U.S. Coast Guard Form CG-719K, Application for Medical Certificate Instructions

Enter any additional medical comments, observations, or clarifications from the medical practitioner; print legibly and include relevant details such as dates, durations, symptoms, medications, and applicant identifiers as needed. Fill only if 'Item 1 - Head, Face, Neck, Scalp: Abnormal', '6. Heart - Abnormal', 'Item 5 - Lungs and Chest: Abnormal', 'Item 4 - Ears/Drums: Abnormal', 'Item 3 - Mouth and Throat (Abnormal)', 'Item 2 - Eyes/Pupils/EOM - Abnormal', 'Item 7 - Upper/Lower Extremities: Abnormal', 'Item 12 - Extremities/Digit — Abnormal', 'Item 11 - General/Systemic - Abnormal', 'Item 10 - Abdomen - Abnormal', 'Item 9 - Vascular System: Abnormal', 'Item 8 - Spine/Musculoskeletal: Abnormal', 'Item 13 - Skin: Abnormal', 'Item 16 - Hernia - Yes', 'Item 15 - Mental Status: Abnormal', 'Item 14 - Neurologic: Abnormal' is 'Yes' in any fields.

Check this box if you wish to provide an alternate phone number as a contact method (enter the alternate number in the adjacent field).

Enter the applicant's alternate telephone number where they can be reached, including area code and any extension if applicable.

Check this box when the applicant was tested using the Farnsworth D-15 Hue Test (used only for engineers, radio officers, tankermen, or MODU personnel) and you will attach the evaluation/test results.

Check this box when the applicant underwent a formal color vision evaluation by an ophthalmologist or optometrist and you will attach the clinic's evaluation/test results.

Check this box when an alternative color vision test (not listed above) that is acceptable to the Coast Guard was used and you will attach the evaluation/test results.

Check this box if the applicant refuses or declines to provide consent for release of medical information (i.e., the applicant does not authorize release/discussion of their medical information).

Enter the applicant's date of birth.

Enter the applicant's full name in the order Last name, First name, and Middle initial.

Enter the applicant's Mariner Reference Number or Social Security Number exactly as issued (include any leading zeros or required punctuation).

Enter the applicant's date of birth for identity verification and record-keeping.

Check this box if the applicant's sex is female.

Check this box if the applicant's sex is male.

Enter your legal family surname (last name) exactly as it appears on official documents, including hyphens or apostrophes if applicable.

Enter any generational suffix (for example, Jr., Sr., II, III) exactly as used on your legal documents, or leave blank if none.

Enter your full middle name or a middle initial as it appears on official records, or leave blank if you have none.

Enter your legal given name (first name) exactly as shown on official documents; do not include prefixes or titles.

Enter the applicant's date of birth.

Enter the applicant's name in Last, First, Middle Initial format (include middle initial if available).

Enter the applicant's date of birth.

Enter the applicant's full name in the order Last name, First name, and Middle initial as shown on legal identification.

Enter the applicant's date of birth.

Enter the applicant's full name in the order Last, First, Middle Initial (e.g., Smith, John A.).

Enter the applicant's date of birth.

Enter the applicant's full name in Last, First, Middle Initial format.

Enter the applicant's date of birth.

Enter the applicant's full name in the order Last name, First name, and Middle initial as applicable.

Enter the applicant's date of birth.

Enter the applicant's full name in the order Last name, First name, and Middle initial (e.g., Smith, John A.).

Enter the applicant's date of birth.

Enter the applicant's full name in the order Last, First, Middle Initial as shown on legal documents.

Enter the applicant's date of birth for identification of the applicant.

Enter the applicant's full legal name in the order Last, First, Middle Initial as it should appear on the medical certificate.

Check this box when the applicant did not provide acceptable proof of identity and you are indicating identity was not provided.

Check this box when the applicant has provided acceptable proof of identity and you are confirming that identity was provided.

Enter the applicant's handwritten signature to certify that the information on the form is complete and truthful.

Enter the date on which the applicant signed this certification.

Check this box when the preliminary screening indicates the applicant is not at high risk of having a condition that poses a significant risk of sudden incapacitation or a debilitating complication. Fill only if 'Endorsement Held or Sought – Entry-level with lookout duties' is 'No'.

Check this box when the preliminary screening indicates the applicant is at high risk of having a condition that poses a significant risk of sudden incapacitation or a debilitating complication. Fill only if 'Endorsement Held or Sought – Entry-level with lookout duties' is 'No'.

Check this box when the preliminary screening is inconclusive or raises concerns that require additional evaluation or review before making a high-risk determination. Fill only if 'Endorsement Held or Sought – Entry-level with lookout duties' is 'No'.

Check this box when the medical practitioner recommends certification for the applicant (i.e., the applicant meets the medical requirements).

Check this box when the medical practitioner does not recommend certification for the applicant because they do not meet the medical requirements.

Check this box when the medical practitioner cannot make a recommendation at this time and additional evaluation or information is required before certifying.

Check this box when the AOC (1965) test was used and the applicant made 6 or fewer errors on plates 1–15.

Check this box when the AOC-HRR (2nd Edition) test was used and the applicant made no errors on test plates 7–11.

Check this box when the HRR PIP (4th Edition) test was used and the applicant made no errors on test plates 5–10.

Check this box when the Richmond (2nd and 4th Edition) test was used and the applicant made six or fewer errors.

Check this box when the Titmus Vision Tester/OPTEC 2000 was used and the applicant made no errors on the six plates.

Check this box when the OPTEC 900 colored lights test was administered according to the instruction booklet and the applicant met the passing criteria specified therein.

Check this box when the Ishihara 14-plate pseudoisochromatic test was used to assess color vision and record the number of errors (passing criterion shown: 5 or fewer errors).

Check this box when the Ishihara 24-plate pseudoisochromatic test was used to assess color vision and record the number of errors (passing criterion shown: 6 or fewer errors).

Check this box when the Ishihara 38-plate pseudoisochromatic test was used to assess color vision and record the number of errors (passing criterion shown: 8 or fewer errors).

