0.5.12 - ci-build

SpaceflightHealthSimulationsReferenceDocumentation - Local Development build (v0.5.12) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Questionnaire: FAA Form 8500-8 Questionnaire

Official URL: http://hl7.org/fhir/uv/aerospace/Questionnaire/faa-form-8500-8 Version: 0.5.12
Active as of 2025-05-21 Computable Name:

Copyright/Legal: Federal Aviation Administration

FAA Form 8500-8 Application for Airman Medical Certificate converted to FHIR Questionnaire format

Application for Airman Medical Certificate or Airman Medical & Student Pilot Certificate

Structure

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. FAA Form 8500-8 Application for Airman Medical Certificate converted to FHIR Questionnaire formatQuestionnairehttp://hl7.org/fhir/uv/aerospace/Questionnaire/faa-form-8500-8#0.5.12
... application-infoAPPLICATION INFORMATION0..1group
.... application-typeAPPLICATION FOR1..1choiceOptions: 2 options
.... certificate-classCLASS OF MEDICAL CERTIFICATE APPLIED FOR1..1choiceOptions: 3 options
... personal-infoPERSONAL INFORMATION0..1group
.... nameNAME (Last, First, Middle)1..1string
.... ssnSOCIAL SECURITY NUMBER0..1string
.... addressADDRESS (Street, City, State, ZIP)1..1string
.... telephoneTELEPHONE NUMBER1..1string
.... date-of-birthDATE OF BIRTH (MM/DD/YYYY)1..1date
.... hair-colorCOLOR OF HAIR1..1choiceOptions: 7 options
.... eye-colorCOLOR OF EYES1..1choiceOptions: 6 options
.... sexSEX1..1choiceOptions: 2 options
... airman-infoAIRMAN INFORMATION0..1group
.... certificate-heldTYPE OF AIRMAN CERTIFICATE(S) YOU HOLD1..*choiceOptions: 10 options
.... occupationOCCUPATION1..1string
.... employerEMPLOYER1..1string
.... total-pilot-timeTOTAL PILOT TIME TO DATE1..1quantity
.... pilot-time-6-monthsTOTAL PILOT TIME PAST 6 MONTHS1..1quantity
.... medical-certificate-dateDATE OF LAST FAA MEDICAL APPLICATION0..1date
.... medical-certificate-deniedHAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED, OR REVOKED?1..1boolean
..... medical-certificate-denied-detailsIf yes, provide date0..1dateEnable When: medical-certificate-denied =
.... current-medicationsDO YOU CURRENTLY USE ANY MEDICATION (PRESCRIPTION OR NONPRESCRIPTION)?1..1boolean
..... medication-listList medication(s) and dosage0..*stringEnable When: current-medications =
.... contact-lensesDO YOU EVER USE NEAR VISION CONTACT LENS(ES) WHILE FLYING?1..1boolean
... medical-historyMEDICAL HISTORY - Have you ever in your life been diagnosed with, had, or do you presently have any of the following?0..1group
.... headachesFrequent or severe headaches1..1boolean
.... dizzinessDizziness or fainting spells1..1boolean
.... unconsciousnessUnconsciousness for any reason1..1boolean
.... eye-troubleEye or vision trouble except glasses1..1boolean
.... hay-feverHay fever or allergy1..1boolean
.... asthmaAsthma or lung disease1..1boolean
.... heart-troubleHeart or vascular trouble1..1boolean
.... blood-pressureHigh or low blood pressure1..1boolean
.... stomach-troubleStomach, liver, or intestinal trouble1..1boolean
.... kidney-troubleKidney stone or blood in urine1..1boolean
.... diabetesDiabetes1..1boolean
.... neurologicalNeurological disorders; epilepsy, seizures, stroke, paralysis, etc.1..1boolean
.... mental-disordersMental disorders of any sort; depression, anxiety, etc.1..1boolean
.... substance-abuseSubstance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years1..1boolean
.... alcohol-dependenceAlcohol dependence or abuse1..1boolean
.... suicide-attemptSuicide attempt1..1boolean
.... motion-sicknessMotion sickness requiring medication1..1boolean
.... military-medical-dischargeMilitary medical discharge1..1boolean
.... medical-rejectionMedical rejection by military service1..1boolean
.... insurance-rejectionRejection for life or health insurance1..1boolean
.... hospital-admissionAdmission to hospital1..1boolean
.... history-otherOther illness, disability, or surgery1..1boolean
.... medical-disability-benefitsMedical disability benefits1..1boolean
.... arrestsHistory of arrest(s), conviction(s), and/or administrative action(s)1..1boolean
.... history-convictionsHistory of nontraffic convictions1..1boolean
.... medical-history-explanationExplanation for any above YES answers (include dates, condition, treatment, and names/addresses of medical providers)0..1text
... healthcare-visitsVISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS1..1boolean
.... healthcare-visit-detailsDate, Name, Address and Type of Health Professional Consulted & Reason0..*textEnable When: healthcare-visits =
... physical-examinationPHYSICAL EXAMINATION (FOR AME USE ONLY)0..1group
.... heightHEIGHT (inches)1..1decimal
.... weightWEIGHT (pounds)1..1decimal
.... soda-issuedSTATEMENT OF DEMONSTRATED ABILITY (SODA) ISSUED0..1boolean
..... soda-serialSODA SERIAL NUMBER0..1stringEnable When: soda-issued =
.... body-systems-examinationBODY SYSTEMS EXAMINATION0..1group
..... head-face-neckHead, face, neck, and scalp0..1choiceOptions: 2 options
..... noseNose0..1choiceOptions: 2 options
..... sinusesSinuses0..1choiceOptions: 2 options
