# **TO: Flight Crew and Alternate Flight Crew Members (Students and Journalists)**

# **RE: Medical Examination Requirements for Flight Crew Members -- 2009 Flights**

NASA/JSC requires that all prospective flight crew / alternate flight
crew members / journalists participating in the NASA Reduced Gravity
Student Flight Opportunities Program complete a medical examination
performed by a

FAA Certified Aviation Medical Examiner (AME) or Designated Military
Flight Surgeon. The examination data is then reviewed by NASA's
Physiological Training Office to determine an individual's "fitness for
flight". Once they are physically qualified, individuals are eligible to
participate in a Physiological Training course at JSC (which they will
attend as part of their Houston experience).

**[A complete \"Medical Examination Packet\" is attached which
includes:]{.underline}**

-   Letter of explanation addressed to the FAA Certified AME

-   NASA/JSC Medical Examination Requirements

-   Height and Weight Table / Common Omissions

-   JSC Form 8500 - [Report of Medical Examination]{.underline} (Rev
    8/00) - two pages

```{=html}
<!-- -->
```
-   Page 1 - to be completed by applicant

-   Page 2 - to be completed by FAA Certified AME

**[Each flight team member is responsible for the
following:]{.underline}**

-   Locate a FAA Certified AME and make an appointment. Refer to dates
    and deadlines for the deadline for your flight week. The FAA website
    provides a Directory of AMEs at
    http://www.faa.gov/pilots/amelocator/.

```{=html}
<!-- -->
```
-   Read through this entire Medical Exam packet so you will be familiar
    with its contents and any additional medical exams (beyond the
    basic) that may apply to you.

-   Make sure to print the **[team\'s school]{.underline}** and **[your
    full legal name]{.underline}** in top right corner on each page of
    the medical forms.

-   Complete page one of the JSC 8500 (your medical history).

-   Report to AME for medical exam. Don\'t forget to bring the letter to
    the AME, Medical Exam Requirements, Height and Weight Table / Common
    Omissions and JSC Form 8500.

-   Pay all expenses associated with the medical exam.

-   Check with the AME\'s office after the exam is completed to make
    sure that the report has been signed and forwarded to JSC by the
    deadline date. The AME's staff should fax the forms directly to the
    NASA Physiological Training Office.

**[Additional Notes:]{.underline}**

-   Female flight crew members should notify the AME if there is reason
    to suspect pregnancy.

-   Flight crew members who have been previously certified as
    \"qualified\" to fly as part of this program MAY be exempt from the
    medical exam and / or physiological training requirement. Please
    provide the team member\'s full legal name and date of program
    participation to JSC's Program Coordinator for verification.

-   Flight crew members who hold a pilot\'s license MAY be exempt from
    the Medical Exam requirement. A complete copy of [the qualifying
    medical exam report]{.underline}, usually FAA Form 8500, MUST be
    provided to the JSC Physiological Training Officer for
    determination. A copy of the medical certificate or pilot\'s license
    is **NOT** required.

Direct questions concerning the NASA/JSC medical examination
requirements for program participants to:

> **Physiological Training Officer**
>
> **Phone: 281-792-5724**
>
> **email: jsc-htsgad@mail.nasa.gov**
>
> **Fax: 281-792-5731**

![](media/image1.wmf){width="1.2194444444444446in"
height="0.975in"}**[nasa reduced gravity Education Flight
program]{.smallcaps}**

**[Johnson Space Center]{.smallcaps}**

**[2009 Flight Campaign]{.smallcaps}**

May 12, 2008

Dear FAA Certified Aviation Medical Examiner / Designated Military
Flight Surgeon:

The person who has given you this letter is a member of a university
team that has been selected to fly a micro-gravity experiment aboard
NASA's C-9 reduced gravity aircraft. NASA / JSC specifies that all
prospective flyers must obtain a medical examination performed by a FAA
Certified AME or Designated Military Flight Surgeon. **The examination,
however, is not considered to be an official FAA exam; the results are
for NASA use only.**

Attached to this letter, you should find:

-   NASA/JSC Medical Examination Requirements

-   Height and Weight Table / Common Omissions

```{=html}
<!-- -->
```
-   JSC Form 8500 - [Report of Medical Examination]{.underline} (Rev
    8/00) - two pages

```{=html}
<!-- -->
```
-   Page 1 - to be completed by applicant

-   Page 2 - to be completed by AME

After the examination, please fax [ONLY the signed and completed JSC
Form 8500]{.underline} (two pages) to:

