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Initial Pilot Questionnaire

Today's Date:   Pilot License Number:
Given Names:
Mailing Address:   Postal Code:
Phone Numbers:       
PHN (Personal Health Care Number):   Province:
Date of Birth:
Family Doctor:   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?    Year quit:
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?    When?
Any lifestyle concerns you wish Dr. Adams to be aware of? Details

Do you have any of the following conditions/concerns?
Asthma Diabetes Appetite Bronchitis Thyroid Digestion Anxiety
Cough Nerves Stomach Allergy Skin Headaches Gallbladder
Arthritis Pneumonia Blackouts Liver Swelling Vision Hearing
Sleeping Jaundice Kidney Heart Depression Constipation Bladder
Chest Pain Cancer Bleeding Bruising Color Vision Epilepsy Seizures
Sexual Concerns Alcohol Problems Drug Problems Blood Pressure      

Relative Age if alive Health Details* Age at Death Cause of Death How long Ill?

Occupation:   Employer:
Type of Pilot license currently held:   Type desired:
Highest stage of education reached (eg. Grade 12, University etc.)
Country of Birth   Current Citizenship
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 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  Business  Career
Do you wear glasses?          Reading glasses?
Contacts?          Eye surgery?
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.