..... mouth-throatMouth and throat0..1choiceOptions: 2 options
..... ears-generalEars, general0..1choiceOptions: 2 options
..... ear-drumsEar drums0..1choiceOptions: 2 options
..... eyes-generalEyes, general0..1choiceOptions: 2 options
..... ophthalmoscopicOphthalmoscopic0..1choiceOptions: 2 options
..... pupilsPupils (Equality and Reaction)0..1choiceOptions: 2 options
..... ocular-motilityOcular motility0..1choiceOptions: 2 options
..... lungs-chestLungs and chest0..1choiceOptions: 2 options
..... heartHeart0..1choiceOptions: 2 options
..... vascular-systemVascular system0..1choiceOptions: 2 options
..... abdomen-visceraAbdomen and viscera0..1choiceOptions: 2 options
..... anusAnus0..1choiceOptions: 3 options
..... skinSkin0..1choiceOptions: 2 options
..... genitourinaryGenitourinary system0..1choiceOptions: 3 options
..... extremitiesMusculoskeletal - Upper and lower extremities0..1choiceOptions: 2 options
..... spineSpine, other musculoskeletal0..1choiceOptions: 2 options
..... marks-scarsIdentifying body marks, scars, tattoos0..1choiceOptions: 2 options
..... lymphaticsLymphatics0..1choiceOptions: 2 options
..... neurologicalNeurological0..1choiceOptions: 2 options
..... psychiatricPsychiatric0..1choiceOptions: 2 options
..... general-systemicGeneral Systemic0..1choiceOptions: 2 options
.... vision-testsVISION TESTS0..1group
..... distance-visionDistant Vision0..1group
...... distance-right-uncorrectedRight eye uncorrected1..1string
...... distance-right-correctedRight eye corrected0..1string
...... distance-left-uncorrectedLeft eye uncorrected1..1string
...... distance-left-correctedLeft eye corrected0..1string
...... distance-both-uncorrectedBoth eyes uncorrected1..1string
...... distance-both-correctedBoth eyes corrected0..1string
..... near-visionNear Vision0..1group
...... near-right-uncorrectedRight eye uncorrected1..1string
...... near-right-correctedRight eye corrected0..1string
...... near-left-uncorrectedLeft eye uncorrected1..1string
...... near-left-correctedLeft eye corrected0..1string
...... near-both-uncorrectedBoth eyes uncorrected1..1string
...... near-both-correctedBoth eyes corrected0..1string
..... intermediate-visionIntermediate Vision (32 in)0..1group
...... intermediate-right-uncorrectedRight eye uncorrected0..1string
...... intermediate-right-correctedRight eye corrected0..1string
...... intermediate-left-uncorrectedLeft eye uncorrected0..1string
...... intermediate-left-correctedLeft eye corrected0..1string
...... intermediate-both-uncorrectedBoth eyes uncorrected0..1string
...... intermediate-both-correctedBoth eyes corrected0..1string
..... color-visionColor Vision1..1string
..... field-of-visionField of Vision1..1string
..... heterophoriaHeterophoria (20')0..1group
...... esophoriaEsophoria0..1string
...... exophoriaExophoria0..1string
...... right-hyperphoriaRight Hyperphoria0..1string
...... left-hyperphoriaLeft Hyperphoria0..1string
.... hearing-vitalsHEARING, BLOOD PRESSURE, AND ECG0..1group
..... hearingHearing0..1group
...... audiometric-speechAudiometric Speech Discrimination0..1string
...... voice-testConversational Voice Test at 6 Feet0..1group
....... right-ear-passRight Ear0..1boolean
....... left-ear-passLeft Ear0..1boolean
...... audiometric-thresholdAudiometric Threshold in Decibels0..1group
....... threshold-right-500Right Ear 500 Hz0..1decimal
....... threshold-right-1000Right Ear 1000 Hz0..1decimal
....... threshold-right-2000Right Ear 2000 Hz0..1decimal
....... threshold-right-3000Right Ear 3000 Hz0..1decimal
....... threshold-right-4000Right Ear 4000 Hz0..1decimal
....... threshold-left-500Left Ear 500 Hz0..1decimal
....... threshold-left-1000Left Ear 1000 Hz0..1decimal
....... threshold-left-2000Left Ear 2000 Hz0..1decimal
....... threshold-left-3000Left Ear 3000 Hz0..1decimal
....... threshold-left-4000Left Ear 4000 Hz0..1decimal
..... blood-pressureBlood Pressure0..1group
...... systolicSystolic (mmHg)1..1integer
...... diastolicDiastolic (mmHg)1..1integer
...... bp-armArm used for reading0..1choiceOptions: 3 options
..... pulsePulse1..1integer
..... urinalysisUrinalysis0..1group
...... urine-albuminAlbumin0..1string
...... urine-sugarSugar0..1string
..... ecgElectrocardiogram (ECG)0..1string
... ame-certificationAME CERTIFICATION0..1group
.... ame-commentsAME Comments on History and Findings0..1text
.... disqualifying-defectsDISQUALIFYING DEFECTS (List by item number)0..1text
.... medical-certificateMedical Certificate Issued1..1choiceOptions: 5 options
.... certificate-limitationsCertificate Limitations/Conditions0..1text
.... ame-declarationI hereby certify that I have personally reviewed the medical history and personally examined the applicant named on this medical examination report. This report with any attachment embodies my findings completely and correctly.1..1display
.... ame-signatureAME Signature1..1string
.... ame-nameAME Name1..1string
.... ame-addressAME Address1..1string
.... ame-designation-numberAME Designation Number1..1string
.... date-of-examinationDate of Examination1..1date