> **NASA Johnson Space Center**
>
> **Human Test Support Group - Mail Code SD-37**
>
> **Houston, Texas 77059**
>
> **Attn: Physiological Training Officer**
>
> **Fax: 281-792-5731**
>
> **Please *[do not send]{.underline}* EKGs, laboratory analyses, etc.**

[The NASA Physiological Training Office finds the following items
**frequently omitted** on the JSC Form 8500, Report of Medical
Examination. Before faxing the form, PLEASE ask your staff to ensure all
items are completed, including:]{.mark}

> **Applicant\'s Height and Weight Blocks 14 & 15**
>
> **Date of EKG (for applicants age 35 and older) Block 49**

###  Results of EKG (normal, WNL, etc) Block 50

> **AME\'s Comments on History and Findings from Item 12 Block 51**
>
> **AME's Name, Signature, Serial Number & Phone Number Block 54**

Questions concerning any of the medical requirements contained herein
should be directed to:

> **Physiological Training Officer**
>
> **Ph: 281-792-5724**
>
> **email: jsc-htsgad@mail.nasa.gov**

Thank you for helping NASA provide this outstanding educational
experience to teachers and students. If you have any further questions,
please don't hesitate to contact Ms. Sara Malloy, Program Coordinator at
281-483-7847.

> With best regards,
>
> Sara Malloy
>
> Reduced Gravity
>
> Program Coordinator

**MEDICAL EXAMINATION REQUIREMENTS**

![](media/image1.wmf){width="1.2194444444444446in"
height="0.975in"}**[nasa reduced gravity Education Flight
program]{.smallcaps}**

**2009 Flight Campaign**

**[EXAMINING PHYSICIAN]{.underline}:** MUST be FAA Certified Aviation
Medical Examiner (AME).

**[EXAM REQUIREMENTS:]{.underline}** [Applicant\'s Medical History and
Physical Examination]{.underline} is reported on JSC Form 8500
(attached). This examination is NOT considered to be an official FAA
exam. Medical results / opinions reported are for NASA use only. The
Chief of the Medical Sciences Division at the Johnson Space Center
serves as the final authority on the examinee\'s qualification for
flight aboard the C-9 microgravity aircraft.

