Enclosure (3) to COMDTINST 16798.2
Date_______
Coast Guard Auxiliary
Air Crew Medical Screening
Applicant _______________________________________ DOB ___________________
Note to the physician. Please examine the member in each category below
and place an "X" in the appropriate block. Explain any "No" answers on
return the completed form to the examinee.
Yes
No
Distant Vision - 20/40 or better in each eye with or without
correction
___
___
Near Vision - 20/40 or better in each eye at 16 inches
___
___
Color Vision - Able to discern Red, Green, & Yellow
___
___
Hearing - Hearing average conversational voice in a quiet room
Using both ears at 6 feet, with the back turned to the examiner or ___
___
Pass the audiometric test below.
Audiometry - Pure tone audiometric test: Unaided, no worse than:
500 HZ
1,000HZ
2,000HZ
3,000HZ
Better Ear
35 Db
30 Db
30 Db
40 Db
Worst Ear
35 Db
50 Db
50 Db
60 Db
___
___
ENT - Absence of any ear condition manifested by vertigo or a
Disturbance of speech or equilibrium.
___
___
Pulse - Normal
___
___
Blood Pressure - Not over 155/95 with___ or without ___ medication
Medication:_________________________________ ___
___
Mental - Absence of psychosis, bipolar disorder, or severe
___
___
ANSC 7042
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