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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 a substitute for the offical FAA MedXpress Application. No minimize potential issues we recommend waiting to submit the MedXpress application until the day of your appointment or once Dr. Arslanian gives you the OK. Once the application is submitted the exam process begins. Dr. Arslanian will typically reach out to you with questions after reviewing the intake form.

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 FORM is not the official FAA MedXpress application and is being used for consultation and preflight purposes only. Final determination will be made during your actual examination.
YES
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Information submitted is encrypted and sent directly to our clinical staff for your file.

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