+---------+-------------+------+------+-------+-----------------------+
| **FAA   |             |      |      |       |                       |
| GUIDE   |             |      |      |       |                       |
| FOR     |             |      |      |       |                       |
| A       |             |      |      |       |                       |
| VIATION |             |      |      |       |                       |
| MEDICAL |             |      |      |       |                       |
| EXAM    |             |      |      |       |                       |
| INERS** |             |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **      |             |      |      |       |                       |
| Medical |             |      |      |       |                       |
| St      |             |      |      |       |                       |
| andards |             |      |      |       |                       |
| --      |             |      |      |       |                       |
| Ef      |             |      |      |       |                       |
| fective |             |      |      |       |                       |
| Se      |             |      |      |       |                       |
| ptember |             |      |      |       |                       |
| 16,     |             |      |      |       |                       |
| 1996 -  |             |      |      |       |                       |
| Third   |             |      |      |       |                       |
| Class   |             |      |      |       |                       |
| Medical |             |      |      |       |                       |
| Certif  |             |      |      |       |                       |
| icate** |             |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
|         |             |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **      | 20/40 or    |      |      |       |                       |
| DISTANT | better in   |      |      |       |                       |
| V       | each eye    |      |      |       |                       |
| ISION** | separately, |      |      |       |                       |
|         | with or     |      |      |       |                       |
|         | without     |      |      |       |                       |
|         | correction. |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **NEAR  | 20/40 or    |      |      |       |                       |
| V       | better in   |      |      |       |                       |
| ISION** | each eye    |      |      |       |                       |
|         | separately  |      |      |       |                       |
|         | (Snellen    |      |      |       |                       |
|         | e           |      |      |       |                       |
|         | quivalent), |      |      |       |                       |
|         | with or     |      |      |       |                       |
|         | without     |      |      |       |                       |
|         | correction, |      |      |       |                       |
|         | as measured |      |      |       |                       |
|         | at          |      |      |       |                       |
|         | 16 inches.  |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **INTER | No          |      |      |       |                       |
| MEDIATE | r           |      |      |       |                       |
| V       | equirement. |      |      |       |                       |
| ISION** |             |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **COLOR | Ability to  |      |      |       |                       |
| V       | perceive    |      |      |       |                       |
| ISION** | those       |      |      |       |                       |
|         | colors      |      |      |       |                       |
|         | necessary   |      |      |       |                       |
|         | for safe    |      |      |       |                       |
|         | performance |      |      |       |                       |
|         | of airman   |      |      |       |                       |
|         | duties.     |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **HE    | Demonstrate |      |      |       |                       |
| ARING** | hearing of  |      |      |       |                       |
|         | an average  |      |      |       |                       |
|         | con         |      |      |       |                       |
|         | versational |      |      |       |                       |
|         | voice in a  |      |      |       |                       |
|         | quiet room, |      |      |       |                       |
|         | using both  |      |      |       |                       |
|         | ears at 6   |      |      |       |                       |
|         | feet, with  |      |      |       |                       |
|         | the back    |      |      |       |                       |
|         | turned to   |      |      |       |                       |
|         | the         |      |      |       |                       |
|         | examiner    |      |      |       |                       |
|         | [or]{       |      |      |       |                       |
|         | .underline} |      |      |       |                       |
|         | pass one of |      |      |       |                       |
|         | the         |      |      |       |                       |
|         | audiometric |      |      |       |                       |
|         | tests below |      |      |       |                       |
|         | (Speech     |      |      |       |                       |
|         | Di          |      |      |       |                       |
|         | scrimiation |      |      |       |                       |
|         | or Pure     |      |      |       |                       |
|         | Tone)       |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **AUDI  | Audiometric |      |      |       |                       |
| OLOGY** | Speech      |      |      |       |                       |
|         | Dis         |      |      |       |                       |
|         | crimination |      |      |       |                       |
|         | Test        |      |      |       |                       |
|         | (Whisper    |      |      |       |                       |
|         | Test):      |      |      |       |                       |
|         | Score at    |      |      |       |                       |
|         | least 70%   |      |      |       |                       |
