Form-3 - M.e.a. Medical Department Cadet Pilots Medical Screening Form

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M.E.A. MEDICAL DEPARTMENT
Form-3
CADET PILOTS MEDICAL SCREENING
Name of Applicant
Last
First
Middle
Date of Birth
Day
Month
Year
Medical History
Have you ever had any history of:
1.
Pneumonia, Pleurisy, Tuberculosis
YES
NO
_________________________
2.
Heart or Vascular problems, High Blood Pressure
YES
NO
_________________________
3.
Asthma, Hay fever (Allergical Rhinitis)
YES
NO
_________________________
4.
Sinusitis, Repeated Tonsillitis or Otitis
YES
NO
_________________________
5.
Gastric or Duodenal Ulcer, Jaundice, Malaria, Hernia
YES
NO
_________________________
6.
Kidney Stones, Albumine or Blood in Urine
YES
NO
_________________________
7.
Low Back Pain, Severe Wounds, Fractures
YES
NO
_________________________
8.
Mental disease, Epilepsy, Depression, Attempted Suicide
YES
NO
_________________________
9.
Loss of consciousness
YES
NO
_________________________
10. Repeated episodes of alcoholism
YES
NO
_________________________
*
11. Smoker
YES
NO
*Declaration & Obligation
.
12. Drug use or addiction
YES
NO
_________________________
13 Hearing or Ear problems, Motion Sickness (Dizziness)
YES
NO
_________________________
14. Abnormal speech or stuttering
YES
NO
_________________________
15. Eye or vision problems
YES
NO
_________________________
16. LASIK or vision correction surgery
YES
NO
_________________________
17. Admission to hospital, surgical operations if any
YES
NO
_________________________
18. Congenital disease or sickness
YES
NO
_________________________
If answer to any of the above is YES, provide explanation on an additional paper.
Provide details of physical activity or exercise that you do regularly:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Chronic Medication: Type: _______________________________________________ Frequency ______________________
______________________________________________________________________________________________________
Family History
Father
Alive
Died
Age _____
Cause of Death _____________________________________________
Mother
Alive
Died
Age _____
Cause of Death _____________________________________________
Is there any history in the family of Mental Disease, Diabetes, High Blood Pressure, Dyslipidemia Myopia and other
family disease
YES
NO
Explain _________________________________________________________________________
__________________________________________________________________________________________________
Medical Declaration
I hereby declare that all statements and answers done by myself in this form are complete and true.
In addition to the above, I pledge to refrain & to desist from smoking at all times in conformity with MEA’s regulations.
Also, I undertake to give my wholly agreeable consent without any reservation or constraint of any sort to the MEA examining
Medical Officer to communicate with any hospital or physician as to verify the above information which has been declared by
myself.
Date: _____________________________
Doctor Name: __________________
__________________________________
Day
Month
Year
Applicant’s Signature
Signature: _____________________
Stamp: ________________________

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