The comprehensive medical examination required to conduct operations under § 61.113(i) must include a checklist containing the following:
(a) A section, for the individual to complete that contains -
(1) Boxes 3 through 13 and boxes 16 through 19 of the FAA Form 8500-8 (3-99); and
(2) A signature line for the individual to affirm that -
(i) The answers provided by the individual on that checklist, including the individual's answers regarding medical history, are true and complete;
(ii) The individual understands that he or she is prohibited under FAA regulations from acting as pilot in command, or any other capacity as a required flight crew member, if he or she knows or has reason to know of any medical deficiency or medically disqualifying condition that would make the individual unable to operate the aircraft in a safe manner; and
(iii) The individual is aware of the regulations pertaining to the prohibition on operations during medical deficiency and has no medically disqualifying conditions in accordance with applicable law;
(b) A section with instructions for the individual to provide the completed checklist to the State-licensed physician performing the comprehensive medical examination required under § 68.5; and
(c) A section, for the physician to complete, that instructs the physician -
(1) To perform a clinical examination of -
(i) Head, face, neck, and scalp;
(ii) Nose, sinuses, mouth, and throat;
(iii) Ears, general (internal and external canals), and eardrums (perforation);
(iv) Eyes (general), ophthalmoscopic, pupils (equality and reaction), and ocular motility (associated parallel movement, nystagmus);
(v) Lungs and chest (not including breast examination);
(vi) Heart (precordial activity, rhythm, sounds, and murmurs);
(vii) Vascular system (pulse, amplitude, and character, and arms, legs, and others);
(viii) Abdomen and viscera (including hernia);
(ix) Anus (not including digital examination);
(x) Skin;
(xi) G-U system (not including pelvic examination);
(xii) Upper and lower extremities (strength and range of motion);
(xiii) Spine and other musculoskeletal;
(xiv) Identifying body marks, scars, and tattoos (size and location);
(xv) Lymphatics;
(xvi) Neurologic (tendon reflexes, equilibrium, senses, cranial nerves, and coordination, etc.);
(xvii) Psychiatric (appearance, behavior, mood, communication, and memory);
(xviii) General systemic;
(xix) Hearing;
(xx) Vision (distant, near, and intermediate vision, field of vision, color vision, and ocular alignment);
(xxi) Blood pressure and pulse; and
(xxii) Anything else the physician, in his or her medical judgment, considers necessary;
(2) To exercise medical discretion to address, as medically appropriate, any medical conditions identified, and to exercise medical discretion in determining whether any medical tests are warranted as part of the comprehensive medical examination;
(3) To discuss all drugs the individual reports taking (prescription and nonprescription) and their potential to interfere with the safe operation of an aircraft or motor vehicle;
(4) To sign the checklist, stating: “I certify that I discussed all items on this checklist with the individual during my examination, discussed any medications the individual is taking that could interfere with his or her ability to safely operate an aircraft or motor vehicle, and performed an examination that included all of the items on this checklist. I certify that I am not aware of any medical condition that, as presently treated, could interfere with the individual's ability to safely operate an aircraft.”; and
(5) To provide the date the comprehensive medical examination was completed, and the physician's full name, address, telephone number, and State medical license number.