Check this box when the Farnsworth Lantern colored-lights test was used to assess color vision, and follow the instruction booklet for administration and record the test result.

Check this box when the Dvorine 15-plate pseudoisochromatic test (2nd Edition) was used to assess color vision and record the number of errors (passing criterion shown: 6 or fewer errors).

Check this box when the applicant passed the color vision test (meets the required color vision standard).

Check this box when the applicant failed the color vision test (did not meet the required color vision standard).

Enter the total number of errors the applicant made on the color vision test as shown on the test results.

Enter the medical practitioner's freeform comments about the applicant's physical ability, including any observations, limitations, explanations of test results, or recommended follow-up; include applicant name/date as needed. Fill only if 'Applicant does NOT have the physical strength, agility, and flexibility to perform all items' is 'Yes'.

Check this box if your delivery/mailing address is different from your home address and you will provide the delivery street, city, state, and ZIP code in the fields below.

Enter the city for the delivery/mailing address if different from your home address.

Enter the state or territory for the delivery/mailing address (use the two-letter abbreviation or full name).

Enter the delivery/mailing ZIP Code (five-digit ZIP or ZIP+4, e.g., 12345 or 12345-6789).

Enter the delivery/mailing street address (PO Box acceptable) including apartment or unit number if applicable.

Describe any medical conditions or concerns that require further review (including those noted in Section III(b)), providing details, relevant findings, and any recommended follow‑up; print or type your response.

Check this box to indicate that the e-mail address you entered is a preferred method of contact for this application.

Enter the applicant's primary e-mail address for contact (e.g., [email protected]).

Check this box if you currently hold or are applying for a Deck endorsement.

Check this box if you currently hold or are applying for an STCW (Standards of Training, Certification and Watchkeeping) endorsement.

Check this box if you currently hold or are applying for an Engine endorsement.

Check this box if you currently hold or are applying for a Food Handler certification/endorsement.

Check this box if you currently hold or are applying for a U.S. Registered Pilot endorsement for Great Lakes pilotage.

Check this box if you currently hold or are applying for a First-Class Pilot endorsement or are serving as a pilot under Federal Pilotage (46 CFR 15.812).

Check this box if you are seeking an entry-level endorsement that includes lookout duties.

Enter a brief explanation naming the other endorsement(s) you hold or are seeking that are not listed above (e.g., specific credential, rating, or job duty). Fill only if 'Other (Please explain)' is 'Yes'.

Check this box if you hold or are applying for an endorsement not listed above and provide an explanation on the line provided.

Check this box when, for an entry-level applicant, the practitioner determines the applicant is free from any medical condition likely to be aggravated by service at sea or to render the seafarer unfit for such service. Fill only if 'Endorsement Held or Sought – Entry-level with lookout duties' is 'Yes'.

Check this box when, for an entry-level applicant, the practitioner determines the applicant is not free from such medical conditions and therefore is not fit for service. Fill only if 'Endorsement Held or Sought – Entry-level with lookout duties' is 'Yes'.

Check this box when, for an entry-level applicant, the practitioner believes further review is required before a determination of fitness can be made. Fill only if 'Endorsement Held or Sought – Entry-level with lookout duties' is 'Yes'.

Check this box when the applicant's horizontal field of vision is greater than or equal to 100 degrees (normal).

Check this box when the applicant's horizontal field of vision is less than 100 degrees or otherwise considered abnormal.

List any functional, physical, or work-related limitations or restrictions resulting from the fifth medical condition. Fill only if 'Section III(a) Item 35' is 'Yes'.

State the current clinical status of the fifth condition (for example: active, resolved, stable) and any pertinent findings. Fill only if 'Section III(a) Item 35' is 'Yes'.

Describe current and past treatments, medications, procedures, or therapies used to manage the fifth condition. Fill only if 'Section III(a) Item 35' is 'Yes'.

Enter the name and brief description of the medical condition or diagnosis for the fifth item. Fill only if 'Section III(a) Item 35' is 'Yes'.

Check this box when you have attached additional documents or evaluation data related to the fifth medical condition (Item #35) described on this page. Fill only if 'Section III(a) Item 35' is 'Yes'.

Enter the item number assigned to this (fifth) medical condition as shown on the form (e.g., 35). Fill only if 'Section III(a) Item 35' is 'Yes'.

Provide the date when this condition began or was first diagnosed for the fifth medical condition. Fill only if 'Section III(a) Item 35' is 'Yes'.

Record the audiometer threshold measured at 500 Hz for the applicant's right ear (unaided) from the first audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Record the audiometer threshold measured at 1,000 Hz for the applicant's right ear (unaided) from the first audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Record the audiometer threshold measured at 2,000 Hz for the applicant's right ear (unaided) from the first audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Record the audiometer threshold measured at 3,000 Hz for the applicant's right ear (unaided) from the first audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Record the average audiometer threshold across the tested frequencies for the applicant's right ear (unaided) from the first audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Describe any functional limitations, activity restrictions, or work-related limitations caused by this condition. Fill only if 'Section III(a) Item 23' is 'Yes'.

Summarize the current clinical status of the condition (e.g., resolved, stable, improving, worsening) and any follow-up needs. Fill only if 'Section III(a) Item 23' is 'Yes'.

Describe treatments, medications, surgeries, therapies, or other medical management used for this condition. Fill only if 'Section III(a) Item 23' is 'Yes'.

Provide the medical condition or diagnosis name for this item (for example, the specific disorder, disease, or symptom). Fill only if 'Section III(a) Item 23' is 'Yes'.

Check this box when additional evaluation data or supporting documents for the first medical condition (Item #23) have been attached to the form. Fill only if 'Section III(a) Item 23' is 'Yes'.

Enter the date when this condition began or was first diagnosed. Fill only if 'Section III(a) Item 23' is 'Yes'.

Enter the item number that identifies this medical condition on the form. Fill only if 'Section III(a) Item 23' is 'Yes'.

Check this box when the medical practitioner determines the applicant is free from communicable diseases that pose a direct threat to health or safety of others. Fill only if 'Food Handler' is 'Yes'.

