FAA8500Questionnaire
type: Questionnaire
node role: treeRoot
id:
  v: FAA8500Questionnaire
text:
  status:
    v: extensions
  div:
    v: Generated Narrative: Questionnaire FAA8500Questionnaire Structure LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> FAA Form 8500-8 Application for Airman Medical Certificate converted to FHIR Questionnaire format Questionnaire http://hl7.org/fhir/uv/aerospace/Questionnaire/faa-form-8500-8#0.5.12 #xD; application-info APPLICATION INFORMATION 0..1 group #xD; application-type APPLICATION FOR 1..1 choice Options: 2 options #xD; certificate-class CLASS OF MEDICAL CERTIFICATE APPLIED FOR 1..1 choice Options: 3 options #xD; personal-info PERSONAL INFORMATION 0..1 group #xD; name NAME (Last, First, Middle) 1..1 string #xD; ssn SOCIAL SECURITY NUMBER 0..1 string #xD; address ADDRESS (Street, City, State, ZIP) 1..1 string #xD; telephone TELEPHONE NUMBER 1..1 string #xD; date-of-birth DATE OF BIRTH (MM/DD/YYYY) 1..1 date #xD; hair-color COLOR OF HAIR 1..1 choice Options: 7 options #xD; eye-color COLOR OF EYES 1..1 choice Options: 6 options #xD; sex SEX 1..1 choice Options: 2 options #xD; airman-info AIRMAN INFORMATION 0..1 group #xD; certificate-held TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD 1..* choice Options: 10 options #xD; occupation OCCUPATION 1..1 string #xD; employer EMPLOYER 1..1 string #xD; total-pilot-time TOTAL PILOT TIME TO DATE 1..1 quantity #xD; pilot-time-6-months TOTAL PILOT TIME PAST 6 MONTHS 1..1 quantity #xD; medical-certificate-date DATE OF LAST FAA MEDICAL APPLICATION 0..1 date #xD; medical-certificate-denied HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED, OR REVOKED? 1..1 boolean #xD; medical-certificate-denied-details If yes, provide date 0..1 date Enable When: medical-certificate-denied = #xD; medications MEDICATION INFORMATION 0..1 group #xD; current-medications DO YOU CURRENTLY USE ANY MEDICATION (PRESCRIPTION OR NONPRESCRIPTION)? 1..1 boolean #xD; medication-list List medication(s) and dosage 0..* string Enable When: current-medications = #xD; contact-lenses DO…
url:
  v: http://hl7.org/fhir/uv/aerospace/Questionnaire/faa-form-8500-8
  l: faa-form-8500-8
version:
  v: 0.5.12
title:
  v: FAA Form 8500-8 Questionnaire
status:
  v: active
date:
  v: 2025-05-21
publisher:
  v: MITRE
contact:
  name:
    v: MITRE
  telecom:
    system:
      v: url
    value:
      v: https://www.mitre.org/
description:
  v: FAA Form 8500-8 Application for Airman Medical Certificate converted to FHIR Questionnaire format
purpose:
  v: Application for Airman Medical Certificate or Airman Medical & Student Pilot Certificate
copyright:
  v: Federal Aviation Administration
item:
  link id:
    v: application-info
  text:
    v: APPLICATION INFORMATION
  type:
    v: group
  item:
    link id:
      v: application-type
    text:
      v: APPLICATION FOR
    type:
      v: choice
    required:
      v: true
    answer option:
      value: Coding
    answer option:
      value: Coding
  item:
    link id:
      v: certificate-class
    text:
      v: CLASS OF MEDICAL CERTIFICATE APPLIED FOR
    type:
      v: choice
    required:
      v: true
    answer option:
      value: String
        v: First
    answer option:
      value: String
        v: Second
    answer option:
      value: String
        v: Third
item:
  link id:
    v: personal-info
  text:
    v: PERSONAL INFORMATION
  type:
    v: group
  item:
    link id:
      v: name
    text:
      v: NAME (Last, First, Middle)
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: ssn
    text:
      v: SOCIAL SECURITY NUMBER
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: address
    text:
      v: ADDRESS (Street, City, State, ZIP)
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: telephone
    text:
      v: TELEPHONE NUMBER
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: date-of-birth
    text:
      v: DATE OF BIRTH (MM/DD/YYYY)
    type:
      v: date
    required:
      v: true
  item:
    link id:
      v: hair-color
    text:
      v: COLOR OF HAIR
    type:
      v: choice
    required:
      v: true
    answer option:
      value: String
        v: Brown
    answer option:
      value: String
        v: Black
    answer option:
      value: String
        v: Blonde
    answer option:
      value: String
        v: Red
    answer option:
      value: String
        v: Gray
    answer option:
      value: String
        v: White
    answer option:
      value: String
        v: Bald
  item:
    link id:
      v: eye-color
    text:
      v: COLOR OF EYES
    type:
      v: choice
    required:
      v: true
    answer option:
      value: String
        v: Brown
    answer option:
      value: String
        v: Blue
    answer option:
      value: String
        v: Green
    answer option:
      value: String
        v: Hazel
    answer option:
      value: String
        v: Gray
    answer option:
      value: String
        v: Black
  item:
    link id:
      v: sex
    text:
      v: SEX
    type:
      v: choice
    required:
      v: true
    answer option:
      value: Coding
    answer option:
      value: Coding
item:
  link id:
    v: airman-info
  text:
    v: AIRMAN INFORMATION

v: urn:oid:2.16.840.1.113883.6.1
l: 2.16.840.1.113883.6.1

v: 432401000124109

v: Medical Certificate

v: urn:oid:2.16.840.1.113883.6.1
l: 2.16.840.1.113883.6.1

v: 446021008

v: Medical and Student Pilot Certificate

v: male

v: Male

v: female

v: Female

v: group

link id:
  v: certificate-held
text:
  v: TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD
type:
  v: choice
required:
  v: true
repeats:
  v: true
answer option:
  value: String
    v: Airline Transport
answer option:
  value: String
    v: Commercial
answer option:
  value: String
    v: Private
answer option:
  value: String
    v: Student
answer option:
  value: String
    v: Recreational
answer option:
  value: String
    v: Sport
answer option:
  value: String
    v: Flight Instructor
answer option:
  value: String
    v: Flight Engineer
answer option:
  value: String
    v: Flight Navigator
answer option:
  value: String
    v: None

link id:
  v: occupation
text:
  v: OCCUPATION
type:
  v: string
required:
  v: true

link id:
  v: employer
text:
  v: EMPLOYER
type:
  v: string
required:
  v: true

link id:
  v: total-pilot-time
text:
  v: TOTAL PILOT TIME TO DATE
type:
  v: quantity
required:
  v: true

link id:
  v: pilot-time-6-months
text:
  v: TOTAL PILOT TIME PAST 6 MONTHS
type:
  v: quantity
required:
  v: true

link id:
  v: medical-certificate-date
text:
  v: DATE OF LAST FAA MEDICAL APPLICATION
type:
  v: date
required:
  v: false

link id:
  v: medical-certificate-denied
text:
  v: HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED, OR REVOKED?
type:
  v: boolean
required:
  v: true
item:
  link id:
    v: medical-certificate-denied-details
  text:
    v: If yes, provide date
  type:
    v: date
  enable when:
    question:
      v: medical-certificate-denied
    operator:
      v: =
    answer: Boolean
      v: true
  required:
    v: false

link id:
  v: medications
text:
  v: MEDICATION INFORMATION
type:
  v: group
item:
  link id:
    v: current-medications
  text:
    v: DO YOU CURRENTLY USE ANY MEDICATION (PRESCRIPTION OR NONPRESCRIPTION)?
  type:
    v: boolean
  required:
    v: true
  item:
    link id:
      v: medication-list
    text:
      v: List medication(s) and dosage
    type:
      v: string
    enable when:
      question:
        v: current-medications
      operator:
        v: =
      answer: Boolean
        v: true
    required:
      v: false
    repeats:
      v: true
item:
  link id:
    v: contact-lenses
  text:
    v: DO YOU EVER USE NEAR VISION CONTACT LENS(ES) WHILE FLYING?
  type:
    v: boolean
  required:
    v: true

