Form 4497 is an Internal Revenue Service Form that is used to report information about a sale or exchange of certain property. The form is used to report the sale price, the adjusted basis, and the gain or loss from the sale. It must be filed for each property transaction, including bartering transactions and gifts. The IRS may use this information to determine if you have correctly reported your income and capital gains. You should always consult a tax professional to ensure that you are filing your taxes correctly.
| 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 |
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BLODD PRESS |
16. PULSE |
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17. |
HEIGHT (Ins) |
18. WEIGHT (Lbs) |
19. |
%BODY FAT |
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20a. |
DEPTH PERCEPTION TEST |
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b. TEST SCORE |
c. TEST RESULT |
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VTA |
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VERHOEFF |
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RANDOT |
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PASS |
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FAIL |
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CIRCLES |
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21. EYE EXAMINATION |
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22. INTRAOCULAR |
23. AUDIOMETRIC SCREENING (DECIBELS) |
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PRESSURE |
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a. DISTANT VISION |
b. NEAR VISION |
500 Hz |
1000 |
2000 |
3000 |
4000 |
6000 |
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RIGHT |
20/ |
corr to 20/ |
20/ |
corr to 20/ |
mmHg |
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LEFT |
20/ |
corr to 20/ |
20/ |
corr to 20/ |
mmHg |
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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 |