Check this box when the medical practitioner determines the applicant is NOT free from communicable diseases that pose a direct threat to health or safety of others. Fill only if 'Food Handler' is 'Yes'.

Check this box when the question about being free from communicable disease is not applicable to this applicant or situation. Fill only if 'Food Handler' is 'Yes'.

Enter the audiometer threshold for the left ear (aided) at 500 Hz in decibels (dB) as measured on the audiogram. Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Enter the audiometer threshold for the left ear (aided) at 1,000 Hz in decibels (dB) as measured on the audiogram. Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Enter the audiometer threshold for the left ear (aided) at 2,000 Hz in decibels (dB) as measured on the audiogram. Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Enter the audiometer threshold for the left ear (aided) at 3,000 Hz in decibels (dB) as measured on the audiogram. Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Enter the average audiometer threshold for the left ear (aided) across the tested frequencies in decibels (dB). Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Describe any functional, activity, or work limitations resulting from this condition. Fill only if 'Section III(a) Item 16' is 'Yes'.

Specify the current clinical status of the condition (for example: active, resolved, stable) and any brief relevant details. Fill only if 'Section III(a) Item 16' is 'Yes'.

Describe current and past treatments, medications, surgeries, or therapies used for this condition. Fill only if 'Section III(a) Item 16' is 'Yes'.

Provide the medical condition or diagnosis name for this item. Fill only if 'Section III(a) Item 16' is 'Yes'.

Check this box if additional supporting documents or evaluation data are attached for the fourth listed medical condition (Item #16). Fill only if 'Section III(a) Item 16' is 'Yes'.

Enter the identifier or item number assigned to this medical condition entry. Fill only if 'Section III(a) Item 16' is 'Yes'.

Enter the date when the condition began or was first diagnosed. Fill only if 'Section III(a) Item 16' is 'Yes'.

Enter the applicant's unaided right-ear functional speech discrimination score at 65 dB as a percentage (for example 0–100%). Fill only if 'First - Right Ear (Unaided) Average Threshold', 'Second Row - Left Ear (Unaided) Average Threshold' is greater than 30 in any fields selection.

Enter the applicant's unaided left-ear functional speech discrimination score at 65 dB as a percentage (for example 0–100%). Fill only if 'First - Right Ear (Unaided) Average Threshold', 'Second Row - Left Ear (Unaided) Average Threshold' is greater than 30 in any fields selection.

Enter the applicant's aided right-ear functional speech discrimination score at 65 dB as a percentage (for example 0–100%). Fill only if 'First - Right Ear (Unaided) Average Threshold', 'Second Row - Left Ear (Unaided) Average Threshold' is greater than 30 in any fields selection.

Enter the applicant's aided left-ear functional speech discrimination score at 65 dB as a percentage (for example 0–100%). Fill only if 'First - Right Ear (Unaided) Average Threshold', 'Second Row - Left Ear (Unaided) Average Threshold' is greater than 30 in any fields selection.

Check this box when the applicant demonstrates normal hearing (forced whispered voice ≥ 5 feet with or without hearing aids) and does not require further audiometric testing or a hearing aid.

Check this box when the applicant demonstrates abnormal hearing and requires further testing (functional speech discrimination at 65 dB or an audiogram) or follow-up per medical guidance.

Check this box when the applicant requires a hearing aid to meet hearing standards or when aided thresholds indicate the need for hearing amplification.

Enter the city for your home address.

Enter the ZIP code for your home address (typically the 5-digit postal code).

Enter your home street address (PO Box not acceptable), including street number, street name, and apartment or unit number if applicable.

Check this box when your home street address (not a PO Box) is a preferred method of contact and you will provide the Street, City, State, and Zip fields.

Enter the U.S. state for your home address (either the two-letter state abbreviation or the full state name).

Check this box when the medical practitioner identifies any abnormal findings for the applicant's head, face, neck, or scalp and intends to document them.

Check this box when the medical practitioner determines the applicant's head, face, neck, and scalp are normal with no abnormal findings.

Check this box if you currently have, have ever had, or have required treatment for blurry vision, poor night vision, eye disease or injury, eye surgery, abnormal color vision, cataracts, or glaucoma.

Check this box if you have never had and do not presently have any of the eye conditions listed for Item 1.

Check this box if the eye condition for Item 1 was previously reported in earlier records (i.e., noted before this application).

Check this box if you have a medical waiver that applies to the Item 1 eye condition and have provided a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner finds any abnormality of the applicant's abdomen; provide details in the medical comments section.

Check this box when the medical practitioner finds the applicant's abdomen to be normal with no abnormalities on examination.

Check this box if you have ever had, required treatment for, or currently have a stomach, liver, or intestinal disorder that requires ongoing medical care/medication, causes significant bleeding or debilitating pain, or a history of hepatitis or jaundice.

Check this box if you have never had and do not currently have any stomach, liver, or intestinal disorder as described.

Check this box if this stomach, liver, or intestinal condition was previously reported on an earlier form.

Check this box if you have a medical waiver (MW) for this stomach, liver, or intestinal condition and have provided a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner finds one or more abnormalities on the applicant's general/systemic exam and provide comments in the space for abnormal findings.

Check this box when the medical practitioner finds the applicant's general/systemic exam to be normal with no abnormalities to report.

Check this box if you have ever had, required treatment for, or presently have kidney problems, kidney stones, or blood in your urine.

Check this box if you have never had and do not currently have kidney problems, kidney stones, or blood in your urine.

Check this box if this kidney-related condition was previously reported on an earlier form or medical record.

Check this box if you have an approved medical waiver for this condition and have provided a copy to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner found abnormal findings in the applicant's extremities or digits that should be commented on in the additional medical comments section.

Check this box when the medical practitioner found the applicant's extremities and digits to be normal with no abnormal findings on exam.

Check this box if you currently have, have ever had, or required treatment for any other urinary or bladder problems not listed above.

Check this box if you have never had or required treatment for any other urinary or bladder problems not listed above.