link id:
  v: medical-history
text:
  v: MEDICAL HISTORY - Have you ever in your life been diagnosed with, had, or do you presently have any of the following?
type:
  v: group
item:
  link id:
    v: headaches
  code: http://snomed.info/id/398057008
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 398057008
    display:
      v: Tension-type headache
  text:
    v: Frequent or severe headaches
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: dizziness
  code: http://snomed.info/id/69096003
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 69096003
    display:
      v: Dizziness
  text:
    v: Dizziness or fainting spells
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: unconsciousness
  code: http://snomed.info/id/69944003
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 69944003
    display:
      v: Unconscious
  text:
    v: Unconsciousness for any reason
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: eye-trouble
  code: http://snomed.info/id/371405004
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 371405004
    display:
      v: Disorder of eye
  text:
    v: Eye or vision trouble except glasses
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: hay-fever
  text:
    v: Hay fever or allergy
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: asthma
  code: http://snomed.info/id/195967001
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 195967001
    display:
      v: Asthma
  text:
    v: Asthma or lung disease
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: heart-trouble
  code: http://snomed.info/id/128238001
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 128238001
    display:
      v: Chronic heart disease
  text:
    v: Heart or vascular trouble
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: blood-pressure
  code: http://snomed.info/id/38341003
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 38341003
    display:
      v: Hypertensive disorder
  text:
    v: High or low blood pressure
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: stomach-trouble
  code: http://snomed.info/id/328383001
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 328383001
    display:
      v: Chronic liver disease
  text:
    v: Stomach, liver, or intestinal trouble
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: kidney-trouble
  code: http://snomed.info/id/95570007
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 95570007
    display:
      v: Kidney stone
  text:
    v: Kidney stone or blood in urine
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: diabetes
  code: http://snomed.info/id/73211009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 73211009
    display:
      v: Diabetes mellitus
  text:
    v: Diabetes
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: neurological
  code: http://snomed.info/id/84757009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 84757009
    display:
      v: Epilepsy
  text:
    v: Neurological disorders; epilepsy, seizures, stroke, paralysis, etc.
  type:
    v: boolean
  required:
    v: true

link id:
  v: mental-disorders
code: http://snomed.info/id/74732009
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 74732009
  display:
    v: Mental disorder
text:
  v: Mental disorders of any sort; depression, anxiety, etc.
type:
  v: boolean
required:
  v: true

link id:
  v: substance-abuse
code: http://snomed.info/id/66214007
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 66214007
  display:
    v: Substance abuse
text:
  v: Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years
type:
  v: boolean
required:
  v: true

link id:
  v: alcohol-dependence
code: http://snomed.info/id/66590003
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 66590003
  display:
    v: Alcohol dependence
text:
  v: Alcohol dependence or abuse
type:
  v: boolean
required:
  v: true

link id:
  v: suicide-attempt
code: http://snomed.info/id/82313006
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 82313006
  display:
    v: Suicide Attempt
text:
  v: Suicide attempt
type:
  v: boolean
required:
  v: true

link id:
  v: motion-sickness
code: http://snomed.info/id/37031009
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 37031009
  display:
    v: Motion sickness
text:
  v: Motion sickness requiring medication
type:
  v: boolean
required:
  v: true

link id:
  v: military-medical-discharge
text:
  v: Military medical discharge
type:
  v: boolean
required:
  v: true

link id:
  v: medical-rejection
text:
  v: Medical rejection by military service
type:
  v: boolean
required:
  v: true

link id:
  v: insurance-rejection
text:
  v: Rejection for life or health insurance
type:
  v: boolean
required:
  v: true

link id:
  v: hospital-admission
code: http://snomed.info/id/32485007
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 32485007
  display:
    v: Hospital admission
text:
  v: Admission to hospital
type:
  v: boolean
required:
  v: true

link id:
  v: history-other
text:
  v: Other illness, disability, or surgery
type:
  v: boolean
required:
  v: true

link id:
  v: medical-disability-benefits
text:
  v: Medical disability benefits
type:
  v: boolean
required:
  v: true

