Navigating the intricacies of the 4497 form, officially known as the Interim (Abbreviated) Flying Duty Medical Examination, is a pivotal step for individuals within the military and related sectors engaging in aviation duties. This form, governed by AR 40-501 and championed by the OTSG, serves as a comprehensive document, encapsulating a wide range of information critical to assessing the medical fitness of those in aviation roles. From personal identification details, including name, social security number, and rank, to more specific aviation-related information such as component type and aviation duty, the form delves into the fine details necessary for a thorough evaluation. It also covers unit assignment, contact information, and medical waivers in effect, ensuring a holistic review of the applicant's medical status and history. Another significant aspect of this document is the emphasis on the applicant’s responsibility to disclose any changes in their health status or medical history since their last examination, affirming the importance of transparency in maintaining operational safety. Moreover, the form includes sections for recording vital signs, vision and hearing assessments, a detailed health and physical examination, and ultimately, the medical personnel’s recommendations regarding the applicant's qualification for flying duties. Designed to streamline the assessment process while ensuring no critical detail is overlooked, the 4497 form exemplifies the meticulous approach taken towards safeguarding the health and safety of those who serve in challenging and high-risk aviation roles.
Question | Answer |
---|---|
Form Name | Form 4497 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | flying duty medical, da interim duty download, physician form 4497 online, da form 4497 |
INTERIM (ABBREVIATED) FLYING DUTY MEDICAL EXAMINATION
For use of this form, see AR
1. EXAM DATE (DD/MM/YY)
2.NAME (LAST, FIRST, MI)
3. SSN
4. RANK
5. BIRTH DATE (DD/MM/YY)
6.COMPONENT (CHECK ONE OR MORE)
7. AVIATION DUTY (CHECK ONE)
AVIATOR
FS/APA
ARNG
DAC
CIV CONTRACTOR
AEROSCOUT
CLASS 3
ATC (CLASS 4)
8. UNIT OF ASSIGNMENT AND COMPLETE UNIT ADDRESS
9. UNIT PHONE
10. HOME PHONE
12. LIST YOUR MEDICATIONS AND DOSAGES
11. LIST YOUR AEROMEDICAL WAIVERS IN EFFECT
13.I understand that I must be cleared by a flight surgeon after hospitalization or sick in quarters, or after treatment or activities requiring restriction. I am informing the flight surgeon of my medical history or any change in my health since my last FDME. I have read AR
PATIENT'S SIGNATURE
14a. EXAM FACILITY ADDRESS
b. EXAM FACILITY PHONE |
c. AEDR FACILITY CODE |
|
|
15. |
|
BLODD PRESS |
16. PULSE |
|
|
17. |
HEIGHT (Ins) |
18. WEIGHT (Lbs) |
19. |
%BODY FAT |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
20a. |
DEPTH PERCEPTION TEST |
|
|
|
|
b. TEST SCORE |
c. TEST RESULT |
||||||||||
|
|
VTA |
|
|
VERHOEFF |
|
RANDOT |
|
|
|
|
|
PASS |
|
FAIL |
||
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
CIRCLES |
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
21. EYE EXAMINATION |
|
|
|
22. INTRAOCULAR |
23. AUDIOMETRIC SCREENING (DECIBELS) |
||||||
|
|
|
|
|
PRESSURE |
|
|
|
|
|
|
|
a. DISTANT VISION |
b. NEAR VISION |
500 Hz |
1000 |
2000 |
3000 |
4000 |
6000 |
|||
|
|
||||||||||
RIGHT |
20/ |
corr to 20/ |
20/ |
corr to 20/ |
mmHg |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LEFT |
20/ |
corr to 20/ |
20/ |
corr to 20/ |
mmHg |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
24.HISTORY AND EXAMINATION. Enter pertinent history and physical findings below as per ATB 2. Continue on reverse, if required. If review of the most recent USAAMA AEDR History Verification Form shows no change in history, enter "No significant Interval history."
25. ELECTROCARDIOGRAM FINDINGS
THIS BOX IS FOR USAAMA USE ONLY
26.RECOMMENDATION QUALIFIED
DISQUALIFIED, CONTINUE WAIVERS
NEW DISQUALIFICATION, SEND AEROMEDICAL SUMMARY AND SF 88/93
27. AEROMEDICAL PHYSICIAN ASSISTANT STAMP AND SIGNATURE
28. FLIGHT SURGEON STAMP AND SIGNATURE
DA FORM 4497, MAR 2002 |
PREVIOUS EDITIONS ARE OBSOLETE |
USAPA V1.00 |