Check this box if these other urinary or bladder problems were previously reported (occurred in the past) but are not currently active.

Check this box if you have a medical waiver (MW) for these other urinary or bladder problems and have provided a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner finds any abnormality, lesion, rash, or other concerning sign on the applicant's skin.

Check this box when the medical practitioner finds the applicant's skin to be normal with no abnormal signs or findings.

Check this box if you currently have, have required treatment for, or have been diagnosed with skin disorders requiring medical treatment (for example, cancer, tumors, scleroderma, or lupus).

Check this box if you have never had or do not presently have any of the skin disorders listed in Item 13.

Check this box if these skin disorders were reported previously on an earlier application or medical review.

Check this box if you have a medical waiver (MW) for the skin disorder listed in Item 13 and have provided a copy to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner observes any abnormal neurologic findings or signs; provide details in the comments space.

Check this box when the medical practitioner finds the neurologic exam to be normal with no abnormal signs or symptoms to report.

Check this box if you currently have, or have required treatment for, severe allergies or allergic reactions to any substance, medication, food, or insect stings.

Check this box if you have never had and do not currently have severe allergies or allergic reactions to any substance, medication, food, or insect stings.

Check this box if severe allergies or allergic reactions occurred in the past and were previously reported (they are not currently active).

Check this box if you have a medical waiver relating to severe allergies or allergic reactions and will provide a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the applicant's mental status is assessed as abnormal; if checked, provide details/comments about the abnormal findings.

Check this box when the applicant's mental status is assessed as normal with no abnormal findings.

Check this box if you have ever had, required treatment for, or presently have a communicable or chronic infectious disease (for example, tuberculosis, HIV/AIDS, or hepatitis).

Check this box if you have never had and do not presently have any communicable or chronic infectious disease listed for Item 15.

Check this box if this condition was previously reported on an earlier form or medical record.

Check this box if you have a medical waiver for this condition (and provide a copy of the waiver to the Medical Practitioner as instructed). Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if the medical examiner observed or confirmed the presence of a hernia during the physical examination.

Check this box if the medical examiner found no evidence of a hernia during the physical examination.

Check this box if you currently have, have required treatment for, or have ever had any sleep problems (for example, obstructive sleep apnea, restless leg syndrome, narcolepsy, shift work sleep disorder, or insomnia).

Check this box if you have never had and do not presently have any of the sleep problems listed for Item 16.

Check this box if the sleep problem for Item 16 was previously reported on earlier medical documentation or applications.

Check this box if you have a medical waiver related to the sleep condition and will provide a copy of the waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you currently have or have ever had epilepsy, fits, or seizures (i.e., you have or have required treatment for this condition).

Check this box if you have never had epilepsy, fits, or seizures and do not presently have this condition.

Check this box if epilepsy, fits, or seizures were previously reported on earlier paperwork or to the medical practitioner.

Check this box if you have a medical waiver related to epilepsy, fits, or seizures and have provided a copy to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you have ever had, required treatment for, or presently have a history of serious head injury, loss of consciousness, or memory loss.

Check this box if you have never had, required treatment for, and do not presently have a history of serious head injury, loss of consciousness, or memory loss.

Check this box if the condition in Item 18 (serious head injury, loss of consciousness or memory loss) has been reported previously on an earlier form or to the medical practitioner.

Check this box if a medical waiver (MW) applies to Item 18 and you have provided a copy of that waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you have ever had, currently have, or have required treatment for frequent or severe headaches.

Check this box if you have never had frequent or severe headaches and have not required treatment for them.

Check this box if your history of frequent or severe headaches was previously reported on an earlier application.

Check this box if you have a medical waiver for frequent or severe headaches and have provided a copy to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner observes any abnormality in the applicant's eyes, pupils, or extraocular movements that should be documented.

Check this box when the medical practitioner finds the applicant's eyes, pupils, and extraocular movements to be normal with no abnormal findings.

Check this box if you currently have, have had, or have required treatment for hearing loss, use a hearing aid, ear surgery, facial deformities, an open tracheostomy, or frequent severe nose bleeds.

Check this box if you have never had and do not currently have any of the conditions listed for Item 2.

Check this box if the Item 2 condition(s) have been previously reported on earlier medical forms or records.

Check this box if you have a medical waiver that applies to the Item 2 condition(s) and will provide a copy of the waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you currently have, or have ever had and required treatment for, dizziness, fainting spells, or balance problems.

Check this box if you do not have and have never had dizziness, fainting spells, or balance problems.

Check this box if this condition was reported previously (it occurred in the past and has already been reported elsewhere).

Check this box if you have an approved medical waiver for this condition and have provided a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you currently have, or have required treatment for, frequent motion sickness that requires medication.

Check this box if you have never had and do not presently have frequent motion sickness requiring medication.

Check this box if this condition was reported previously on an earlier application or to a medical authority.

Check this box if you have an approved medical waiver for this condition and will provide a copy to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you have had, required treatment for, or presently have a stroke, transient ischemic attack (TIA), brain tumor, or any other brain disorder.

Check this box if you have never had and do not currently have a stroke, transient ischemic attack (TIA), brain tumor, or any other brain disorder.

Check this box if the condition described in Item 22 was reported previously (on a prior form or disclosure).

Check this box if a medical waiver (MW) applies to Item 22; if checked, provide a copy of the waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you currently have, have required treatment for, or have ever had any neurologic disorder or nerve problem (including numbness and/or paralysis) described in item 23.

Check this box if you have never had and do not currently have any neurologic disorder or nerve problem described in item 23.

Check this box if this neurologic disorder or nerve problem was previously reported (on earlier forms or to a medical practitioner).

Check this box if you have an approved medical waiver that applies to the neurologic disorder or nerve problem in item 23 and have provided a copy to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check if you have ever had, required treatment for, or presently have attention deficit disorder (with or without hyperactivity).

Check if you have never had and do not presently have attention deficit disorder (with or without hyperactivity).

Check if this attention deficit disorder was previously reported on another form or prior application.

