FAA Pilot Physical Request Form
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First & Last Name *
Address
Telephone Number
Date of Birth
MM
/
DD
/
YYYY
FAA Online MedExpress Application Number
Employer
Employer ID Number
In the following situations, how likely are you to doze off or fall asleep, in contrast to just feeling tired?  Use the following scale to choose the most appropriate number for each situation:  0= would NEVER dose or sleep; 1= SLIGHT chance of dozing or sleeping; 2= MODERATE chance of dozing or sleeping; 3= HIGH chance of dozing or sleeping
0
1
2
3
Sitting and Reading
Watching TV
Sitting inactive in a public place
Being a passenger in a car for an hour
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Stopping for a few minutes in traffic while driving
Clear selection
Preferred Day and Time of your upcoming FAA Physical Exam:
Thank you!
You will be contacted shortly to confirm your appointment with Dr. Springston.  
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