ALAR. orf 35. (eeifea) C.A. Form 35 (Revised) ae are GOVERNMENT OF INDIA arr fare frm CIVIL AVIATION DEPARTMENT sreet wa ot MEDICAL CERTIFICATE 4, a Cem BA TA epee swafirr ween & AB (1) See een ae —_ wer otter. tet mae tae es & at ate fy act ter aye a GE Ua wAlge @ wee A Hen & chet wea 8 aha/entra/ere 0 abe TT TB ) |, the undersigned certify that(1) born at.. a the “ domiciled at has undergone a medical examination for ina issvetrenewal of Licence and that he/she has been found funfVtemporaiy Unfit to serve in the capacity of a flight crew member as (2) Race aot a Ree Recommendations of Medical Officer a fehe ar aftr arate Patera, fore Ser, args Gear, aE Reh ever fear oe This report is subject to final assessment by the Director of Medical Services. Air Headquarter, New Detti IR Te. ‘ay far ma i sot. wl afta & ween fatto There & SRT Signature of person examined Signature of Medical Examiner arate yee Office stamp (1) arm, get ary, gear are ste Geng (oa) aH Name, Sumame, Principal name/and Christian (sub) names. 2) ser wiles @ weer o wa H fa Aras a ger wen 1 Indication of the capacity in which to be employed as fight crew member. “ga are ae tht ae | A safes Teeth wT aN anf B Sew art aw AY are aE Gea aA gf she TA 4 Reh Sond ar sree 8 ARI GST hereby declare that since the date of the above medical examination | have not been involved in any ‘accident, nor suffered from any illness or disability. So ater were Place Date, Signature. “at creed wen gy 30 Ra A aw aT A ger a ch owe BW ouefae Meo ae OMT ERT a TAT * The candidate should sign the above declaration, if more than 30 days have passed since his medical examination.seta aL. wrt 34 (ga: siete) CONFIDENTIAL CA Form 34 (Re-Revised) ea wore Government of India sare Rrra Pear Civil Aviation Department sreftee Rear area orf area & forge raed cite fee MEDICAL EXAMINATION REPORT FOR INITIAL ISSUE OF AVIATION LICENCES. area fey at so a ag raed} wia/ Medical Examination held at ete eta eee on artnet licence. (Roof ag core Pera wee Pacer sae eet eT HEPES eae Bet, oA she arg Ae, AT Pamir mentee a arefor, Severs Hee meoeeTiT wang arge eT, a Reet ah Geet Aor Rar (Note:-This form duly completed should be forwarded by the Medical Examiner PROMPTLY to the Assistant Director General of Medical Services, Directorate of Training and Licensing, Office ofthe Director. General of Civil Aviation, Technical Centre, Opposite Safdarjung Airport, New Delhi-110003.) ara - 1 meee ET eT OTA PART-1 TO BE COMPLETED BY THE APPLICANT. 1a (are oer A) start apart o Name in full (Block letters) MR/MRS/MISS 2 teen wa Wem PMR File No. eect en re 3 weer = ar = oe Nationality Place of Birth. 5. ort RY —— Date of Birth, Occupation... as 7. we at Blood Group... 8, dara oer vd tata a Present Address & Telephone No. RMI cence Permanent AdGI@8S wisest Ff = me 10, SERRE STRAT WOR CERAM / CAAA /AM. ()/AEL/ TH AA TAA TEMA (TTT FA) ‘Type of Licence applied of: ALTP/SCP/CP/CP(H)/FE/FN/PP/SP/GP/FRTO/Others (specify) 11 aft ed wtf aT at Seer we te Som ‘Type and Number of Licence if held .. ae on FE Flying Experience, if any : Fiying Hours. Aircraft type 19. wen Ror Se Pre oMTe aes ah wrath BE BP Have you previously been examined for aviation duties? 13. (91) af Bi, St me aa when aA aerate IA IFYES, place and date of last examination... 13. (@) a ae ar erat ae wr PHA A a? aaa Were your dectared FIT or UNFIT? FivUnfit 13.