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Get DA 4497 2002-2021

AEROMEDICAL PHYSICIAN ASSISTANT STAMP AND SIGNATURE DA FORM 4497 MAR 2002 NEW DISQUALIFICATION SEND AEROMEDICAL SUMMARY AND SF 88/93 28. U.S. DOD Form dod-da-4497 1. EXAM DATE DD/MM/YY INTERIM ABBREVIATED FLYING DUTY MEDICAL EXAMINATION For use of this form see AR 40-501 the proponent agency is OTSG 2. NAME Last First MI 3. SSN 6. COMPONENT Check one or more AD-RA AD-USAR ARNG-AGR 5. BIRTH DATE DD/MM/YY 7. AVIATION DUTY Check one USAR-AGR ARNG 4. RANK DAC USAR-TPU USAR-IRR CIV CONTRACTOR AVIATOR RET-MIL 8. UNIT OF ASSIGNMENT AND COMPLETE UNIT ADDRESS FS/APA AEROSCOUT CLASS 3 9. UNIT PHONE ATC CLASS 4 10. HOME PHONE 12. LIST YOUR MEDICATIONS AND DOSAGES 11. LIST YOUR AEROMEDICAL WAIVERS IN EFFECT 13. I understand that I must be cleared by a flight surgeon after hospitalization or sick in quarters or after PATIENT S SIGNATURE treatment or activities requiring restriction* I am informing the flight surgeon of my medical history or any change in my health since my last FDME* I have read AR 600-105 Aviation service and AR 40-8 Exogenous factors. 14a* EXAM FACILITY ADDRESS 15. BLODD PRESS 16. PULSE 17. HEIGHT Ins 20a* DEPTH PERCEPTION TEST b. EXAM FACILITY PHONE c* AEDR FACILITY CODE VTA 21. EYE EXAMINATION VERHOEFF 22. INTRAOCULAR PRESSURE a* DISTANT VISION b. NEAR VISION RIGHT 20/ corr to 20/ b. TEST SCORE 19. BODY FAT c* TEST RESULT RANDOT CIRCLES PASS FAIL 23. AUDIOMETRIC SCREENING Decibels 500 Hz mmHg LEFT 18. WEIGHT Lbs 24. HISTORY AND EXAMINATION* Enter pertinent history and physical findings below as per ATB 2. Continue on reverse if required* If review of the most recent USAAMA AEDR History Verification Form shows no change in history enter No significant Interval history. 25. ELECTROCARDIOGRAM FINDINGS THIS BOX IS FOR USAAMA USE ONLY 26. RECOMMENDATION QUALIFIED DISQUALIFIED CONTINUE WAIVERS 27. NAME Last First MI 3. SSN 6. COMPONENT Check one or more AD-RA AD-USAR ARNG-AGR 5. BIRTH DATE DD/MM/YY 7. AVIATION DUTY Check one USAR-AGR ARNG 4. RANK DAC USAR-TPU USAR-IRR CIV CONTRACTOR AVIATOR RET-MIL 8. AVIATION DUTY Check one USAR-AGR ARNG 4. RANK DAC USAR-TPU USAR-IRR CIV CONTRACTOR AVIATOR RET-MIL 8. UNIT OF ASSIGNMENT AND COMPLETE UNIT ADDRESS FS/APA AEROSCOUT CLASS 3 9. UNIT PHONE ATC CLASS 4 10. UNIT OF ASSIGNMENT AND COMPLETE UNIT ADDRESS FS/APA AEROSCOUT CLASS 3 9. UNIT PHONE ATC CLASS 4 10. HOME PHONE 12. LIST YOUR MEDICATIONS AND DOSAGES 11. LIST YOUR AEROMEDICAL WAIVERS IN EFFECT 13. I understand that I must be cleared by a flight surgeon after hospitalization or sick in quarters or after PATIENT S SIGNATURE treatment or activities requiring restriction* I am informing the flight surgeon of my medical history or any change in my health since my last FDME* I have read AR 600-105 Aviation service and AR 40-8 Exogenous factors. HOME PHONE 12. LIST YOUR MEDICATIONS AND DOSAGES 11. LIST YOUR AEROMEDICAL WAIVERS IN EFFECT 13. I understand that I must be cleared by a flight surgeon after hospitalization or sick in quarters or after PATIENT S SIGNATURE treatment or activities requiring restriction* I am informing the flight surgeon of my medical history or any change in my health since my last FDME* I have read AR 600-105 Aviation service and AR 40-8 Exogenous factors. 14a* EXAM FACILITY ADDRESS 15. BLODD PRESS 16. PULSE 17. HEIGHT Ins 20a* DEPTH PERCEPTION TEST b. EXAM FACILITY PHONE c* AEDR FACILITY CODE VTA 21. .

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