Ren Exam

APPENDIX - 17
CAA-112
CONFIDENTIAL
CIVIL AVIATION AUTHORITY

RENEWAL MEDICAL EXAMINATION/BOARD FOR AIRCREW MEMBERS
OTHER THAN PRIVATE AND GLIDER PILOTS
MEDICAL EXAMINATION/BOARD held at .Date Class
1. PARTICULARS TO BE ENETERED BY THE EXAMINEE, (BLOCK LETTERS)

Full Name of Examinee
Name of Father/Husband
(State Title or Rank or Whether Mr., Mrs., or Miss
Address
Place and date of Birth
Number of hours flown: Total since last examination
Nature of recent flying duties
Types of aircraft flown since last examination
(pilots only)
Class or licence required in respect of this examination
Details of licence if held:
(i) Category of Licence

(ii) Licence No:
(iii) Date of Expiry:
II. CERTIFICATE TO BE COMPLETED BY THE EXAMINEE

(IN THE PRESENCE OF AND WITNESSED BY THE MEDICAL EXAMINER)
I certify Mat I was medically examined in connection with my

Licence on or about 19 as a result of which
examination I was assessed fit/unfit to serve as since when I
have not been involved in any accident nor suffered from any illness or disability except
__________ which occurred on or about
19
SIGNATURE of the person examined
Date WITNESS
Aviation Medical Examiner
Note: Any falsification made, may render cancellation of licence and any other penal
action by DGCAA according to Civil Aviation Rules.
1
GENERAL MEDICAL AND SURGICAL EXAMINATION
Height (without footwear) inches

Weight (without clothes) lbs.
Any body Marks, Scars or Deformities
Any evidence of Wounds, Injuries or Operation
Any thyroid enlargement
Any evidence of splenic, Hepatic or glandular enlargement
Any evidence of Metabolic, Nutritional or Endocrine disorder
Any evidence of Hernia, varicose veins, Hydrocole or Varicocele.
Any abnormality of movement of the joints
Any abnormal skin condition
Chest circumference on Inspiration on Expiration
Impression given by Physique
Pulse rate. Sitting Standing
Condition of Arterial Waits
Blood Pressure. Systolic Diastolic
Heart Size Sounds Rhythm
Any evidence of abnormality of the Cardiovascular System
Result of X-Ray of the Chest (only if considered advisable).
Result of Electro-cardiographic examination, if carried Out
Any evidence of abnormality of the Nervous system
Reflexes. Knee Ankle Triceps Abdominal

Planter Any evidence of Cranial Injury
Cranial Nerves
Tremors Fingers Eyelids
Any evidence of abnormality of the Alimentary system
Any evidence of abnormality of the Uro-genital System
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Psycho-active substances
Additional remarks by the Medical Examiner
Date Signature
2
EAR, NOSE AND THROAT EXAMIANTION
Any previous relevant history of Ear, Nose or Throat trouble
Is there any evidence of disease, injury or malformation of the External Ear, the Meatus,
the tympanic membrane of the Eustachian tubes.
Is there any evidence of past or present Mastoid infection
Is there any evidence of abnormality of the Cochlear apparatus.
Or of the Vestibular apparatus.
Is there any evidence of disease, injury or malformation of the

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
The Nasal Accessory Sinuses.
Is there any evidence of speech impediment.
Audiotry Acuity
At what distance can a forced whisper be heard (in a quiet room)

In the right Ear in the Left Ear
At what distance can a conversational voice be heard (in a quiet room)
The record of a pure tone audiogram. ( if required).
R.E. FREQUENCIES L.E.

4,000
3,000
2,000
1,000
500
The result of Weber’s Test
The result of Rinne's Test
3
Date Signature
EYE EXAMINATION
Any previous relevant history of eye trouble
Is there any evidence of disease or abnormality of the Lids, the Lacrymal Apparatus or the Orbit
Is there any evidence of disease or injury to the eyes
Is there any evidence of abnormality of the Ocular fundus or Media
Is there is any evidence of deficiency in the power of Convergence
Is there any lack of Accommodative power
VISUAL ACUITY
Distant Vision Without Glasses R.E. L.E.

With Glasses R.E. L.E.
Near Vision Without Glasses R.E. L.E.
Is there any limitation of the fields of Vision
Prescription of glasses if worn for distant or near vision
Contact lenses
What is the measure of his Manifest Hypermetropia if present

R.E. L.E.
Note:
If the candidate requires correcting glasses to bring his vision upto the required standards, does he
possess glasses suitable for that purposes? (Two sets)
Date: Signature
OBSERVATIONS AND FINDINGS
Date: Signature
On the above examination, I assess this candidate:

FIT
UNFIT
Temporarily unfit for a period
of as:
Commercial Pilot
Senior Commercial Pilot
Airline Transport Pilot Class - I
Flight Navigator
Flight Engineer
Flight Radio Telephone Operator
4
Date: Signature
Chief of Aviation Medicine
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
5


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
6
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500

7
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
8
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
9
Date WITNESS


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
10
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
11
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
12
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
13
Date WITNESS


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
14
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity

15
4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
16
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:

17
19
Date WITNESS


Cranial Nerves

18
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity

19

4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
20
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:
21

19
Date WITNESS


Cranial Nerves
22
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity
23

4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
24
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)
25
(ii) Licence No:


19
Date WITNESS


26
Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
27
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses
28
R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

29

(ii) Licence No:


19
Date WITNESS


30
Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
31
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

32
Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
33
(pilots only)

(ii) Licence No:


