Pilots taking hydroxychloroquine (Plaquenil) or chloroquine (Aralen) have the ophthalmologist or optometrist who monitors the medication complete this one-page FAA summary of retinal toxicity screening. It records when treatment began, the date and type of the latest screening, the risk result, and findings on retinal exam, visual field testing and optical coherence tomography.
The ophthalmologist or optometrist who monitors the medication completes and signs it. The pilot fills in name, birthdate, applicant ID and PI number.
Download the current version from the source each time; forms change without notice.
Hydroxychloroquine (HCQ)/ Chloroquine (CQ) Status Summary (Plaquenil/Aralen)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The ophthalmologist or optometrist who monitors the pilot's hydroxychloroquine or chloroquine. They enter their name and title, the treatment start date, the latest screening details and findings, then sign and date it. The pilot returns it to the AME.
Yes. It asks whether spectral-domain OCT and automated threshold visual field testing showed abnormalities, if indicated, with N/A available when a test was not indicated. The items are modified from the 2016 American Academy of Ophthalmology guideline recommendations cited on the form.