link id:
  v: arrests
text:
  v: History of arrest(s), conviction(s), and/or administrative action(s)
type:
  v: boolean
required:
  v: true

link id:
  v: history-convictions
text:
  v: History of nontraffic convictions
type:
  v: boolean
required:
  v: true

link id:
  v: medical-history-explanation
text:
  v: Explanation for any above YES answers (include dates, condition, treatment, and names/addresses of medical providers)
type:
  v: text
required:
  v: false

link id:
  v: healthcare-visits
text:
  v: VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS
type:
  v: boolean
required:
  v: true
item:
  link id:
    v: healthcare-visit-details
  text:
    v: Date, Name, Address and Type of Health Professional Consulted & Reason
  type:
    v: text
  enable when:
    question:
      v: healthcare-visits
    operator:
      v: =
    answer: Boolean
      v: true
  required:
    v: false
  repeats:
    v: true

link id:
  v: physical-examination
text:
  v: PHYSICAL EXAMINATION (FOR AME USE ONLY)
type:
  v: group
item:
  link id:
    v: height
  code: http://snomed.info/id/1153637007
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 1153637007
    display:
      v: Body height
  text:
    v: HEIGHT (inches)
  type:
    v: decimal
  required:
    v: true
item:
  link id:
    v: weight
  code: http://snomed.info/id/27113001
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 27113001
    display:
      v: Body weight
  text:
    v: WEIGHT (pounds)
  type:
    v: decimal
  required:
    v: true
item:
  link id:
    v: soda-issued
  text:
    v: STATEMENT OF DEMONSTRATED ABILITY (SODA) ISSUED
  type:
    v: boolean
  required:
    v: false
  item:
    link id:
      v: soda-serial
    text:
      v: SODA SERIAL NUMBER
    type:
      v: string
    enable when:
      question:
        v: soda-issued
      operator:
        v: =
      answer: Boolean
        v: true
    required:
      v: false
item:
  link id:
    v: body-systems-examination
  text:
    v: BODY SYSTEMS EXAMINATION
  type:
    v: group
  item:
    link id:
      v: head-face-neck
    text:
      v: Head, face, neck, and scalp
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: nose
    text:
      v: Nose
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: sinuses
    text:
      v: Sinuses
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: mouth-throat
    text:
      v: Mouth and throat
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: ears-general
    text:
      v: Ears, general
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: ear-drums
    text:
      v: Ear drums
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: eyes-general
    text:
      v: Eyes, general
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: ophthalmoscopic
    text:
      v: Ophthalmoscopic
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: pupils
    text:
      v: Pupils (Equality and Reaction)
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal
  item:
    link id:
      v: ocular-motility
    text:
      v: Ocular motility
    type:
      v: choice
    answer option:
      value: String
        v: Normal
    answer option:
      value: String
        v: Abnormal

link id:
  v: lungs-chest
text:
  v: Lungs and chest
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: heart
text:
  v: Heart
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: vascular-system
text:
  v: Vascular system
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: abdomen-viscera
text:
  v: Abdomen and viscera
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: anus
text:
  v: Anus
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal
answer option:
  value: String
    v: Not Examined

link id:
  v: skin
text:
  v: Skin
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: genitourinary
text:
  v: Genitourinary system
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal
answer option:
  value: String
    v: Not Examined

link id:
  v: extremities
text:
  v: Musculoskeletal - Upper and lower extremities
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: spine
text:
  v: Spine, other musculoskeletal
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: marks-scars
text:
  v: Identifying body marks, scars, tattoos
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: lymphatics
text:
  v: Lymphatics
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: neurological
text:
  v: Neurological
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: psychiatric
text:
  v: Psychiatric
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: general-systemic
text:
  v: General Systemic
type:
  v: choice
answer option:
  value: String
    v: Normal
answer option:
  value: String
    v: Abnormal

