Aviation Medical Hypertension Evaluation Worksheet

Aviation Medical Hypertension Evaluation Worksheet
Please complete this form to provide information required for your aviation medical hypertension assessment.
Personal Information
Please provide your basic personal details.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
Please answer the following questions about your medical history.
Have you ever been diagnosed with hypertension (high blood pressure)?
Do you currently experience any of the following symptoms? (Select all that apply)
Other
Please provide your recent blood pressure readings (if available):
Rows Date Systolic (mmHg) Diastolic (mmHg)
Reading 1
Reading 2
Reading 3
Are you currently taking any medication for hypertension?
If yes, please list your current hypertension medications (name and dosage):
Lifestyle Factors
Please answer the following about your lifestyle.
How often do you engage in physical exercise?
Do you currently smoke or use tobacco products?
How often do you consume alcoholic beverages?
Family History
Please indicate if any immediate family members have a history of hypertension or cardiovascular disease.
Family history of hypertension or cardiovascular disease?
If yes, please specify relationship(s) and condition(s):
Examiner Comments / Additional Notes
Signature of Applicant
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