APPLICATION FOR DRIVER'S MEDICAL CERTIFICATE
THIS CERTIFIES THAT (Full Name and Address)
Date of Birth Height Weight Hair Eyes Sex
Limitations:
Corrective lenses required while driving?
No Yes
Date of Examination:
Examiners Signature
Examiner's typed Name:
Driver's Signature:
FAA TYPE CLASS III
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION INSTRUCTIONS
1. This medical certificate may be completed by your personal physician.
2. This examination is for a driver's Race Boat competition license.
3. Have the physician complete medical history information.
4. Record your medical findings.
5. Reverse side of this form to be completed in full. If unable to complete or obtain any findings refer the patient to a second physician and attach any suppliments.
6. Return completed original form to applicant
7. License will be valid for two years from the month of the physical.
8. Application will be returned for any incomplete information requested.
9. Medical examiner MUST sign and initial reverse side of this form.
10. Copy of receipt or confirmation of Exam on Doctor's letterhead must accompany this examination form.
MEDICAL HISTORY
HAVE YOU EVER HAD OR DO YOU NOW HAVE ANY OF THE FOLLOWING: (For each "yes" checked, describe condition in remarks)

 Y    N   CONDITION
a. Frequent or severe headaches
b. Dizziness or fainting spells
c. Unconscienceness for any reason
d. Eye trouble except glasses
e. Hay fever
f. Asthma

  Y    N   CONDITION
g. Heart Trouble
h. High or Low blood pressure
i. Stomach trouble
j. Kidney stone or blood in urine
k. Sugar or albunim in urine.
l. Epilipsy or fits		  Y    N   CONDITION
m. Nervous trouble of any sort
n. Any drug or narcotic habit
o. Excessive drinking habit
p. Attempted suicide
q. Motion sickness requiring drugs
r. Military medical discharge		  Y    N   CONDITION
s. Medical rejection from or for military service
t. Rejection for life insurance
u. Admission to hospital
v. Record of traffic convictions
w. Record of other convictions
x. Other illnesses
Remarks:
MEDICAL TREATMENT WITHIN PAST 5 YEARS
Date
Name and Address of physician consulted
Reason
* * *
* * *
* * *
APPLICANT'S DECLARATION: I hereby certify that all statements and answers provided by me in this examination form are complete and true to the best of my knowledge, and I agree that they are to be considered part of the basis for issuance of any IHBA Certificate to me.
SIGNATURE OF APPLICANT (in ink) Date
 
REPORT OF MEDICAL EXAMINATION (Please type)
Nor
mal
CHECK EACH ITEM IN APPROPRIATE COLUMN (Enter NE if not evaluated)
Ab
nor
mal
Notes: Describe every abnormality in detail, enter applicable item number before each comment. Use additional sheets if necessary and attach to this form
* 25. Head, face neck, and scalp *
* 26. Nose *
* 27. Sinuses *
* 28. Mouth and throat *
* 29. Ears, general (Internal and external canals) *
* 30. Drums (Perforation) *
* 31. Eyes, general (Visual acuity under 50 & 51) *
* 32. Opthalmoscopic *
* 33. Pupils (Equality and reaction) *
* 34. Ocular motility (Associated with parallel movement, mystogmus) *
* 35. Lungs and chest (Including breasts) *
* 36. Heart (Thrust, size, rhythm, sounds) *
* 37. Vascular system *
* 38. Abdomen and viscera (Including hernia) *
* 39. Anus and rectum (Hemorrhoids, fistula, prostate) *
* 40. Endocrine system *
* 41. G - U System *
* 42. Upper and lower extremities (Strength, range of motion) *
* 43. Spine, other muscluloskeletal *
* 44. Identifying body marks, scars, tattoos *
* 45. Skin and lymphatics *
* 46. Neurologic (Tendon reflexes, equilibrium, senses, coordination) *
* 47. Psychiatric (Specify any personality deviation) *
* 48. General systemic *
INTEROCULAR TENSION DISTANT VISION
(Standard test types only)		 NEAR VISION
(Use linear values)
*   
Tactile
Right
Eye
Left Eye
*
Tonometric
*
*
Right Eye 20/ Corrected to 20/
Left Eye 20/ Corrected to 20/
Both Eyes 20/ Corrected to 20/
20/ Corrected to 20/
20/ Corrected to 20/
20/ Corrected to 20/
FIELD OF VISION
 COLOR VISION (Test used, number of plates missed)
Right Eye
Left Eye


BLOOD PRESSURE
PULSE (wrist)
Recumbent
MM Mercury
Systolic
Diastolic
* * *
Resting
After Exercise
2 min after exercise
URINALYSIS
OTHER TESTS
Albumen
Sugar
* *
 
COMMENTS ON HISTORY AND FINDINGS, RECOMMENDATIONS (Attach all consults, ECG's, X-Rays, etc. to this report before mailing)
APPLICANT'S NAME
DISQUALIFYING DEFECTS (List by item no.)


* Normal, Healthy
* Further Evaluation Required
MEDICAL EXAMINATION DECLARATION: I hereby certify that I personally examined the applicant named on the medical examination report, and that this report and any attachment embodies my findings completely and correctly.
DATE OF EXAMINATION
MEDICAL EXAMINERS NAME AND ADDRESS (Type or print)
MEDICAL EXAMINER'S SIGNATURE



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