19
Date WITNESS

34

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

35
Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY
36
Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
37
(pilots only)

(ii) Licence No:


19
Date WITNESS

38

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature
39

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
40
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


41
Address
(pilots only)

(ii) Licence No:


19
Date WITNESS

42

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

43

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
44
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL

45

Address
(pilots only)

(ii) Licence No:


19
Date WITNESS

46

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature
47

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
48
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL
49

Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
50

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature
51

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
52
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
53
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
54


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature
55

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
56
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
57
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
58


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
59
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
60
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
61
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
62


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
63
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
64
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
65
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
66
Date WITNESS


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
67
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
68
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

69
FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


70
19
Date WITNESS


Cranial Nerves
71
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity

72
4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
73
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:
74

19
Date WITNESS


Cranial Nerves
75
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity

76

4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
77
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)
78
(ii) Licence No:


19
Date WITNESS


79
Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
80
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses
81
R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

82

(ii) Licence No:


19
Date WITNESS


83
Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
84
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

85
Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
86
(pilots only)

(ii) Licence No:


19
Date WITNESS

87

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

88
Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY
89
Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
90
(pilots only)

(ii) Licence No:


19
Date WITNESS

91

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature
92

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
93
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


94
Address
(pilots only)

(ii) Licence No:


19
Date WITNESS

95

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature

96

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
97
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL

98

Address
(pilots only)

(ii) Licence No:


19
Date WITNESS

99

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature
100

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
EYE EXAMINATION
101
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL
102

Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
103

Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature
104

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
Date Signature
105
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
106
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
107


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
Date Signature
108

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
109
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
110
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
111


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
112
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
113
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
Commercial Pilot
114
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
Date WITNESS
115


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
116
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
1,000
500
117
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

FIT
UNFIT
of as:
118
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
APPENDIX - 17
CAA-112
CONFIDENTIAL


Address
(pilots only)

(ii) Licence No:


19
119
Date WITNESS


Cranial Nerves
Urinalysis Glucose
Albumen Sugar
Blood Sugar
120
Date Signature

Buccal Cavity
The Teeth
The Gums
The Pharynx
The Larynx
The Nose.
The Naso-pharyns
Audiotry Acuity


4,000
3,000
2,000
121
1,000
500
Date Signature
EYE EXAMINATION
VISUAL ACUITY

Contact lenses

R.E. L.E.
Note:
Date: Signature
Date: Signature

122
FIT
UNFIT
of as:
Commercial Pilot
Flight Navigator
Flight Engineer
Date: Signature
123

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APPENDIX - 17

CIVIL AVIATION AUTHORITY

MEDICAL EXAMINATION/BOARD held at .Date Class

1. PARTICULARS TO BE ENETERED BY THE EXAMINEE, (BLOCK LETTERS)

Class or licence required in respect of this examination

Details of licence if held:

(i) Category of Licence

II. CERTIFICATE TO BE COMPLETED BY THE EXAMINEE

I certify Mat I was medically examined in connection with my

SIGNATURE of the person examined

Height (without footwear) inches

Any evidence of abnormality of the Nervous system

Reflexes. Knee Ankle Triceps Abdominal

Any evidence of abnormality of the Uro-genital System

Additional remarks by the Medical Examiner

Any previous relevant history of Ear, Nose or Throat trouble

Is there any evidence of past or present Mastoid infection

Is there any evidence of abnormality of the Cochlear apparatus.

Or of the Vestibular apparatus.

Is there any evidence of disease, injury or malformation of the

Is there any evidence of speech impediment.

At what distance can a forced whisper be heard (in a quiet room)

R.E. FREQUENCIES L.E.

The result of Weber’s Test

The result of Rinne's Test

Additional remarks by the Medical Examiner

Any previous relevant history of eye trouble

Is there any evidence of disease or injury to the eyes

Is there any evidence of abnormality of the Ocular fundus or Media

Is there is any evidence of deficiency in the power of Convergence

Is there any lack of Accommodative power

Distant Vision Without Glasses R.E. L.E.

Is there any limitation of the fields of Vision

Prescription of glasses if worn for distant or near vision

What is the measure of his Manifest Hypermetropia if present

Additional remarks by the Medical Examiner

OBSERVATIONS AND FINDINGS

On the above examination, I assess this candidate:

CIVIL AVIATION AUTHORITY

MEDICAL EXAMINATION/BOARD held at .Date Class

1. PARTICULARS TO BE ENETERED BY THE EXAMINEE, (BLOCK LETTERS)

Class or licence required in respect of this examination

Details of licence if held:

(i) Category of Licence

II. CERTIFICATE TO BE COMPLETED BY THE EXAMINEE

I certify Mat I was medically examined in connection with my

SIGNATURE of the person examined

GENERAL MEDICAL AND SURGICAL EXAMINATION

Height (without footwear) inches

Any evidence of abnormality of the Nervous system

Reflexes. Knee Ankle Triceps Abdominal

Any evidence of abnormality of the Uro-genital System

Additional remarks by the Medical Examiner

EAR, NOSE AND THROAT EXAMIANTION

Any previous relevant history of Ear, Nose or Throat trouble

Is there any evidence of past or present Mastoid infection

Is there any evidence of abnormality of the Cochlear apparatus.

Or of the Vestibular apparatus.

Is there any evidence of disease, injury or malformation of the

Is there any evidence of speech impediment.

At what distance can a forced whisper be heard (in a quiet room)

R.E. FREQUENCIES L.E.

The result of Weber’s Test