|         | dis         |      |      |       |                       |
|         | crimination |      |      |       |                       |
|         | in one ear. |      |      |       |                       |
|         |             |      |      |       |                       |
|         | Pure tone   |      |      |       |                       |
|         | Audiometric |      |      |       |                       |
|         | Test:       |      |      |       |                       |
|         | Unaided,    |      |      |       |                       |
|         | with        |      |      |       |                       |
|         | thresholds  |      |      |       |                       |
|         | no worse    |      |      |       |                       |
|         | than:       |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
|         |             |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
|         |             | [500 | [1   | [     | [3,000                |
|         |             | Hz]  | ,000 | 2,000 | Hz]{.underline}       |
|         |             | {.un | Hz]  | Hz]{. |                       |
|         |             | derl | {.un | under |                       |
|         |             | ine} | derl | line} |                       |
|         |             |      | ine} |       |                       |
+---------+-------------+------+------+-------+-----------------------+
|         | Better Ear  | 35   | 30Db | 30 Db | 40 Db                 |
|         |             | Db   |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
|         | Worst Ear   | 35   | 50   | 50 Db | 60 Db                 |
|         |             | Db   | Db   |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **ENT** | No ear      |      |      |       |                       |
|         | disease or  |      |      |       |                       |
|         | condition   |      |      |       |                       |
|         | manifested  |      |      |       |                       |
|         | by, or that |      |      |       |                       |
|         | may         |      |      |       |                       |
|         | reasonably  |      |      |       |                       |
|         | be expected |      |      |       |                       |
|         | to be       |      |      |       |                       |
|         | manifested  |      |      |       |                       |
|         | by, vertigo |      |      |       |                       |
|         | or a        |      |      |       |                       |
|         | disturbance |      |      |       |                       |
|         | of speech   |      |      |       |                       |
|         | or          |      |      |       |                       |
|         | e           |      |      |       |                       |
|         | quilibrium. |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **      | No          |      |      |       |                       |
| PULSE** | di          |      |      |       |                       |
|         | squalifying |      |      |       |                       |
|         | per se.     |      |      |       |                       |
|         | Used to     |      |      |       |                       |
|         | determine   |      |      |       |                       |
|         | cardiac     |      |      |       |                       |
|         | system      |      |      |       |                       |
|         | status and  |      |      |       |                       |
|         | resp        |      |      |       |                       |
|         | onsiveness. |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **BLOOD | No          |      |      |       |                       |
| PRE     | specified   |      |      |       |                       |
| SSURE** | values      |      |      |       |                       |
|         | stated in   |      |      |       |                       |
|         | the         |      |      |       |                       |
|         | standards.  |      |      |       |                       |
|         | H           |      |      |       |                       |
|         | ypertension |      |      |       |                       |
|         | covered     |      |      |       |                       |
|         | under       |      |      |       |                       |
|         | general     |      |      |       |                       |
|         | medical     |      |      |       |                       |
|         | standard    |      |      |       |                       |
|         | and in the  |      |      |       |                       |
|         | *Guide for  |      |      |       |                       |
|         | Aviation    |      |      |       |                       |
|         | Medical     |      |      |       |                       |
|         | Examiners.* |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **EKG** | Not         |      |      |       |                       |
|         | routinely   |      |      |       |                       |
|         | required    |      |      |       |                       |
|         | for persons |      |      |       |                       |
|         | under the   |      |      |       |                       |
|         | age of 35.  |      |      |       |                       |
|         | Required at |      |      |       |                       |
|         | age 35 and  |      |      |       |                       |
|         | within the  |      |      |       |                       |
|         | past year   |      |      |       |                       |
|         | for persons |      |      |       |                       |
|         | age 40 and  |      |      |       |                       |
|         | over.       |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+
| **M     | No          |      |      |       |                       |
| ENTAL** | diagnosis   |      |      |       |                       |
|         | of          |      |      |       |                       |
|         | psychosis,  |      |      |       |                       |
|         | or bipolar  |      |      |       |                       |
|         | disorder,   |      |      |       |                       |
|         | or severe   |      |      |       |                       |
|         | personality |      |      |       |                       |
|         | disorders.  |      |      |       |                       |
+---------+-------------+------+------+-------+-----------------------+