link id:
  v: vision-tests
text:
  v: VISION TESTS
type:
  v: group
item:
  link id:
    v: distance-vision
  code: http://snomed.info/id/246633000
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 246633000
    display:
      v: Distance vision
  text:
    v: Distant Vision
  type:
    v: group
  item:
    link id:
      v: distance-right-uncorrected
    text:
      v: Right eye uncorrected
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: distance-right-corrected
    text:
      v: Right eye corrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: distance-left-uncorrected
    text:
      v: Left eye uncorrected
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: distance-left-corrected
    text:
      v: Left eye corrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: distance-both-uncorrected
    text:
      v: Both eyes uncorrected
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: distance-both-corrected
    text:
      v: Both eyes corrected
    type:
      v: string
    required:
      v: false
item:
  link id:
    v: near-vision
  code: http://snomed.info/id/830128004
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 830128004
    display:
      v: Near vision
  text:
    v: Near Vision
  type:
    v: group
  item:
    link id:
      v: near-right-uncorrected
    text:
      v: Right eye uncorrected
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: near-right-corrected
    text:
      v: Right eye corrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: near-left-uncorrected
    text:
      v: Left eye uncorrected
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: near-left-corrected
    text:
      v: Left eye corrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: near-both-uncorrected
    text:
      v: Both eyes uncorrected
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: near-both-corrected
    text:
      v: Both eyes corrected
    type:
      v: string
    required:
      v: false
item:
  link id:
    v: intermediate-vision
  text:
    v: Intermediate Vision (32 in)
  type:
    v: group
  item:
    link id:
      v: intermediate-right-uncorrected
    text:
      v: Right eye uncorrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: intermediate-right-corrected
    text:
      v: Right eye corrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: intermediate-left-uncorrected
    text:
      v: Left eye uncorrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: intermediate-left-corrected
    text:
      v: Left eye corrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: intermediate-both-uncorrected
    text:
      v: Both eyes uncorrected
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: intermediate-both-corrected
    text:
      v: Both eyes corrected
    type:
      v: string

v: false

link id:
  v: color-vision
code: http://snomed.info/id/271726001
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 271726001
  display:
    v: Color vision
text:
  v: Color Vision
type:
  v: string
required:
  v: true

link id:
  v: field-of-vision
text:
  v: Field of Vision
type:
  v: string
required:
  v: true

link id:
  v: heterophoria
text:
  v: Heterophoria (20')
type:
  v: group
item:
  link id:
    v: esophoria
  code: http://snomed.info/id/62176008
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 62176008
    display:
      v: Esophoria
  text:
    v: Esophoria
  type:
    v: string
  required:
    v: false
item:
  link id:
    v: exophoria
  code: http://snomed.info/id/46343005
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 46343005
    display:
      v: Exophoria
  text:
    v: Exophoria
  type:
    v: string
  required:
    v: false
item:
  link id:
    v: right-hyperphoria
  code: http://snomed.info/id/421452007
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 421452007
    display:
      v: Hyperphoria
  text:
    v: Right Hyperphoria
  type:
    v: string
  required:
    v: false
item:
  link id:
    v: left-hyperphoria
  code: http://snomed.info/id/421452007
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 421452007
    display:
      v: Hyperphoria
  text:
    v: Left Hyperphoria
  type:
    v: string
  required:
    v: false