€@) aR arate @ a seem Bw Cause of Unfitness if UNFIT?2 14, we ae Prefers eh Se eA ek re ART 8? Have you ever suffered from or have you now any of the following? [sedan ert # frat 6) seme ohe ager & srenfa Pea & secret wy] [Tick mark (J) appropriate column and elaborate under REMARKS] wt YES NO a me YES NO aReapries Nervous/mental trouble safer oe a1 ear Insomnia, Sleep walking fect ahve ar ree Tega oT ‘Any drug or narcotic habit wep ARTI BT SAT Excessive drinking habit sarereet wr AT aT Attempted suicide ‘tert & aR oo Re waae SR a RS Fainting or giddiness, Fits or convulsions. fee @ ete an aftererrera Head injury, concussion Un fared on annie Severe headches, migraine aR. oR oars a wR aa eT PReal aT ‘Sea, Car, Air sickness wm Heart trouble oe fe var ae High or Low blood pressure agar a ae AT Palpitation or breathlessness oat a / aie eect the, BART aa Lung trouble/consumption, bronchitis, pneumonia o pleurisy AT ERA wR Asthma, hay fever te oO ait ‘Stomach or bowel trouble are a US are ae Indigestion or pain after food are Diabetes waft, a ser TT Malaria, other tropical diseases aa BRE wo Kidney or bladder trouble faba a tse ‘Syphilis oF gonorrhoea aaah ere Gynaecologicallobstetrical problems far chet eo et Rheumatism, joint pains oof amo on aem Ear trouble, discharge from ears wenn, om opr RR eT Deafness, noises in the ear, dizziness ar a asd BAR a en are eT I et TC Frequent colds, sore throats or tonsilits ar Eye trouble aR F tah A ae ofoaE Difficulty in seeing in the dark wid th dem, the wenfrar aera seat der fre oe See AE Phen aT Any other iliness, injury operations or investigation not mentioned above aft. a, aaa a, aaa , aie, aR shen aT ‘ware a unftentes gftrene Family history of ciabetes, haemophilia heart disease, nervous trouble, tuber- Costs, fs or attempted suicidetere: 45, WE ora qT ‘Any other information 46. mre ahem Applicant's Declaration A, eres ear gf AY are Ry ay Peet te sae ret aw AT aa ot ate TE te me A A ‘akg era orrare erg el Oar ah ae eT TE A 1 A ae a | PH AAR AA sree aa are we rE TE ge toe cher Per oh A cesta oe fre Se mT TT A eae GAT aT TT aA aa fe art aT form ah Poh Ah 8a foe stand a ore Ba wae wet AY eM ten gree gw ia S ae one Ay Ae sarc HiRes aR eer HA vere ren Bar Gee! iT | | herby declare that all statements and answers provided by me above are, to the best of my belief, complete and correct and that | have not withheld any relevant information or made any misleading statement. | understand, that if | have, with intent to deceive, made any false representations for the purpose of procuring myself a medical certificate, | may be guilty of a criminat's offence, | give my consent to the examining or assessing medical officer or department to communicate with any physician or hospital whom I have consulted ‘or may consult during the period covered by the medical certificate issued following this examination. ores wee Signature of Applicant Recent ae Photograph of Witnessed by Applicant (Refrreen veere weer, a, onEoTa shy we) (Signature, Name, Qualifications and Address of Medical Examiner)4 om I sae fer PART Il MEDICAL EXAMINATION = wie @ aie ‘A. Physical and Mental ee 2 we RF 8) Identicaton:A Marks Height without shoes) om 3 (RN 8) a Weight (rue) ts ‘Body Mass Index NM 5. of arte em ce AEE STE A A fee Chest crumrenc: Inspiration on Expration om, 6. wen ates = ae Fer 8 Be Systemic Examination Norm! Abnomal Pale (seated) Mn = RI Skin sto He ay ater ‘ood pressure recumbent roy Lymphnodes and Lymphatos ethane ene sees 2 Bee nee, aie ectroceroqram: Noma/AbrormalNotdue* Head, face, neck, scalp : ef oe or et oa a Xray Chest: Normal/Abnormal” Upper and lower extremities ‘ts ote ew arch WF Rader ‘Spince and muscule skeletal system Urine analysis: rh te bt ‘fire ere Chest and lungs Sp. gravity a wea Heart Sugar cater ates Vescular systems Protein wet she sein (ene, ha te wePa we) eres ‘Abdomen and viscera (including liver, spleen, hernia) Microscopie BME, Fe a Perincum, anus nia oe ees ert