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Update Questionnaire

Pilot License Number:   Type Held:   Type Desired:
Welcome back to our Aviation Medical Office. We take pride in servicing the medical needs of some of the best pilots in the world! To expedite your medical, please answer the following questions (which are the same as appear on the Transport Canada Medical Form). Basically, we need to know what has changed since we last saw you – so if none of the questions quite cover your situation, just say so!
Name as it appears on your license:
Former Last Name if applicable:    Captain?    First Officer?
Has your Address Changed from your last medical?  
If YES, New Address:   New Postal Code:
Phone Numbers:     
Email Address   Citizenship
Occupation:   Employer:
Pilot Flight Time (solo plus dual) in: Last 90 days:   12 months:   Overall total:
Have you ever been denied an aviation license for medical reasons?
Have you had an aircraft accident since your last medical?
What City did your last medical take place in?
Name of your Family Doctor:    None   (hint: Dr. Adams is NOT your family doctor)
Are you receiving pension or disability?
Date of your last AVIATION:     
Primary type of flying intended:  Recreational   Business   Career
Do you wear glasses?     Reading glasses?  
Contacts?          Eye surgery?
Do you take, or have you recently stopped any medications? Please list:
Do you now have any medical problems of note that may be relevant to holding a flight license?
Since your last medical, has anyone is your family developed any new medical problems? (We are particularly interested in diabetes, cardiovascular and mental health issues in people genetically related to you)
Since your last medical have you developed any medical problems? Seen a doctor?  
If YES, please give details:
Have you had any surgery since your last medical?  
If YES, please give details:
Do you smoke?     Cigarettes per day:    Alcoholic drinks per week: (hint - number please, "social" is NOT a number)
Have you developed any new medical concerns
We evaluate you, now please evaluate us! How are we doing? Is there anything we can do to improve our office/services?
Thank you for your kind cooperation in filling out all these questions. It will make your medical go more smoothly (Honest)

YBW Aeromedical Clinic is a registered trade name of Brendan D. Adams Professional Corporation.