FAA 8700-2: BasicMed Comprehensive Medical Examination Checklist

The individual must complete SECTION 2 of this checklist and provide the checklist in its entirety (including the completed SECTION 2) to the state-licensed physician performing the medical examination.

After completing all mandatory fields in SECTION 2, provide both SECTION 2 and SECTION 3 to the state-licensed physician who will perform your medical examination.

In order to act as PIC under BasicMed, an individual must receive a comprehensive medical examination by a state-licensed physician during the previous 48 months in accordance with 14 CFR 61.23(c)(3)(i).

The completed checklist shall be retained in the individual's logbook (in any legible paper or electronic format) and made available on request.

OMITTED: Leave blank.

List current name. List any former name(s) in the “additional comments or explanation” box found in #18 of the checklist form.

Entry is optional.

Enter permanent mailing address and country of residence. Include the nine digit ZIP code, if known. (e.g., 20003-3230). Provide your current telephone number, including area code.

List month, day, and year (e.g., 01/31/1960). Country of citizenship: Enter citizenship (e.g., USA).

Color of hair: Specify as black, blond, brown, gray, red, or bald.

Color of eyes: Specify actual (not contact lenses) eye color as black, blue, brown, green, gray, or hazel.

Sex: Indicate male or female.

Select the checkboxes that apply. If "Other" is selected, write in the name of the type of certificate.

Occupation: Enter major employment. Entry is optional.

Employer: Enter your employer. Entry is optional.

Select "Yes" or "No." If "Yes” is selected, list the month and year (e.g., 01/1999) of the action.

Enter month and year. If you have no prior application, you cannot use BasicMed.

Do you currently use any medication (prescription or non-prescription): Select "Yes" or "No." If "Yes" is selected, enter the name of the medication(s), dosage, and frequency used.

17b. Do you ever use near vision contact lenses while flying: Select “Yes” or “No.” If you wear a contact in only one eye to correct for near vision, check “Yes.”

Select “Yes” or “No” for each item listed. Mark “Yes” if you have or had any of the following conditions at ANY TIME in your life. For every condition you have ever been diagnosed with, had, or presently have, you must answer "Yes."

a. Frequent or severe headaches; b. Dizziness or fainting spell; c. Unconsciousness for any reason; d. Eye or vision trouble (except for glasses); e. Hay fever or allergy; f. Asthma or lung disease; g. Heart or vascular trouble; h. High or low blood pressure; i. Stomach, liver, or intestinal trouble; j. Kidney stone or blood in urine; k. Diabetes; l. Neurological disorders (epilepsy, seizures, stroke, paralysis, etc.).

m. Mental disorders of any sort (depression, anxiety, etc.); n. Substance dependence, failed a drug test ever, or substance abuse or use of illegal substance in the last 2 years; o. Alcohol dependence or abuse; p. Suicide attempt; q. Motion sickness requiring medication; r. Military medical discharge; s. Medical rejection by military service; t. Rejection for life or health insurance; u. Admitted to a hospital; x. Other illness, disability, or surgery.

You must give an explanation for each item marked “Yes” in the “additional comments or explanation” box. Explain when it occurred, the severity, how it was treated, and if you are currently taking any medication or having treatment for the condition or have to see a physician for the condition. Discuss any “Yes” responses with the physician doing this exam.

(1) Have you ever been convicted (which may include paying a fine or forfeiting bond or collateral) of an offense involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; or (2) Have you ever been convicted, and/or subject to an administrative action by a state or other jurisdiction for an offense for which your driver's license was denied, suspended, cancelled, or revoked or which resulted in attendance at an educational or rehabilitation program?

Individual traffic convictions are not required to be reported if they did not involve alcohol/drugs, suspension, revocation, cancellation, or denial of driving privileges, or attendance at an educational or rehabilitation program.

If "Yes" is checked, you must give a description of the conviction(s) and/or administrative action(s) in the “additional comments or explanation” box. The description must include: The alcohol or drug offense for which you were arrested and/or convicted or the type of administrative action involved ; The name of the state or other jurisdiction involved; and The date of the conviction(s) and/or administrative action(s).

Have you ever had any other (non-traffic) convictions (e.g., assault, battery, public intoxication, robbery, etc.)? If so, name the charge for which you were convicted and the date of conviction in the “additional comments or explanation" box.

List all visits in the last 3 years to a physician, physician assistant, nurse practitioner, psychologist, clinical social worker, or substance abuse specialist for treatment, examination, or medical/mental evaluation.

Enter the date of visit as month and year (e.g., 01/1990), name, address, and type of health professional consulted and briefly state reason for consultation. Multiple visits to one health professional for the same condition may be grouped together on one line.

You do not need to report: Occasional common illnesses such as colds or sore throats that resolved; Routine dental, eye, and FAA periodic medical examinations; or Consultations with your employer-sponsored employee assistance program (EAP) unless the consultations were for substance abuse or unless the consultations resulted in referral for psychiatric evaluation or treatment.

The Airman's Signature and Declarations: The answers provided by me on this checklist, including my answers regarding my medical history, are true and complete; I understand that I am prohibited under Federal Aviation Administration regulations from acting as pilot in command, or in any other capacity as a required flight crewmember, if I know or have reason to know of any medical deficiency or medically disqualifying condition that would make me unable to operate the aircraft in a safe manner; and I am aware of the regulations pertaining to the prohibition on operations during medical deficiency and I have no medically disqualifying conditions in accordance with applicable law.

The examination checklist may only be completed by a state-licensed physician.

By signing, you certify that you are not aware of any medical condition that, as presently treated, could interfere with the individual's ability to safely operate an aircraft.

Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willingly falsifies, conceals or covers up by any trick, scheme, or device a material fact, or who makes any false, fictitious or fraudulent statements or representations, or entry, may be fined up to $250,000 or imprisoned not more than 5 years, or both (checked October 20, 2026).

To operate an aircraft under BasicMed, you may only use this checklist to comply with 14 CFR 61.113(i) if you: Hold or have held a valid first-, second-, or third-class medical certificate issued by the FAA at any time after July 14, 2006; and The most recent medical certificate held (including an authorization for a special issuance certificate) must have not been denied, suspended, revoked, or withdrawn.