**NOAA Health Services Aviation Questionnaire**

**Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Your E-Mail:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Last First Your Phone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**SSN:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Birth Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Sex: \_\_\_\_\_
\_\_\_\_\_ NOAA Program:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**(mm/dd/yr) M F NOAA Supervisor:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**NOAA Supervisor E-Mail: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Your Phone Numbers: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (W)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (H)**

**Emergency Contact:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Name Phone Relationship**

**GENERAL MEDICAL SCREENING**

**YES NO Do you have, or have you ever had: (explain any positive
responses on Continuation Page)**

1.  **Disease of the eyes, ears, sinuses, seasonal allergies, hayfever,
    difficulty with clearing your ears, severe hearing loss, or pain in
    your ears or sinuses from diving or flying?**

2.  **Chest pain, angina, heart attack, heart disease, heart murmur,
    palpitations, cardiac catheterizations, or pacemaker?**

3.  **Hypertension, stroke, blood clots in legs, swelling in feet, or
    excessive fatigue with mild exertion?**

4.  **Asthma, wheezing, emphysema, chronic cough, tuberculosis,
    collapsed lung, or shortness of breath with mild exertion?**

5.  **Diseases of the bowel, ulcers, rectal bleeding, chronic abdominal
    pain, hernia, kidney stone, or painful or frequent urination?**

6.  **Arthritis, joint deformity, chronic back pain, or limitation of
    use of your back or extremities?**

7.  **Paralysis, weakness of muscles, seizures, epilepsy, migraine or
    other severe headaches, loss of consciousness, fainting spells,
    dizziness, or amnesia?**

8.  **Mania, depression, schizophrenia, suicide attempt, alcoholism,
    illegal drug use, panic attacks, fear of flying, fear of heights, or
    fear of enclosed spaces?**

9.  **Anemia, diabetes, cancer(s), arterial gas embolism, decompression
    sickness, severe motion sickness, surgery, hospitalization, or other
    chronic medical conditions not listed?**

10. **Are you currently pregnant?**

11. **Are you currently taking any medications?**

**List Current Medications: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\*\*\*If you have been scuba diving within 24 hours of flying, have
had any dental procedures within 48 hours of flying, or are currently
pregnant -- YOU MUST CONSULT WITH A FLIGHT SURGEON.**

**Are you aware of any other medical condition(s) that may affect your
suitability for aviation duty? No Yes**

If yes, please explain on the continuation page

If you have any questions, please contact the appropriate Health
Services Office:

**Aircraft Operations Center: 813-828-3310 x-3102 (Office) /
813-294-6703 (Cellular)**

**Marine Operations Atlantic: 757-441-6320 (Office) / 757-615-6619
(Cellular)**

**Marine Operations Pacific: 206-553-8704 (Office) / 206-409-8725
(Cellular)**

**Director, NMAO Health Services: 301-523-7792 x-186 (Office) /
301-523-7792 (Cellular)**

I certify that I have reviewed the foregoing information supplied by me
and that it is true and complete to the best of my knowledge. I
understand that falsification of information on Government forms is
punishable by fine and/or imprisonment. **[ANY CHANGES IN YOUR MEDICAL
CONDITION SINCE YOU LAST COMPLETED THIS MEDICAL HISTORY FORM, MUST BE
REPORTED TO THE NOAA FLIGHT SURGEON IMMEDIATELY]{.underline}.**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee Signature Date (mm/dd/yy)

**\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--\[Below
section to be completed by NOAA Medical
Officer\]\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--**

**MEDICALLY CLEARED FOR AVIATION DUTY BY HISTORY: YES NO NEED MORE
INFO**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AOC / MOA / MOP Regional Director of Health Services Date (mm/dd/yy)

**Page \_\_\_ of \_\_\_** Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**NOAA Health Services Aviation Questionnaire Continuation Page**