mara, Genitourinary systom Pe ae aoe dead. Endocrine system Aig ne cM eae (afte fom aga, aaa, Hak st) Neurologic (reflexes, equiibrium, cordnation, sence, ete.) SIAM Fh f__ mitten oLcP Fb Bann Psychiatic EEG ees a sitet & aa a M 8 % Incase of women ae A ota: armresrrerartt Examination of Breasts: Norma/Abnormal* Ce Last menstruation date ooh am aa ae oe a) * Delete the inappropriate,5 7, Prater (aR amas at aR re mT aR Ey HTT Propel ar Aa wher &) Remark (Elaborate (ABNORMAL findings using additional sheets if required) Reais Pater wot (exam TH sega ste wen) Date Medical Examiner (Signature, Name, Qualification and Address) a sia ar rer B EYE NORMAL ABNORMAL 1. AS, so See, TACIT, AA, Aw, SH, ASI, AT, SAT Lids, Lachrymal apparatus, conjucnetival, cornea, Pupils, lens media, fundi, tension 2, afte da (aera er ere) Visual fields (By confronation test) 3. Aen arr (er ATR, Hae, rere) cular motility (associated paralle! movement, nystagmus) 4. after Visual Acuity % RAW a a. Distant vision RT LT BOTH fret ae Without Glasses 6... Bln. (arrras aero By free) wei 3 arr (standard test type) With Glasses 6h... Bhan. BF wa sarees 7 (90-50 BoA, B eT FT We) b._ Near vision (N type in the range 30 - 50 cm) fae ae /aet ere er S ee A ae Able to read NS without glassesiwith glasses* aL ratios are (100 &. A TH WER) Cc. Intermediate vision (N type at 100 cm) fer eae are 14 wy A ert Able to read N14 without glasses/ glasses" warm (ar wet or eH Ta 30 SA, fy B aur) 4d, Accommodiation (Near point 30 em with or without glasses) a N PRT FB AT enn ae Mt Without Glasses on a om FRR PY spe aA. With Glasses per asad +h arya 8 oe wre By * Delete the inappropriate.5, aIee Afar Mra External Ocular Muscles aaa. wat a. Com, Sc. om. fifteen 3 afte oun Power of convergence AB Meccnnn ww be $ oo 38 Wow b. Result of Cover test At 33cm eur A a, Asa ae 2 tow C. Maddox Rod ‘A 3 orn 6. ea shea ae wer #2 art Does the candidate possess glasses? YES/NO cael or Pater af ary & ae ae Prescription of glasses, if applicable Right Left wT a gq w a gq s c A s c A ® Distant aod Near a ite C. Colour perception a wa YES NO 1. et AAS (ehenr/aI) WER B Se a oe Gia A aE at AIT en Ta? Is the normal when tested by pseudoisochromatic (Ishihara/Japanese) type plates? }__| 2, aR ae sree ah ear ae ha area B Rear hr aa ARMA we oT QaRR at eet t? Ifabnormal, is there any difficulty in distinguishing readily aviation Coloured lights displayed by colour lentern? argc = (aR reer @ at sii ee or sei axa gy, suATIA Prema & Rega at 2) Remarks: (Elaborate ABNORMAL findings using additional sheets if required) fee fern rere (eee, TH Date tere st at Medical Examiner (Signature Name, Qualification and Address3 or, ae otk 9a D._EAR, NOSE AND THROAT tet or waa | aware | 2. ar or carara | mara Extemalies Normal | Abnormal] Middle ears Normal | Abnormal . whace a. Tympanum 3 Rien oe b. Eustachean Tube a. ove cc. Mastoid 3.9m or 4, gem eT eT Internal ears Nose & Paranasal sinuses (airway, septum, Ployp) woe a. Cochlear functions @. wer-firar b. Vestibular functions 5. ©, war 6. a Mouth, teth, throat Speech 7 OT safe eter (512) AA. AM) | Ww. sey 4. Hearing a ees a TUNING FORK TESTS (512) ara or ater wai or val ot Rtear | Test | tTear RT ear Pr an Rione's Tear = Webers sil aa BOTH ‘ABC Che aw oem stem TT TOR 70 dea waar | oat wa ar aie (Oa aT] a) (etiaa ere)} (Ga. Gs) (e4taa ere) ‘SPEECH INTELLIGIBILITY TEST RTear | Frequencies Lear VS BACKGROUND 70 dB NOISE (db Loss) (Hz) (db loss) (only if applicable) 250 % Weis | wart | aeeaa % Score | Normal |. Abnormal {___| RT ear ea oT wai oF LTear9. fighter (aR saree eat after Me ar men ad Ey arr Ret aT Reg whet Remarks (Elaborate ABNORMAL finding using