Pilots treated for low testosterone or hypogonadism can bring this one-page FAA summary to the urologist, endocrinologist or physician who manages the condition. Five yes or no questions cover stability and side effects, phlebotomy, venous thromboembolism history, hematocrit above 54% on a CBC within 90 days, and clinical concerns, plus current medications. If every answer is NO, the pilot may qualify under the Low T CACI.
The urologist, endocrinologist or treating physician completes, signs and dates it, or writes a current, detailed Clinical Progress Note covering every item. The pilot fills in name, birthdate, applicant ID and PI number.
Download the current version from the source each time; forms change without notice.
Low Testosterone (Low T) Hypogonadism Status Summary
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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A hematocrit greater than 54% on a CBC from the previous 90 days falls in the YES* column, so the AME must defer. The pilot brings a copy of the current CBC with the summary so the AME can check it.
No. Clinical records may be submitted instead, but the FAA says the summary streamlines and significantly decreases review time. If every answer is NO, the pilot may qualify under the CACI for low testosterone and the AME can issue at the exam.