**MEDICAL EXAMINATION REQUIREMENTS**

**HEIGHT / WEIGHT / COMMON OMISSIONS**

**NASA [reduced gravity Education Flight program]{.smallcaps}**

**2008 Flight Campaign**

**Body Mass Index (BMI) Table**

***Height (inches) Weight (pounds) C-9 Aircraft (under BMI 35)***

  --------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- --------
  **BMI**   **19**   **20**   **21**   **22**   **23**   **24**   **25**   **26**   **27**   **28**   **29**   **30**   **31**   **32**   **33**   **34**   **35**

  **58**    91       96       100      105      110      115      119      124      129      134      138      143      148      153      158      162      167

  **59**    94       99       104      109      114      119      124      128      133      138      143      148      153      158      163      168      173

  **60**    97       102      107      112      118      123      128      133      138      143      148      153      158      163      168      174      179

  **61**    100      106      111      116      122      127      132      137      143      148      153      158      164      169      174      180      185

  **62**    104      109      115      120      126      131      136      142      147      153      158      164      169      175      180      186      191

  **63**    107      113      118      124      130      135      141      146      152      158      163      169      175      180      186      191      197

  **64**    110      116      122      128      134      140      145      151      157      163      169      174      180      186      192      197      204

  **65**    114      120      126      132      138      144      150      156      162      168      174      180      186      192      198      204      210

  **66**    118      124      130      136      142      148      155      161      167      173      179      186      192      198      204      210      216

  **67**    121      127      134      140      146      153      159      166      172      178      185      191      198      204      211      217      223

  **68**    125      131      138      144      151      158      164      171      177      184      190      197      203      210      216      223      230

  **69**    128      135      142      149      155      162      169      176      182      189      196      203      209      216      223      230      236

  **70**    132      139      146      153      160      167      174      181      188      195      202      209      216      222      229      236      243

  **71**    136      143      150      157      165      172      179      186      193      200      208      215      222      229      236      243      250

  **72**    140      147      154      162      169      177      184      191      199      206      213      221      228      235      242      250      258

  **73**    144      151      159      166      174      182      189      197      204      212      219      227      235      242      250      257      265

  **74**    148      155      163      171      179      186      194      202      210      218      225      233      241      249      256      264      272

  **75**    152      160      168      176      184      192      200      208      216      224      232      240      248      256      264      272      279
  --------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- -------- --------

**COMMON OMISSIONS**

The NASA Physiological Training Office frequently finds the following
items commonly omitted on the JSC Form 8500, Report of Medical
Examination. Before faxing the forms, please check to make sure all
items are completed, including:

> **Applicant\'s Height and Weight Blocks 14 & 15**
>
> **Date of EKG (for applicants age 35 or older) Block 49**

###  Results of EKG (normal, WNL, etc) Block 50

> **AME\'s Comments on History and Findings from Item 12 Block 51**
>
> **AME's Name, Signature, Serial Number & Phone Number Block 54**