Check if you have an approved medical waiver that covers this attention deficit disorder (provide a copy to the medical practitioner). Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you have ever had, required treatment for, or presently have anxiety, depression, bipolar disorder, adjustment disorder, PTSD, or schizophrenia.

Check this box if you have never had and do not currently have any of the conditions listed for Item 25.

Check this box if the condition(s) listed in Item 25 were reported previously on earlier forms or records.

Check this box if you have a medical waiver (MW) for the condition(s) in Item 25 and will provide a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you have ever had, required treatment for, or presently have suicide attempt(s) or thoughts of suicide (suicidal ideation).

Check this box if you have never had, required treatment for, nor presently have suicide attempt(s) or thoughts of suicide (suicidal ideation).

Check this box if this condition was previously reported on an earlier application or record.

Check this box if you have a medical waiver covering this condition and have provided a copy of the waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you have had evaluation, treatment, or hospitalization for alcohol or substance use, abuse, addiction, or dependence (including illegal drugs, prescription medications, or other substances).

Check this box if you have never had evaluation, treatment, or hospitalization for alcohol or substance use, abuse, addiction, or dependence.

Check this box if the evaluation, treatment, or hospitalization for alcohol or substance use was reported previously on this application or another required form.

Check this box only if you have a medical waiver (MW) related to Item 27 and have provided a copy of that waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you have had, required treatment for, or presently have any other psychiatric disorder or have had mental health evaluation, treatment, or hospitalization.

Check this box if you have not had and do not currently have any other psychiatric disorder and have not had related mental health evaluation, treatment, or hospitalization.

Check this box if this psychiatric condition or its treatment was previously reported on an earlier form or prior application.

Check this box only if a medical waiver has been issued for this condition and you will provide a copy of the waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you currently have or have had back, neck, or joint problems that impair movement or cause debilitating pain.

Check this box if you have never had back, neck, or joint problems that impair movement or cause debilitating pain.

Check this box if these back, neck, or joint problems were previously reported on earlier medical records or a prior version of this form.

Check this box if you have an approved medical waiver for these back, neck, or joint problems and will provide a copy to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner observes any abnormal findings in the applicant's mouth or throat and document the findings in the medical comments section.

Check this box when the medical practitioner finds the applicant's mouth and throat to be within normal limits with no abnormal findings.

Check this box if you currently have, have ever had, or have required treatment for high or low blood pressure.

Check this box if you have never had and do not currently have high or low blood pressure and have not required treatment for it.

Check this box if high or low blood pressure was reported previously (on an earlier form or medical record).

Check this box if you have an approved medical waiver for high or low blood pressure and have provided a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you currently have, or have required treatment for, an amputation, use a prosthesis, or regularly use ambulatory devices (for example, cane, walker, or braces).

Check this box if you have never had and do not currently have the condition described (no amputation, prosthesis use, or need for ambulatory devices).

Check this box if this condition was previously reported on an earlier form or section.

Check this box if you have a medical waiver that covers this condition and you have provided a copy of the waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you currently have or have had injuries, fractures, or recurrent dislocations that cause impairment or limit motion of any joint.

Check this box if you have never had injuries, fractures, or recurrent dislocations that cause impairment or limit motion of any joint.

Check this box if this condition was previously reported on an earlier application or form.

Check this box if you have an approved medical waiver for this condition and have provided a copy to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you have been signed off a vessel as sick or repatriated for medical reasons within the last six years.

Check this box if you have NOT been signed off a vessel or repatriated for medical reasons within the last six years.

Check this box if the sign-off or repatriation event(s) were previously reported on another application or earlier in this form.

Check this box if you hold a current medical waiver (MW) that applies to the condition of being signed off or repatriated for medical reasons. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if you currently have or have had any diseases, surgeries, cancers, illnesses, or disabilities that are not listed elsewhere on this form.

Check this box if you have never had any diseases, surgeries, cancers, illnesses, or disabilities that are not listed elsewhere on this form.

Check this box if the condition(s) were previously reported on an earlier form or section (mark PR for previously reported).

Check this box if a medical waiver applies to this condition and you have provided a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if the applicant has had any hospital admissions within the last six years that are not listed elsewhere in this section.

Check this box if the applicant has not had any hospital admissions within the last six years that are not listed elsewhere in this section.

Check this box if the hospital admission(s) for this item were already reported elsewhere on this form.

Check this box if a medical waiver (MW) applies to these hospital admission(s) and a copy of the waiver will be provided to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box if the medical practitioner detected any abnormal finding of the ears/tympanic membranes that requires comment or follow-up.

Check this box if the medical practitioner found the ears/tympanic membranes normal with no abnormalities on exam.

Check this box if you have ever had, required treatment for, or presently have any heart or vascular disease described in Item 4 (for example angina, chest pain, irregular heartbeat, heart valve problem/replacement, heart attack/myocardial infarction, or congestive heart failure).

Check this box if you have never had and do not presently have any of the heart or vascular conditions listed in Item 4.

Check this box if the heart or vascular condition in Item 4 was previously reported to a medical practitioner or on a prior application.

Check this box if you have a medical waiver (MW) for the condition in Item 4 and have provided a copy of the waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner identifies any abnormal findings in the lungs or chest during the physical examination.

Check this box when the medical practitioner finds the lungs and chest to be normal with no abnormal signs on examination.

Check this box if you have ever had, required treatment for, or presently have heart surgery and/or implanted devices (for example, angioplasty, stent, pacemaker, or defibrillator).

Check this box if you have never had and do not presently have heart surgery or implanted devices as described in Item 5.

Check this box if the heart surgery or implanted devices were previously reported (i.e., the condition occurred in the past and has already been reported).

Check this box if you have a medical waiver for the heart surgery/implanted devices condition and have provided a copy of the waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner identifies any abnormal findings on the heart examination that require comment or follow-up.

Check this box when the medical practitioner finds the heart examination to be normal with no abnormal signs or findings.

Check this box if you have ever had, required treatment for, or presently have lung disease (for example, asthma, emphysema, or chronic obstructive pulmonary disease/COPD).