additional sheets if required) ate Pfr Tere (Geer, aH, améaiy wei) Date Medical Examiner (Signature, Name, Qualifications and Address) (@) Refine Pace ar ero ste Per E. Findings and Recommendations of the Medical Examiner/Medical Board arte Rafter were/are ate & ore Date (Gere, 714, areery @ eT) Medical Examiner/President, Medical Board (Signature, Name, Qualifications and Address) art TL erPteres ere RTs eer aM sift AAA PART Ill - FINAL ASSESSMENT AT THE DGCA HEADQUARTERS wr : af Pee Place : New Delhi ‘ager Pate /Prter fee Bar Jt. Director/Director Medical Services cnt Re seees ae Pea Date For Director General of Civil Aviationabr thers oh rat INSTRUCTIONS TO THE MEDICAL EXAMINER 4, Pre teres Far Ser eT fry Tach att A weer amfeeta fare Preare werent wr vara & For Guidance on the medical requirements for civil flying licences, the Medical Examiner is referred to the following publications :- BANG WER wr Vang AH 3/1982 (a) Government of India AIC No. 3/1982 a, aerial Snot (1982) @ sire or RARE T (b) Annex | to the Convention of ICAO (1982) a, fer ar ae fears sta Arysret (sre5 8984—¥ CHVE95) (c)_ ICAO Manual of Civil Aviation medicine (DOC8984-AN/895). 2. oer step Pare ret rr oT oT shes Re A mae PEA & Aor er Fe STAC cain rch eA fre snag 8 Only Registered Medical Practitioners holding a recognised degree in modern medicine are authorized to conduct medical examinations for aircrew licences. 3, sea ae mater ret wer & Ferg seer wre (area: ae, wrl-34) ga: aa) gen aie, rH 94 (ge Weta) a eh Per AE ‘Separate medical forms are to be used for intial and renewal medical examinations (CA form 34) (Re-Revised) and 34-A (Re-Revised) respectively. 4 on or rT weecare RTT TT Te Se | A eras wea A A Se wr areata wee ote ET Bea 4 wont we Part | of the form is to be filled up by the applicant in his/her own hand. The Medical Examiner will guide the applicant in the above and also attest as a witness 5. opt a arr 1 Poo ET ART eT STEM A TA tan ary we (|) fre cen ave ter eae BY Be AE OAL arrerara Pet & ait A aft “aga aA a areca Rega Reaver an oe Part Il of the form will be filled up by the Medical Examiner. All columns will be filled up legibly with tick (x/) ‘mark of brief description as applicable. Abnormal findings must be described in detail under the appropriate Remarks coun 6. woh arated & fay arr wher & ater gray) eefatare (Getoh) atarl 1 Aenea ares & fe 40 at og she ed we wets Gia af are Sect ara ear wate | arenes angeiel @ Pre 30 she 40 ai aA ong A eh af Aa a af 40 ad a ong @ are afte HGH era TT Electro cardiographic (ECG) examination is mandatory during the initial medical examination for all licences. For non-commercial licences, ECG must be repeated at the age of 40 years and every 5 years thereafter. For ‘commercial licence, ECG is to be repeated once in two years between 30 and 40 years and annually after the age of 40 years. 7. sere arm aden & eters ore ah ener re are Pred & aie eT ae et Fas se Reem E Rediological examinations of the chest in mandatory during the medical examination and subsequently if clinically indicated, 8. aR aor Rees te an CA aT aT OT aa aa S wETeTG sETATD Pew ex ue we A) after TE ATT a Ips we S Fay Rega ae eh we ‘An abnormal finding whether on clinical examination or by ECG or by any other routine test should be the basis for further detailed investigations for comprehensive evaluation of the overall fitness of the individual. 9. yeh aracth ater Reh eer rete RE aftr aT ate sper # fey were ae Ras eee TT fg es ret oh rh ae The completed medical examination report along with reports of relevant investigations must be forwared PROMPTLY by registered post to the DGCA Headquarters for assessment and approval.