Form 4497 PDF Details

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.

QuestionAnswer
Form NameForm 4497
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesflying duty medical, da interim duty download, physician form 4497 online, da form 4497

Form Preview Example

INTERIM (ABBREVIATED) FLYING DUTY MEDICAL EXAMINATION

For use of this form, see AR 40-501; the proponent agency is OTSG

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)

AD-RA

AD-USAR

USAR-AGR

USAR-TPU

USAR-IRR

AVIATOR

FS/APA

ARNG-AGR

ARNG

DAC

CIV CONTRACTOR

RET-MIL

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 600-105 (Aviation service) and AR 40-8 (Exogenous factors).

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