SSN (9 Digits, No Spaces Nor Dashes) s1

Hypertension Aeromedical Summary

TAB through fields, save and print at local facility. Fax Aeromedical Summary, EKG, and current physical exam to NAMI Code 342 at fax number (850) 452-3883 or DSN 922-. If fax is unavailable, e-mail this form and scanned copy of EKG and current exam to . Check the aeromedical status of the member prior to submission at https://apps.nomi.med.navy.mil/NAMIEPE

Health record reviewed and aeromedical status checked. Member is in compliance with all previous waivers and/or physical exam submission requirements.

Health record reviewed and aeromedical status checked. Member is NOT in compliance with all previous waivers and/or physical exam submission requirements. All additional information required to bring member into compliance has been faxed/sent with this AMS.

Date:

Name (Last, First Middle): SSN:

Age: DOB: Rank/Rate/Title: O-10O-9O-8O-70-6O-5O-4O-3O-2O-1WO-5WO-4WO-3WO-2WO-1E9E8E7E6E5E4E3E2E1N/A Service: USNUSNR (Active)USNR (Sel Res)USNR-TARUSMCUSMCRDoN Employee/contractor

Aviation duty: Designated naval aviatorNaval flight officerNaval flight surgeonNaval aircrewmemberProject specialistParachute jumperAerospace physiology technicianAir traffic controllerUAV operatorNaval aerospace physiologistNaval aerospace optometristNaval aerospace experimental physiologist Designator:

Primary aircraft type: F/A-18F-14EA-6BE-2/C-2E-6T-34/T-6T-45/T-2T-39/T-1P-3C-130AV-88MV-22HelicopterOtherNot Applicable Total flying hours: Flying hours last six months:

Command name: UIC:

Medical Treatment Facility: UIC:

Aeromedical point of contact e-mail: with phone: DSNCommercial

Previous waivers and status:

Significant Medical History (HPI):

Consultant Reports:

Physical Examination:

Ht: ” Wt: lbs. HR: 3-5 Day BP Average (after treatment): /

Cardiovascular:

Fundoscopic:

Other/Comments:

Lab Tests: Comment on all abnormal lab values on lab comment line

Chem 7: Na K Cl CO2 BUN Cr Glucose

CBC: Hgb Hct WBC PLT Indices normalabnormal

TSH:

UA: Protein NegativePositive Blood NegativePostive Microscopic Not PerformedNormalAbnormal

Electrocardiogram:

Echocardiogram (if indicated):

Comments:

Diagnosis: Hypertension, controlled with medication, 401.91Essential Hypertension, 401

Medication: , mg QDBIDTIDQID

, mg QDBIDTIDQID

, mg QDBIDTIDQID

Cardiac Risk Factors have been reviewed and evaluated. Member has been counseled on risks and current treatment guidelines. JNC 7 Guidelines available at http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf

NPQPQ/AANAA DIF SG ISG IISG IIINaval flight officerNaval flight surgeonNaval aircrewmemberProject specialistParachute jumperAerospace physiology technicianAir traffic controllerUAV operatorNaval aerospace physiologistNaval aerospace optometristNaval aerospace experimental physiologist, Waiver RecommendedNOT Recommended.

Member's commanding officer is aware of and concurs with waiver recommendation.

Submitting flight surgeon name:

Flight surgeon name:

Reviewing senior flight surgeon name: