

[01]
[02]

Obtain your MedXPress confirmation number from the FAA portal.

[03]

Complete all required medical history fields in the online form below.

Submit and wait for your pre-flight clinical review confirmation email.

Flight Medical Details

PREFLIGHT EVALUATION INTAKE FORM

This form is for consultation purposes only and is NOT an FAA medical application. DO NOT SUBMIT MEDXPRESS UNTIL ADVISED

SECTION 1: THE PILOT

Birthday
Month
Day
Year
Pilot Certificate
Student
Private
Commercial
ATP
Other
Medical Certificate Applying For
Class 1
Class 2
Class 3
Basic Med
Is this your first FAA Medical?
Yes
No
Have you ever had an FAA medical:

SECTION 2: CURRENT MEDICATIONS


List all medications including over the counter and prescription

Check if taking any of the following:

SECTION 3: Mental Health History

SECTION 4: Cardiac History

SECTION 5: Neurologic History

SECTION 6: Sleep Apnea

Have you ever been diagnosed with Sleep apnea?
If you have/had Sleep Apnea how were you treated?

SECTION 7: Alcohol and Legal History

SECTION 8: Diabetes

SECTION 9: VISION

SECTION 10: Surgical History

SECTION 11: DOCUMENTATION

Do you have any of the following available

SECTION 12: Pilot Concerns

SECTION 12: MedXpress Status

Have you already submitted your application?
Yes
No

SECTION 13: Acknowledgement

I understand this consultation is not an FAA medical examination and no certification decision will be made during the PREFLIGHT EVALUATION
YES
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Information submitted is encrypted and sent directly to our clinical staff for your file.

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