JSC FORM 8500 - REPORT OF MEDICAL EXAMINATION - PAGE 1 of 2

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 12%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 18%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 22%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="20"><p><strong><span class="smallcaps">applicant must
complete this medical history</span></strong></p>
<p><strong><span class="smallcaps">please type or print clearly in dark
ink</span></strong></p></td>
</tr>
<tr class="even">
<td colspan="5"><p><strong><span class="smallcaps">1. application
for</span></strong></p>
<p><span class="smallcaps">RGSFOP</span></p></td>
<td colspan="15"><p><span class="smallcaps"><strong>2. last
name</strong> <strong>first name middle name</strong></span></p>
<p><span class="smallcaps">                 </span></p></td>
</tr>
<tr class="odd">
<td colspan="5"><p><strong><span class="smallcaps">3.
ssn</span></strong></p>
<p><strong><span class="smallcaps">     </span></strong></p></td>
<td colspan="5"><p><strong><span class="smallcaps">4. street
address</span></strong></p>
<p><span class="smallcaps">     </span></p></td>
<td colspan="3"><p><strong><span
class="smallcaps">city</span></strong></p>
<p><strong><span class="smallcaps">     </span></strong></p></td>
<td colspan="3"><p><strong><span
class="smallcaps">state</span></strong></p>
<p><strong><span class="smallcaps">     </span></strong></p></td>
<td colspan="3"><p><strong><span
class="smallcaps">zip</span></strong></p>
<p><strong><span class="smallcaps">     </span></strong></p></td>
<td><p><strong><span class="smallcaps">phone #</span></strong></p>
<p><span class="smallcaps">(      )      </span></p></td>
</tr>
<tr class="even">
<td colspan="3"><p><strong><span class="smallcaps">5. dob
(m/d/y)</span></strong></p>
<p><strong><span class="smallcaps">     </span></strong></p></td>
<td colspan="2"><p><strong><span class="smallcaps">6.
sex</span></strong></p>
<p><strong><span class="smallcaps">     </span></strong></p></td>
<td><p><strong><span class="smallcaps">7. hair color</span></strong></p>
<p><strong><span class="smallcaps">     </span></strong></p></td>
<td colspan="4"><p><strong><span class="smallcaps">8. eye
color</span></strong></p>
<p><strong><span class="smallcaps">     </span></strong></p></td>
<td colspan="6"><p><span class="smallcaps"><strong>9.</strong></span>
<strong><span class="smallcaps">student</span></strong> <strong><span
class="smallcaps">faculty</span></strong></p>
<p> <strong><span class="smallcaps">journalist</span></strong></p></td>
<td colspan="4"><strong><span class="smallcaps">10. school or
employer</span></strong></td>
</tr>
<tr class="odd">
<td colspan="20"><span class="smallcaps">11. <strong>do you currently
use any medication</strong> (</span>prescription or
non-prescription<span class="smallcaps">)?</span> <span
class="smallcaps">yes</span> <span class="smallcaps">no</span> If yes,
list name, purpose dosage &amp; frequency of use below. Attach
additional sheet if needed.</td>
</tr>
<tr class="even">
<td colspan="20"><p><strong><span class="smallcaps">12. medical
history</span></strong> Have you EVER HAD, or do you NOW HAVE, any of
the following conditions? Answer “YES" for every condition you have ever
had in your life.</p>
<p>Describe the condition and the approximate date of occurrence in the
explanation box provided below.</p></td>
</tr>
<tr class="odd">
<td></td>
<td><span class="smallcaps">yes</span></td>
<td colspan="2"><span class="smallcaps">no</span></td>
<td colspan="3"><span class="smallcaps">condition</span></td>
<td></td>
<td><span class="smallcaps">yes</span></td>
<td colspan="2"><span class="smallcaps">no</span></td>
<td colspan="3"><span class="smallcaps">condition</span></td>
<td></td>
<td colspan="3"><span class="smallcaps">yes</span></td>
<td><span class="smallcaps">no</span></td>
<td><span class="smallcaps">condition</span></td>
</tr>
<tr class="even">
<td><span class="smallcaps">a</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">frequent or severe
headaches</span></td>
<td><span class="smallcaps">i</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">stomach, liver or intestinal
trouble</span></td>
<td><span class="smallcaps">q</span></td>
<td colspan="3"></td>
<td></td>
<td><span class="smallcaps">motion sicknesss requiring
medication</span></td>
</tr>
<tr class="odd">
<td><span class="smallcaps">b</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">dizziness or fainting
spells</span></td>
<td><span class="smallcaps">j</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">kidney stone or blood in
urine</span></td>
<td><span class="smallcaps">r</span></td>
<td colspan="3"></td>
<td></td>
<td><span class="smallcaps">military medical discharge</span></td>
</tr>
<tr class="even">
<td><span class="smallcaps">c</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">unconsciousness for any
reason</span></td>
<td><span class="smallcaps">k</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">diabetes</span></td>
<td><span class="smallcaps">s</span></td>
<td colspan="3"></td>
<td></td>
<td><span class="smallcaps">medical rejection by military
service</span></td>
</tr>
<tr class="odd">
<td><span class="smallcaps">d</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">eye or vision trouble (except
glasses)</span></td>
<td><span class="smallcaps">l</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">neurological disorders:
epilepsy, seizures, stroke, paralysis, etc.</span></td>
<td><span class="smallcaps">t</span></td>
<td colspan="3"></td>
<td></td>
<td><span class="smallcaps">rejection for life or health
insurance</span></td>
</tr>
<tr class="even">
<td><span class="smallcaps">e</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">hay fever or allergy</span></td>
<td><span class="smallcaps">m</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">mental discorders of any sort:
depression, anxiety, etc.</span></td>
<td><span class="smallcaps">u</span></td>
<td colspan="3"></td>
<td></td>
<td><span class="smallcaps">admission to hospital</span></td>
</tr>
<tr class="odd">
<td><span class="smallcaps">f</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">asthma or lung
disease</span></td>
<td><span class="smallcaps">n</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">substance dependence or failed
drug test (ever), or substance abuse or use of illegal substance in the
last five years.</span></td>
<td><span class="smallcaps">v</span></td>
<td colspan="3"></td>
<td></td>
<td><span class="smallcaps">other illness, disability or
surgery.</span></td>
</tr>
<tr class="even">
<td><span class="smallcaps">g</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">heart or vascular
trouble</span></td>
<td><span class="smallcaps">o</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">alcohol dependence or
abuse</span></td>
<td colspan="6" rowspan="2"></td>
</tr>
<tr class="odd">
<td><span class="smallcaps">h</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">high or low blood
pressure</span></td>
<td><span class="smallcaps">p</span></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"><span class="smallcaps">suicide attempt</span></td>
</tr>
<tr class="even">
<td colspan="20"><strong><span
class="smallcaps">explanations:</span></strong> If you answered "yes" to
any of the above items, describe the condition and the approximate date
of occurrence. Use additional page if necessary.</td>
</tr>
<tr class="odd">
<td colspan="20"><strong><span class="smallcaps">13. have you visited a
health professional within the last 3 years?</span></strong> <span
class="smallcaps">yes (list below)</span> <span
class="smallcaps">no</span></td>
</tr>
<tr class="even">
<td colspan="2"><span class="smallcaps">date</span></td>
<td colspan="10"><span class="smallcaps">name, address &amp; type of
health professional</span></td>
<td colspan="8"><span class="smallcaps">reason for visit</span></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="10"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="10"></td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="20"><span class="smallcaps"><strong>note.</strong></span>
Whoever, in any manner, within the jurisdiction of any department or
agency of the United States, knowingly and willfully falsifies, conceals
or covers up, by any trick, scheme or device, a material fact; or who
makes any false, fictitious or fraudulent statements, representations or
entry, may be fined up to $250,000 or imprisoned for not more than 3
years, or both (18 U.S. Code Sections 1001; 3571).</td>
</tr>
<tr class="even">
<td colspan="17"><strong><span class="smallcaps">signature of
applicant</span></strong></td>
<td colspan="3"><strong><span
class="smallcaps">date</span></strong></td>
</tr>
</tbody>
</table>