Check this box if you have never had, never required treatment for, and do not presently have any lung disease.

Check this box if this lung disease was reported previously on an earlier form or prior application.

Check this box if you have a medical waiver for lung disease and provide a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner identifies any abnormal findings in the applicant's upper or lower extremities that should be documented.

Check this box when the medical practitioner finds the applicant's upper and lower extremities to be normal with no abnormalities on exam.

Check this box if you currently have, have ever had, or have required treatment for any blood disorder (for example, anemia, hemophilia, blood clots, or polycythemia).

Check this box if you have never had and do not presently have any blood disorder listed for Item 7.

Check this box if this blood disorder was previously reported on an earlier form or to a medical practitioner.

Check this box if you have a medical waiver for this blood disorder and have provided a copy of the waiver to the medical practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner finds any abnormality on the spine or musculoskeletal exam that requires notation or further comment.

Check this box when the medical practitioner finds the spine and musculoskeletal exam to be normal with no abnormalities noted.

Check this box if you currently have, have ever had, or required treatment for diabetes, glucose intolerance, or sugar in the urine.

Check this box if you have never had and do not currently have diabetes, glucose intolerance, or sugar in the urine.

Check this box if the diabetes, glucose intolerance, or sugar in the urine was previously reported (i.e., a past condition) rather than a current condition.

Check this box if you have a medical waiver for diabetes/glucose intolerance and provide a copy of that waiver to the Medical Practitioner. Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Check this box when the medical practitioner identifies abnormal findings in the applicant's vascular system (provide details in the comments space).

Check this box when the medical practitioner finds the applicant's vascular system to be normal with no abnormal signs.

Check this box if you have ever had, required treatment for, or presently have a thyroid problem requiring treatment or hospitalization.

Check this box if you have never had and do not presently have a thyroid problem requiring treatment or hospitalization.

Check this box if this thyroid problem has been previously reported on earlier forms or applications.

Check this box if you have a medical waiver that applies to this thyroid condition (and provide a copy of the waiver to the Medical Practitioner as required). Fill only if 'Medical Waiver (MW) - Yes' is 'Yes'.

Enter the postal ZIP code for the practitioner's office (5-digit ZIP or ZIP+4 format, include the hyphen for ZIP+4).

Enter the U.S. state or territory for the practitioner's office, preferably using the two-letter postal abbreviation (e.g., NY).

Enter the city where the medical practitioner's office is located as it should appear in the mailing address.

Enter the medical practitioner's office street address, including building number and suite or unit if applicable (e.g., 123 Main St, Suite 200).

Enter the date the medical practitioner signed or authenticated this section.

Check this box after the medical practitioner has entered the date in the adjacent date field to indicate when they authenticated/reviewed the form.

Check this box after the medical practitioner has entered or provided their initials in the adjacent initials field to indicate they reviewed and authenticated the section.

Enter the medical practitioner’s initials to verify they reviewed and authenticated the examination information.

Enter the date on which the medical practitioner signed or initialed this block to confirm the assessment.

Check this box after the medical practitioner has entered the date in the adjacent 'DATE' field to indicate when the medical practitioner completed or signed the physical ability block.

Check this box after the medical practitioner has written their initials in the adjacent 'MEDICAL PRACTITIONER INITIALS' field to indicate they reviewed and completed the physical ability block.

Enter the medical practitioner's initials to indicate their review or approval of the applicant's physical ability results.

Check this box if the medical practitioner signing this form is a Doctor of Medicine (MD).

Check this box if the medical practitioner signing this form is a Physician Assistant (PA).

Check this box if the medical practitioner signing this form is a Nurse Practitioner (NP).

Check this box if the medical practitioner signing this form is a Doctor of Osteopathic Medicine (DO).

Enter the date the medical practitioner completed or signed this section.

Enter the date the medical practitioner signed or reviewed this page of the form.

Check this box after the medical practitioner has entered the date on this page to indicate the date of their review/signature.

Enter the medical practitioner's initials to indicate they reviewed and verified the information on this page.

Check this box after the medical practitioner has entered their initials on this page to indicate they reviewed and initialed the page.

Enter the medical practitioner’s initials to indicate they reviewed and verified the applicant’s medical conditions in this section (enter the practitioner's usual initials, e.g., two or three letters).

Enter the date when the medical practitioner initialed or reviewed this page.

Check this box after the medical practitioner has entered the date (MM/DD/YYYY) to confirm the practitioner dated this page when reviewing/completing the form.

Enter the medical practitioner's initials to indicate they have reviewed and/or completed the information on this page.

Check this box after the medical practitioner has entered their initials to confirm they reviewed and initialed the applicant's medical information on this page.

Enter the date the medical practitioner completed or signed this section.

The medical practitioner should enter the date (mm/dd/yyyy) here on the same day they initial the form to record when they completed/reviewed Section III(b).

The medical practitioner should enter their initials here after completing the Medical Conditions section (Section III(b)) to indicate they reviewed and provided the requested information.

Enter the medical practitioner's initials as they should appear to indicate review or completion of this section.

Check this box after the medical practitioner has entered the date in the adjacent 'DATE' field to indicate the date has been provided. Fill only if 'Food Handler' is 'Yes'.

Check this box after the medical practitioner has entered their initials in the adjacent 'MEDICAL PRACTITIONER INITIALS' field to indicate the initials have been provided.

Enter the date the medical practitioner signed or initialed this form. Fill only if 'Food Handler' is 'Yes'.

Enter the medical practitioner's initials to indicate they reviewed and/or completed this section of the form. Fill only if 'Food Handler' is 'Yes'.

Enter the date when the medical practitioner signed or initialed this section.

Check this box after the medical practitioner has signed or initialed the form and entered the date showing when the examination/verification was completed.

Check this box after the medical practitioner has reviewed the vision/hearing results and entered their initials to indicate they verified the exam.

Enter the medical practitioner's initials as their mark of review or authorization for the vision/hearing section.

Check this box to mark the location for the Medical Practitioner to indicate they have reviewed the applicant's medical section and will or have provided their initials and date.

