Generated Narrative: Questionnaire FAA8500Questionnaire Structure LinkID Text Cardinality Type Description & Constraints 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 YOU EVER USE NEAR VISION CONTACT LENS(ES) WHILE FLYING? 1..1 boolean #xD; medical-history MEDICAL HISTORY - Have you ever in your life been diagnosed with, had, or do you presently have any of the following? 0..1 group #xD; headaches Frequent or severe headaches 1..1 boolean #xD; dizziness Dizziness or fainting spells 1..1 boolean #xD; unconsciousness Unconsciousness for any reason 1..1 boolean #xD; eye-trouble Eye or vision trouble except glasses 1..1 boolean #xD; hay-fever Hay fever or allergy 1..1 boolean #xD; asthma Asthma or lung disease 1..1 boolean #xD; heart-trouble Heart or vascular trouble 1..1 boolean #xD; blood-pressure High or low blood pressure 1..1 boolean #xD; stomach-trouble Stomach, liver, or intestinal trouble 1..1 boolean #xD; kidney-trouble Kidney stone or blood in urine 1..1 boolean #xD; diabetes Diabetes 1..1 boolean #xD; neurological Neurological disorders; epilepsy, seizures, stroke, paralysis, etc. 1..1 boolean #xD; mental-disorders Mental disorders of any sort; depression, anxiety, etc. 1..1 boolean #xD; substance-abuse Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years 1..1 boolean #xD; alcohol-dependence Alcohol dependence or abuse 1..1 boolean #xD; suicide-attempt Suicide attempt 1..1 boolean #xD; motion-sickness Motion sickness requiring medication 1..1 boolean #xD; military-medical-discharge Military medical discharge 1..1 boolean #xD; medical-rejection Medical rejection by military service 1..1 boolean #xD; insurance-rejection Rejection for life or health insurance 1..1 boolean #xD; hospital-admission Admission to hospital 1..1 boolean #xD; history-other Other illness, disability, or surgery 1..1 boolean #xD; medical-disability-benefits Medical disability benefits 1..1 boolean #xD; arrests History of arrest(s), conviction(s), and/or administrative action(s) 1..1 boolean #xD; history-convictions History of nontraffic convictions 1..1 boolean #xD; medical-history-explanation Explanation for any above YES answers (include dates, condition, treatment, and names/addresses of medical providers) 0..1 text #xD; healthcare-visits VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS 1..1 boolean #xD; healthcare-visit-details Date, Name, Address and Type of Health Professional Consulted & Reason 0..* text Enable When: healthcare-visits = #xD; physical-examination PHYSICAL EXAMINATION (FOR AME USE ONLY) 0..1 group #xD; height HEIGHT (inches) 1..1 decimal #xD; weight WEIGHT (pounds) 1..1 decimal #xD; soda-issued STATEMENT OF DEMONSTRATED ABILITY (SODA) ISSUED 0..1 boolean #xD; soda-serial SODA SERIAL NUMBER 0..1 string Enable When: soda-issued = #xD; body-systems-examination BODY SYSTEMS EXAMINATION 0..1 group #xD; head-face-neck Head, face, neck, and scalp 0..1 choice Options: 2 options #xD; nose Nose 0..1 choice Options: 2 options #xD; sinuses Sinuses 0..1 choice Options: 2 options #xD; mouth-throat Mouth and throat 0..1 choice Options: 2 options #xD; ears-general Ears, general 0..1 choice Options: 2 options #xD; ear-drums Ear drums 0..1 choice Options: 2 options #xD; eyes-general Eyes, general 0..1 choice Options: 2 options #xD; ophthalmoscopic Ophthalmoscopic 0..1 choice Options: 2 options #xD; pupils Pupils (Equality and Reaction) 0..1 choice Options: 2 options #xD; ocular-motility Ocular motility 0..1 choice Options: 2 options #xD; lungs-chest Lungs and chest 0..1 choice Options: 2 options #xD; heart Heart 0..1 choice Options: 2 options #xD; vascular-system Vascular system 0..1 choice Options: 2 options #xD; abdomen-viscera Abdomen and viscera 0..1 choice Options: 2 options #xD; anus Anus 0..1 choice Options: 3 options #xD; skin Skin 0..1 choice Options: 2 options #xD; genitourinary Genitourinary system 0..1 choice Options: 3 options #xD; extremities Musculoskeletal - Upper and lower extremities 0..1 choice Options: 2 options #xD; spine Spine, other musculoskeletal 0..1 choice Options: 2 options #xD; marks-scars Identifying body marks, scars, tattoos 0..1 choice Options: 2 options #xD; lymphatics Lymphatics 0..1 choice Options: 2 options #xD; neurological Neurological 0..1 choice Options: 2 options #xD; psychiatric Psychiatric 0..1 choice Options: 2 options #xD; general-systemic General Systemic 0..1 choice Options: 2 options #xD; vision-tests VISION TESTS 0..1 group #xD; distance-vision Distant Vision 0..1 group #xD; distance-right-uncorrected Right eye uncorrected 1..1 string #xD; distance-right-corrected Right eye corrected 0..1 string #xD; distance-left-uncorrected Left eye uncorrected 1..1 string #xD; distance-left-corrected Left eye corrected 0..1 string #xD; distance-both-uncorrected Both eyes uncorrected 1..1 string #xD; distance-both-corrected Both eyes corrected 0..1 string #xD; near-vision Near Vision 0..1 group #xD; near-right-uncorrected Right eye uncorrected 1..1 string #xD; near-right-corrected Right eye corrected 0..1 string #xD; near-left-uncorrected Left eye uncorrected 1..1 string #xD; near-left-corrected Left eye corrected 0..1 string #xD; near-both-uncorrected Both eyes uncorrected 1..1 string #xD; near-both-corrected Both eyes corrected 0..1 string #xD; intermediate-vision Intermediate Vision (32 in) 0..1 group #xD; intermediate-right-uncorrected Right eye uncorrected 0..1 string #xD; intermediate-right-corrected Right eye corrected 0..1 string #xD; intermediate-left-uncorrected Left eye uncorrected 0..1 string #xD; intermediate-left-corrected Left eye corrected 0..1 string #xD; intermediate-both-uncorrected Both eyes uncorrected 0..1 string #xD; intermediate-both-corrected Both eyes corrected 0..1 string #xD; color-vision Color Vision 1..1 string #xD; field-of-vision Field of Vision 1..1 string #xD; heterophoria Heterophoria (20') 0..1 group #xD; esophoria Esophoria 0..1 string #xD; exophoria Exophoria 0..1 string #xD; right-hyperphoria Right Hyperphoria 0..1 string #xD; left-hyperphoria Left Hyperphoria 0..1 string #xD; hearing-vitals HEARING, BLOOD PRESSURE, AND ECG 0..1 group #xD; hearing Hearing 0..1 group #xD; audiometric-speech Audiometric Speech Discrimination 0..1 string #xD; voice-test Conversational Voice Test at 6 Feet 0..1 group #xD; right-ear-pass Right Ear 0..1 boolean #xD; left-ear-pass Left Ear 0..1 boolean #xD; audiometric-threshold Audiometric Threshold in Decibels 0..1 group #xD; threshold-right-500 Right Ear 500 Hz 0..1 decimal #xD; threshold-right-1000 Right Ear 1000 Hz 0..1 decimal #xD; threshold-right-2000 Right Ear 2000 Hz 0..1 decimal #xD; threshold-right-3000 Right Ear 3000 Hz 0..1 decimal #xD; threshold-right-4000 Right Ear 4000 Hz 0..1 decimal #xD; threshold-left-500 Left Ear 500 Hz 0..1 decimal #xD; threshold-left-1000 Left Ear 1000 Hz 0..1 decimal #xD; threshold-left-2000 Left Ear 2000 Hz 0..1 decimal #xD; threshold-left-3000 Left Ear 3000 Hz 0..1 decimal #xD; threshold-left-4000 Left Ear 4000 Hz 0..1 decimal #xD; blood-pressure Blood Pressure 0..1 group #xD; systolic Systolic (mmHg) 1..1 integer #xD; diastolic Diastolic (mmHg) 1..1 integer #xD; bp-arm Arm used for reading 0..1 choice Options: 3 options #xD; pulse Pulse 1..1 integer #xD; urinalysis Urinalysis 0..1 group #xD; urine-albumin Albumin 0..1 string #xD; urine-sugar Sugar 0..1 string #xD; ecg Electrocardiogram (ECG) 0..1 string #xD; ame-certification AME CERTIFICATION 0..1 group #xD; ame-comments AME Comments on History and Findings 0..1 text #xD; disqualifying-defects DISQUALIFYING DEFECTS (List by item number) 0..1 text #xD; medical-certificate Medical Certificate Issued 1..1 choice Options: 5 options #xD; certificate-limitations Certificate Limitations/Conditions 0..1 text #xD; ame-declaration 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. 1..1 display #xD; ame-signature AME Signature 1..1 string #xD; ame-name AME Name 1..1 string #xD; ame-address AME Address 1..1 string #xD; ame-designation-number AME Designation Number 1..1 string #xD; date-of-examination Date of Examination 1..1 date #xD; 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
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
CLASS OF MEDICAL CERTIFICATE APPLIED FOR
HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED, OR REVOKED?
DO YOU CURRENTLY USE ANY MEDICATION (PRESCRIPTION OR NONPRESCRIPTION)?
DO YOU EVER USE NEAR VISION CONTACT LENS(ES) WHILE FLYING?
MEDICAL HISTORY - Have you ever in your life been diagnosed with, had, or do you presently have any of the following?
Neurological disorders; epilepsy, seizures, stroke, paralysis, etc.
Mental disorders of any sort; depression, anxiety, etc.
Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years
History of arrest(s), conviction(s), and/or administrative action(s)
Explanation for any above YES answers (include dates, condition, treatment, and names/addresses of medical providers)
VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS
Date, Name, Address and Type of Health Professional Consulted & Reason
STATEMENT OF DEMONSTRATED ABILITY (SODA) ISSUED
Musculoskeletal - Upper and lower extremities
DISQUALIFYING DEFECTS (List by item number)
Not Issued - Deferred for Further Evaluation
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.