[jsc form 8500 / student campaigns / rev 12/01]{.smallcaps}

JSC FORM 8500 - REPORT OF MEDICAL EXAMINATION - PAGE 2 of 2

<table style="width:100%;">
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="29"><p><strong><span class="smallcaps">faa certified ame
must complete this physical examination</span></strong></p>
<p><strong><span class="smallcaps">please type or print clearly in dark
ink</span></strong></p></td>
<td colspan="7"><strong><span class="smallcaps">14. height
(inches)</span></strong></td>
<td colspan="6"><strong><span class="smallcaps">15. weight
(lbs)</span></strong></td>
</tr>
<tr class="even">
<td colspan="42"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong><span class="smallcaps">check column for each
item</span></strong></td>
<td colspan="2"><strong><span
class="smallcaps">normal</span></strong></td>
<td colspan="4"><strong><span
class="smallcaps">abnormal</span></strong></td>
<td colspan="18"><strong><span class="smallcaps">check column for each
item</span></strong></td>
<td colspan="4"><strong><span
class="smallcaps">normal</span></strong></td>
<td colspan="3"><strong><span
class="smallcaps">abnormal</span></strong></td>
</tr>
<tr class="even">
<td colspan="11"><span class="smallcaps">16. head, face, neck,
scalp</span></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">28. vascular system</span>
(pulse, amplitude, character, arms, legs, etc)</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="11"><span class="smallcaps">17. nose</span></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">29. abdomen &amp;
viscera</span> (including hernia)</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="11"><span class="smallcaps">18. sinuses</span></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">30. anus</span> (not including
digital exam)</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="11"><span class="smallcaps">19. mouth and
throat</span></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">31. skin</span></td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="11"><span class="smallcaps">20. ears, general</span>
(internal &amp; external canals; hearing under item #40)</td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">32. G-U system</span> (not
including pelvic exam)</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="11"><span class="smallcaps">21. ear drums</span>
(perforation)</td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">33. upper and lower
extremeties</span> (strength/range of motion)</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="11"><span class="smallcaps">22. eyes, general</span>
(vision under items #41-45)</td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">34. spine, other
musculoskeletal</span></td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="11"><span class="smallcaps">23. ophthalmosopic</span></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">35. identifying body
marks</span> (Scars, Tattoos<span class="smallcaps">)</span> (size &amp;
location)</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="11"><span class="smallcaps">24. pupils</span> (equality
&amp; reaction)</td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">36. lymphatics</span></td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="11"><span class="smallcaps">25. ocular motility</span>
(assoc parallel movement, nystagmus)</td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">37. neurologic</span> (tendon
reflexes, equilibrium, senses, cranial, nerves, coordination, etc)</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="11"><span class="smallcaps">26. lungs &amp; chest</span>
(excluding breasts)</td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">38. psychiatric</span>
(appearance, behavior, mood, communication, memory)</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="11"><span class="smallcaps">27. heart</span> (precardial
activity, rhythm, sounds, murmurs)</td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="18"><span class="smallcaps">39. general
systemic</span></td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="42"><span class="smallcaps"><strong>notes:</strong></span>
Describe any above items checked "abnormal" in detail. Enter item number
before each comment. Use additional sheet if necessary.</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="4"><strong><span class="smallcaps">40.
hearing</span></strong></td>
<td colspan="12"><span class="smallcaps">voice test</span></td>
<td colspan="26"><strong><span class="smallcaps">audiometer threshold
in</span></strong></td>
</tr>
<tr class="even">
<td colspan="6"><span class="smallcaps">right ear</span></td>
<td colspan="6"><span class="smallcaps">left ear</span></td>
<td colspan="12"><span class="smallcaps">right ear</span></td>
<td colspan="14"><span class="smallcaps">left ear</span></td>
</tr>
<tr class="odd">
<td colspan="6" rowspan="2"></td>
<td colspan="6" rowspan="2"></td>
<td colspan="3"><span class="smallcaps">500</span></td>
<td colspan="2"><span class="smallcaps">1000</span></td>
<td colspan="2"><span class="smallcaps">2000</span></td>
<td colspan="4"><span class="smallcaps">3000</span></td>
<td><span class="smallcaps">4000</span></td>
<td colspan="2"><span class="smallcaps">500</span></td>
<td colspan="3"><span class="smallcaps">1000</span></td>
<td colspan="4"><span class="smallcaps">2000</span></td>
<td colspan="4"><span class="smallcaps">3000</span></td>