doco Documentation for this format

Options Sets

Answer options for application-type

  • urn:oid:2.16.840.1.113883.6.1#432401000124109 ("Medical Certificate")
  • urn:oid:2.16.840.1.113883.6.1#446021008 ("Medical and Student Pilot Certificate")

Answer options for certificate-class

  • First
  • Second
  • Third

Answer options for hair-color

  • Brown
  • Black
  • Blonde
  • Red
  • Gray
  • White
  • Bald

Answer options for eye-color

  • Brown
  • Blue
  • Green
  • Hazel
  • Gray
  • Black

Answer options for sex

  • http://hl7.org/fhir/administrative-gender#male ("Male")
  • http://hl7.org/fhir/administrative-gender#female ("Female")

Answer options for certificate-held

  • Airline Transport
  • Commercial
  • Private
  • Student
  • Recreational
  • Sport
  • Flight Instructor
  • Flight Engineer
  • Flight Navigator
  • None

Answer options for head-face-neck

  • Normal
  • Abnormal

Answer options for nose

  • Normal
  • Abnormal

Answer options for sinuses

  • Normal
  • Abnormal

Answer options for mouth-throat

  • Normal
  • Abnormal

Answer options for ears-general

  • Normal
  • Abnormal

Answer options for ear-drums

  • Normal
  • Abnormal

Answer options for eyes-general

  • Normal
  • Abnormal

Answer options for ophthalmoscopic

  • Normal
  • Abnormal

Answer options for pupils

  • Normal
  • Abnormal

Answer options for ocular-motility

  • Normal
  • Abnormal

Answer options for lungs-chest

  • Normal
  • Abnormal

Answer options for heart

  • Normal
  • Abnormal

Answer options for vascular-system

  • Normal
  • Abnormal

Answer options for abdomen-viscera

  • Normal
  • Abnormal

Answer options for anus

  • Normal
  • Abnormal
  • Not Examined

Answer options for skin

  • Normal
  • Abnormal

Answer options for genitourinary

  • Normal
  • Abnormal
  • Not Examined

Answer options for extremities

  • Normal
  • Abnormal

Answer options for spine

  • Normal
  • Abnormal

Answer options for marks-scars

  • Normal
  • Abnormal

Answer options for lymphatics

  • Normal
  • Abnormal

Answer options for neurological

  • Normal
  • Abnormal

Answer options for psychiatric

  • Normal
  • Abnormal

Answer options for general-systemic

  • Normal
  • Abnormal

Answer options for bp-arm

  • Right
  • Left
  • Both

Answer options for medical-certificate

  • First Class
  • Second Class
  • Third Class
  • Not Issued - Letter of Denial Issued
  • Not Issued - Deferred for Further Evaluation