Enter the medical practitioner’s middle initial (single letter); leave blank if none.

Enter the medical practitioner’s given/first name exactly as it appears on their professional records.

Enter the medical practitioner’s family/last name exactly as it appears on their professional records.

Enter the medical practitioner’s professional license number issued by the licensing authority (include any letters, numbers or punctuation as shown).

Enter the U.S. state or other jurisdiction that issued the practitioner’s license (use the standard two‑letter postal abbreviation or full name).

Enter the date the medical practitioner signed the form.

Enter the full signature (typed or printed name) of the medical practitioner certifying the examination.

Provide the primary telephone number where the medical practitioner or office can be reached.

Check this box when the medical practitioner has entered or confirmed the date for Section III(a) (i.e., to indicate the practitioner has dated their review/completion of the section).

Check this box if you have a medical waiver (MW); if checked, provide a copy to the Medical Practitioner and mark the MW box below.

Check this box if you do not have a medical waiver (MW).

Check this box when additional medication sheets are attached by the Applicant and/or Medical Practitioner to complete this section (ensure applicant name and date of birth are included on each additional sheet). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the full name of the medication (brand or generic) being taken for Medication Entry 1. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medication dose including units as a text string (for example '10 mg', '2 tablets', or '0.5 mL'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter how often the medication is taken (for example 'once daily', 'twice a day', 'every 8 hours', or 'as needed'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical condition or reason the medication is taken (for example 'hypertension', 'chronic pain', or 'seasonal allergies'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical practitioner’s comments about this medication, including duration of use, observed side effects, and any other relevant notes. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the full name of the medication for entry 2, including brand or generic name and any active ingredient. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the dose amount and units the applicant takes for this medication (for example, '50 mg', '1 tablet', or '2 puffs'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter how often the medication is taken (for example, 'once daily', 'twice a day', or 'as needed') and include timing details if relevant. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical condition or reason the medication is being taken (for example, 'hypertension', 'asthma', or 'pain'). Fill only if 'Medication Use: Yes' is 'Yes'.

Provide medical practitioner comments for this medication entry, including approximate duration of use and any observed side effects or other relevant notes. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the full name of the medication (prescription or nonprescription) for this third medication entry. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the dose amount and unit for this medication (for example, '5 mg', '10 mL', or '1 tablet'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter how often the medication is taken (for example, 'once daily', 'twice a day', 'every 8 hours', or 'as needed'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical condition or reason the applicant is taking this medication (for example, 'hypertension' or 'seasonal allergies'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter medical practitioner comments about this medication including duration of use, observed side effects, and any other relevant clinical notes. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the name of the medication (prescription or over-the-counter) that corresponds to this fourth medication entry. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the dose or amount of the medication the applicant takes for this entry (for example, '10 mg', '1 tablet', or '5 mL'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter how often the medication is taken for this entry (for example, 'once daily', 'twice a day', or 'every 8 hours'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical condition or reason the medication is being taken for this entry (for example, 'hypertension' or 'allergy'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical practitioner's comments for this medication, including duration of use, any side effects observed, and other relevant clinical notes. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the full name of the medication, supplement, or vitamin the applicant is taking. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the dose or strength the applicant takes, including units (for example, 10 mg, 1 tablet, 5 mL). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter how often the medication is taken (for example, once daily, twice a day, as needed) and any timing details. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical condition, diagnosis, or reason the medication is being used. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter comments from the medical practitioner regarding duration of use, observed side effects, or other relevant clinical notes about this medication. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the full name of the medication (prescription or nonprescription) the applicant is taking. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the dose of the medication as provided, including units (for example, "500 mg", "2 tablets", or "5 mL"). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter how often the medication is taken (for example, "once daily", "twice a day", or "every 8 hours"). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical condition or reason for which the medication is being taken. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical practitioner's comments about the medication, including approximate duration of use and any observed side effects or other relevant notes. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the name of the medication (prescription or nonprescription) the applicant is taking for entry 7. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the dose or amount of the medication for entry 7, including units if applicable (for example, 10 mg). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter how often the applicant takes this medication for entry 7 (for example, once daily, twice weekly, as needed). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical condition or reason the medication is being taken for entry 7. Fill only if 'Medication Use: Yes' is 'Yes'.

Provide medical practitioner comments for entry 7, including duration of use, observed side effects, and any other relevant notes. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the full name of the medication (prescription or nonprescription) the applicant is taking for this entry. Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the amount and strength of the medication dose, including units (for example '50 mg' or '1 tablet'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter how often the medication is taken (for example 'once daily', 'twice a day', or 'as needed'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter the medical condition or reason the medication is being used (for example 'hypertension' or 'seasonal allergies'). Fill only if 'Medication Use: Yes' is 'Yes'.

Enter any medical practitioner comments about duration of use, observed side effects, or other relevant clinical notes for this medication. Fill only if 'Medication Use: Yes' is 'Yes'.

Check this box if the applicant currently uses any medication (prescription or nonprescription), including dietary supplements or vitamins taken or refilled within 30 days prior to the date the applicant signs the form.

Check this box if the applicant does not currently use any medication (prescription or nonprescription), including dietary supplements or vitamins.

Check this box when the applicant wants to provide a contact method not listed (selecting this indicates you will enter that other contact information on the adjacent line).

Enter the details for the 'Other' contact method (e.g., alternate phone, fax, messaging handle, or instructions) so the Coast Guard can contact you using that method.

Check this box when the applicant, based on the medical practitioner's evaluation, meets the physical ability standards and can perform all tasks listed in the physical ability table without assistance.

Check this box when the applicant, based on the medical practitioner's evaluation, does not meet the physical ability standards and cannot perform all tasks listed in the physical ability table.

Enter the applicant's height.

Enter the applicant's resting pulse rate in beats per minute (bpm).

Enter the applicant's weight.

Enter the applicant's blood pressure as systolic/diastolic in mmHg (for example, 120/80).

Enter the applicant's body mass index.