<td><span class="smallcaps">4000</span></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><strong><span class="smallcaps">41. distant
vision</span></strong></td>
<td colspan="18"><strong><span class="smallcaps">42. near
vision</span></strong></td>
<td colspan="9"><strong><span class="smallcaps">43. color
vision</span></strong></td>
</tr>
<tr class="even">
<td colspan="2"><span class="smallcaps">right</span></td>
<td colspan="6"><span class="smallcaps">20 /</span></td>
<td colspan="7"><span class="smallcaps">corrected to</span></td>
<td colspan="5"><span class="smallcaps">right</span></td>
<td colspan="4"><span class="smallcaps">20 /</span></td>
<td colspan="9"><span class="smallcaps">corrected to</span></td>
<td colspan="9" rowspan="3"><p><span class="smallcaps">normal</span></p>
<p><span class="smallcaps">abnormal</span></p></td>
</tr>
<tr class="odd">
<td colspan="2"><span class="smallcaps">left</span></td>
<td colspan="6"><span class="smallcaps">20 /</span></td>
<td colspan="7"><span class="smallcaps">corrected to</span></td>
<td colspan="5"><span class="smallcaps">left</span></td>
<td colspan="4"><span class="smallcaps">20 /</span></td>
<td colspan="9"><span class="smallcaps">corrected to</span></td>
</tr>
<tr class="even">
<td colspan="2"><span class="smallcaps">both</span></td>
<td colspan="6"><span class="smallcaps">20 /</span></td>
<td colspan="7"><span class="smallcaps">corrected to</span></td>
<td colspan="5"><span class="smallcaps">both</span></td>
<td colspan="4"><span class="smallcaps">20 /</span></td>
<td colspan="9"><span class="smallcaps">corrected to</span></td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="3"><p><strong><span class="smallcaps">44. field
of vision</span></strong></p>
<p><span class="smallcaps">normal</span></p>
<p><span class="smallcaps">abnormal</span></p></td>
<td colspan="35"><strong><span class="smallcaps">45. heterophoria
20'</span></strong> (in prism diopters<span
class="smallcaps">)</span></td>
</tr>
<tr class="even">
<td colspan="5"><span class="smallcaps">esophoria</span></td>
<td colspan="10"><span class="smallcaps">exophoria</span></td>
<td colspan="9"><span class="smallcaps">right hyperphoria</span></td>
<td colspan="11"><span class="smallcaps">left hyperphoria</span></td>
</tr>
<tr class="odd">
<td colspan="5"></td>
<td colspan="10"></td>
<td colspan="9"></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="9"><span class="smallcaps"><strong>46. blood
pressure</strong></span> (sitting mm of mercury)</td>
<td colspan="5"><strong><span class="smallcaps">47.
pulse</span></strong> (resting)</td>
<td colspan="20"><strong><span class="smallcaps">48.
urinalysis</span></strong> <span class="smallcaps">normal</span> <span
class="smallcaps">abnormal</span> (give results)</td>
<td colspan="8"><strong><span class="smallcaps">49. EKG
(date)</span></strong></td>
</tr>
<tr class="odd">
<td colspan="6"><span class="smallcaps">systolic</span></td>
<td colspan="3"><span class="smallcaps">diastolic</span></td>
<td colspan="5"></td>
<td colspan="11"><span class="smallcaps">albumin</span></td>
<td colspan="9"><span class="smallcaps">sugar</span></td>
<td colspan="4"><span class="smallcaps">MM</span></td>
<td colspan="2"><span class="smallcaps">dd</span></td>
<td colspan="2"><span class="smallcaps">yy</span></td>
</tr>
<tr class="even">
<td colspan="42"><strong><span class="smallcaps">50. other tests
given</span></strong></td>
</tr>
<tr class="odd">
<td colspan="42"><p><span class="smallcaps"><strong>51. significant
medical history</strong></span> <span class="smallcaps">yes</span> <span
class="smallcaps">no <strong>abnormal physical finding</strong></span>
<span class="smallcaps">yes</span> <span class="smallcaps">no</span></p>
<p>AME shall elaborate on all pertinent data; comment on all "YES"
answers in the Medical History (pg 1, #12) and any abnormal findings of
the exam. AME may develop, by interview, any additional medical history
deemed important, and record any significant findings here.
<strong>ATTACH ADDITIONAL COMMENTS ON HISTORY &amp;
FINDINGS.</strong></p></td>
</tr>
<tr class="even">
<td colspan="18"><strong><span class="smallcaps">52. applicant's
name</span></strong></td>
<td colspan="24"><strong><span class="smallcaps">53. disqualifying
defects (list by item number)</span></strong></td>
</tr>
<tr class="odd">
<td colspan="42"><span class="smallcaps"><strong>54. AME's
declaration.</strong></span> <em>I hereby certify that I have personally
reviewed the medical history and personally examined the applicant named
on this medical examination report. This report, with any attachment,
embodies my findings completely and correctly.</em></td>
</tr>
<tr class="even">
<td colspan="5"><span class="smallcaps">exam date</span></td>
<td colspan="37" rowspan="2"><strong><span class="smallcaps">ame's name
/ address / city / state / zip</span></strong></td>
</tr>
<tr class="odd">
<td><span class="smallcaps">mm</span></td>
<td colspan="2"><span class="smallcaps">dd</span></td>
<td colspan="2"><span class="smallcaps">yy</span></td>
</tr>
<tr class="even">
<td colspan="26"><strong><span
class="smallcaps">signature:</span></strong></td>
<td colspan="6"><strong><span class="smallcaps">AME's serial
number</span></strong></td>
<td colspan="10"><strong><span class="smallcaps">AME's phone
number</span></strong></td>
</tr>
</tbody>
</table>

[jsc form 8500 / student campaigns / rev 12/01]{.smallcaps}