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Initial Pilot Questionnaire
Pilot License Number:
PHN (Personal Health Care Number):
Date of Birth:
Next of Kin:
Ever had surgery? Please list dates and surgery performed:
Ever been in the hospital for anything other than surgery? Dates and details:
Ever been treated for medical condition? (E.g. High blood pressure, depression)
Are you taking, or recently stopped, any medications? List name and dose:
Do you have any allergies? List:
Do you smoke?
Did you ever smoke?
Do you drink alcohol?
Number and types of drinks/week
Do you use other recreational drugs (marijuana, cocaine etc)?
Have you used them in the past?
Any lifestyle concerns you wish Dr. Adams to be aware of? Details
REVIEW OF BODY SYSTEMS
Do you have any of the following conditions/concerns?
Age if alive
Age at Death
Cause of Death
How long Ill?
Type of Pilot license currently held:
Highest stage of education reached (eg. Grade 12, University etc.)
Country of Birth
Pilot Flight Time (solo plus dual) in: Last 90 days:
Have you ever been denied an aviation license for medical reasons?
Have you had an aircraft accident since your last medical?
What city was your last AVIATION medical performed in?
Date of your last AVIATION:
Are you receiving a pension for disability?
Primary type of flying intended: Recreational
Do you wear glasses?
Do you have colour vision difficulties?
If yes, have you passed the colour lantern test?
YBW Aeromedical Clinic is a registered trade name of Brendan D. Adams Professional Corporation.