Check this box to indicate the phone number provided in the adjacent field is your primary contact number.

Enter the applicant's primary telephone number for contact, including country and area code as needed (include digits and any separators such as spaces or hyphens).

Enter the audiometer threshold measured for the left ear (unaided) at 500 Hz for the second audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Enter the audiometer threshold measured for the left ear (unaided) at 1,000 Hz for the second audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Enter the audiometer threshold measured for the left ear (unaided) at 2,000 Hz for the second audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Enter the audiometer threshold measured for the left ear (unaided) at 3,000 Hz for the second audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Enter the average audiometer threshold calculated for the left ear (unaided) for the second audiometer row. Fill only if 'Abnormal Hearing' is 'Yes'.

Describe any functional, activity, or work limitations resulting from the second medical condition. Fill only if 'Section III(a) Item 29' is 'Yes'.

State the present clinical status of the condition (for example active, resolved, stable, or worsening) and any pertinent findings. Fill only if 'Section III(a) Item 29' is 'Yes'.

List current and past treatments, medications, therapies, or interventions used to manage this second condition. Fill only if 'Section III(a) Item 29' is 'Yes'.

Describe the medical condition or diagnosis for the second item, including relevant clinical details. Fill only if 'Section III(a) Item 29' is 'Yes'.

Check this box if additional information or evaluation data for the second medical condition (Item #29) has been attached to the form. Fill only if 'Section III(a) Item 29' is 'Yes'.

Enter the item number assigned to this second medical condition as shown on the form. Fill only if 'Section III(a) Item 29' is 'Yes'.

Enter the date when this second medical condition began or was first diagnosed. Fill only if 'Section III(a) Item 29' is 'Yes'.

Enter the date the applicant signed this consent section. Fill only if 'Declined' is 'No'.

Enter the applicant's signature (typed or handwritten representation) to indicate consent for the medical information release. Fill only if 'Declined' is 'No'.

Enter the date the applicant signed this consent to release information to the third party. Fill only if 'Declined' is 'No'.

Enter the full legal name of the organization or third party authorized to receive your medical information. Fill only if 'Declined' is 'No'.

Provide the full name of the individual at the organization who will act as the primary contact regarding your medical information (if applicable). Fill only if 'Declined' is 'No'.

Enter the primary telephone number for the organization or point of contact, including area code and any extension if applicable. Fill only if 'Declined' is 'No'.

Provide the organization's full street address where correspondence or records should be sent. Fill only if 'Declined' is 'No'.

Enter the city in which the organization is located. Fill only if 'Declined' is 'No'.

Enter the state (abbreviation or full name) for the organization's address. Fill only if 'Declined' is 'No'.

Provide the postal ZIP code (or ZIP+4) for the organization's address. Fill only if 'Declined' is 'No'.

Enter the applicant's signature (typed or printed name) to authorize the Coast Guard to release medical information to the named third party. Fill only if 'Declined' is 'No'.

Enter the date the applicant signed this authorization. Fill only if 'Declined' is 'No'.

Enter the full legal name of the organization or third party being authorized to act on your behalf. Fill only if 'Declined' is 'No'.

Provide the name of the individual at the organization who will serve as the point of contact (if applicable). Fill only if 'Declined' is 'No'.

Enter the telephone number for the organization or point of contact where they can be reached regarding this authorization. Fill only if 'Declined' is 'No'.

Enter the organization or third party's street address, including suite or unit number if applicable. Fill only if 'Declined' is 'No'.

Enter the city of the organization or third party's mailing address. Fill only if 'Declined' is 'No'.

Enter the state or territory for the organization or third party's mailing address. Fill only if 'Declined' is 'No'.

Enter the postal ZIP Code for the organization or third party's mailing address. Fill only if 'Declined' is 'No'.

Provide the applicant's signature (typed name) authorizing the named third party to act on their behalf. Fill only if 'Declined' is 'No'.

Enter the audiometer threshold measured for the right ear (aided) at 500 Hz, typically recorded in decibels (dB). Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Enter the audiometer threshold measured for the right ear (aided) at 1,000 Hz, typically recorded in decibels (dB). Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Enter the audiometer threshold measured for the right ear (aided) at 2,000 Hz, typically recorded in decibels (dB). Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Enter the audiometer threshold measured for the right ear (aided) at 3,000 Hz, typically recorded in decibels (dB). Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

Enter the average audiometer threshold for the right ear (aided) across the tested frequencies. Fill only if 'Abnormal Hearing', 'Hearing Aid Required' is 'Yes' in all fields selection.

List any functional limitations, activity or work restrictions, or required accommodations resulting from this condition. Fill only if 'Section III(a) Item 10' is 'Yes'.

Indicate the current status of the condition (for example: active, resolved, stable, improving) with a short explanation as needed. Fill only if 'Section III(a) Item 10' is 'Yes'.

Describe current and past treatments, medications, therapies, surgeries, or other interventions for this condition. Fill only if 'Section III(a) Item 10' is 'Yes'.

Provide the name of the medical condition or a brief description of the diagnosis. Fill only if 'Section III(a) Item 10' is 'Yes'.

Check this box when additional documentation or attachment(s) related to the third listed medical condition (Item #10) are included with the form. Fill only if 'Section III(a) Item 10' is 'Yes'.

Enter the identifying item number used on the form for this third medical condition. Fill only if 'Section III(a) Item 10' is 'Yes'.

Enter the date when this condition began or was formally diagnosed. Fill only if 'Section III(a) Item 10' is 'Yes'.

Enter the uncorrected distance visual acuity measured for the right eye as recorded after the printed '20/' (e.g., '20', '40', '200', 'CF').

Enter the uncorrected distance visual acuity measured for the left eye as recorded after the printed '20/' (e.g., '20', '40', '200', 'CF').

Enter the distance visual acuity correctable with lenses for the right eye as recorded after the printed '20/' (if correction required), e.g., '20', '40', '200', or 'CF'.

Enter the distance visual acuity correctable with lenses for the left eye as recorded after the printed '20/' (if correction required), e.g., '20', '40', '200', or 'CF'.