link id:
  v: hearing-vitals
text:
  v: HEARING, BLOOD PRESSURE, AND ECG
type:
  v: group
item:
  link id:
    v: hearing
  text:
    v: Hearing
  type:
    v: group
  item:
    link id:
      v: audiometric-speech
    text:
      v: Audiometric Speech Discrimination
    type:
      v: string
    required:
      v: false
  item:
    link id:
      v: voice-test
    text:
      v: Conversational Voice Test at 6 Feet
    type:
      v: group
    item:
      link id:
        v: right-ear-pass
      text:
        v: Right Ear
      type:
        v: boolean
      required:
        v: false
    item:
      link id:
        v: left-ear-pass
      text:
        v: Left Ear
      type:
        v: boolean
      required:
        v: false
  item:
    link id:
      v: audiometric-threshold
    text:
      v: Audiometric Threshold in Decibels
    type:
      v: group
    item:
      link id:
        v: threshold-right-500
      text:
        v: Right Ear 500 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-right-1000
      text:
        v: Right Ear 1000 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-right-2000
      text:
        v: Right Ear 2000 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-right-3000
      text:
        v: Right Ear 3000 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-right-4000
      text:
        v: Right Ear 4000 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-left-500
      text:
        v: Left Ear 500 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-left-1000
      text:
        v: Left Ear 1000 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-left-2000
      text:
        v: Left Ear 2000 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-left-3000
      text:
        v: Left Ear 3000 Hz
      type:
        v: decimal
      required:
        v: false
    item:
      link id:
        v: threshold-left-4000
      text:
        v: Left Ear 4000 Hz
      type:
        v: decimal
      required:
        v: false
item:
  link id:
    v: blood-pressure
  code: http://snomed.info/id/75367002
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 75367002
    display:
      v: Blood pressure
  text:
    v: Blood Pressure
  type:
    v: group
  item:
    link id:
      v: systolic
    code: http://snomed.info/id/271649006
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 271649006
      display:
        v: Systolic blood pressure
    text:
      v: Systolic (mmHg)
    type:
      v: integer
    required:
      v: true
  item:
    link id:
      v: diastolic
    code: http://snomed.info/id/271650006
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 271650006
      display:
        v: Diastolic blood pressure
    text:
      v: Diastolic (mmHg)
    type:
      v: integer
    required:
      v: true
  item:
    link id:
      v: bp-arm
    text:
      v: Arm used for reading
    type:
      v: choice
    required:
      v: false

value: String
  v: Right

value: String
  v: Left

value: String
  v: Both

link id:
  v: pulse
code: http://snomed.info/id/8499008
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 8499008
  display:
    v: Pulse, function
text:
  v: Pulse
type:
  v: integer
required:
  v: true

link id:
  v: urinalysis
text:
  v: Urinalysis
type:
  v: group
item:
  link id:
    v: urine-albumin
  code: http://snomed.info/id/271000000
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 271000000
    display:
      v: Urine albumin measurement
  text:
    v: Albumin
  type:
    v: string
  required:
    v: false
item:
  link id:
    v: urine-sugar
  code: http://snomed.info/id/170755004
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 170755004
    display:
      v: Urine sugar chart
  text:
    v: Sugar
  type:
    v: string
  required:
    v: false

link id:
  v: ecg
code: http://snomed.info/id/54550000
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 54550000
  display:
    v: Electroencephalogram
text:
  v: Electrocardiogram (ECG)
type:
  v: string
required:
  v: false

link id:
  v: ame-certification
text:
  v: AME CERTIFICATION
type:
  v: group
item:
  link id:
    v: ame-comments
  text:
    v: AME Comments on History and Findings
  type:
    v: text
  required:
    v: false
item:
  link id:
    v: disqualifying-defects
  text:
    v: DISQUALIFYING DEFECTS (List by item number)
  type:
    v: text
  required:
    v: false
item:
  link id:
    v: medical-certificate
  text:
    v: Medical Certificate Issued
  type:
    v: choice
  required:
    v: true
  answer option:
    value: String
      v: First Class
  answer option:
    value: String
      v: Second Class
  answer option:
    value: String
      v: Third Class
  answer option:
    value: String
      v: Not Issued - Letter of Denial Issued
  answer option:
    value: String
      v: Not Issued - Deferred for Further Evaluation
item:
  link id:
    v: certificate-limitations
  text:
    v: Certificate Limitations/Conditions
  type:
    v: text
  required:
    v: false
item:
  link id:
    v: ame-declaration
  text:
    v: I 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.
  type:
    v: display
  required:
    v: true
item:
  link id:
    v: ame-signature
  text:
    v: AME Signature
  type:
    v: string
  required:
    v: true
item:
  link id:
    v: ame-name
  text:
    v: AME Name
  type:
    v: string
  required:
    v: true
item:
  link id:
    v: ame-address
  text:
    v: AME Address
  type:
    v: string
  required:
    v: true
item:
  link id:
    v: ame-designation-number
  text:
    v: AME Designation Number
  type:
    v: string
  required:
    v: true
item:
  link id:
    v: date-of-examination
  text:
    v: Date of Examination
  type:
    v: date
  required:
    v: true