Treating physician finds the condition stable on current regimen and no changes recommended Yes S ymptoms controlled either on or off medication Yes for all of the following Freq ID: 825302
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CACI thmaWorksheet(Updated/2015The Exami
CACI thmaWorksheet(Updated/2015The Examiner must review a current status report by the treating physician and any supporting documents to determine the applicant’s eligibility for certification. If the applicant meets ALL the acceptable certification criteriaisted below, the Examiner can issue.Applicants for firstor secondclass must provide this information annually; applicants for thirdclass must provide the information with each required exam. Treating physician finds the condition stable on current regimen and no changes recommended[ ] Yes Symptoms-controlled (either on or off medication) [ ] Yes for all of the following: Frequency of symptomsno more than 2days per weekUse of inhaled shortacting beta agonist (rescue inhaler) Use of oral corticosteroidfor exacerbations no more than 2 times per yearIn the last yearo inpatient hospitalizationmore than 2 outpatient clinicurgent care visits for exacerbationswith ymptoms fully resolved Acceptable Medications [ ] One or more of the following Inhaled acting beta agonistInhaled shortacting beta agonist (.g.,albuterol)nhaled corticoleukotriene receptor antagoniste.g. ontelukast [Singulair Note: A short course of oral or IM steroids during an exacerbationis acceptable.Examiner must caution airman not to fly until course of oral steroids is completed and airman is symptom fr P (PFT)* *PFT is not required if the only treatment is PRN use on one or two days a week of a shortacting beta agonist (e.g. albuterol).[ ] Current within last 90 days [ ]FEV1, FVC, FEV1/FVC are allequal to or greater than 80% AME MUST NOTEin Block 60 of the following:ng:CACI qualified asthma[ ] Not CACI qualified asthma. Issued per valid SI/ASSI. (Submit supporting documents.)[ ] NOT CACI qualified asthma. I have deferred.(Submit supporting documents.) CACI thma Worksheet(Updated 04//2015The Examiner must review a current status report by the treating physician and any supporting documents to determine the applicant’s eligibility for certification. If the applicant meets ALL the acceptable certification criteria listed below, the Examiner can issue.Applicants for first- or second- class must provide this information annually; applicants for thirdclass must provide the information with each required exam.AME MUST REVIEWACCEPTABLE CERTIFICATION CRITERIATreating physician finds the condition stable on current regimen and no changes recommended[ ] Yes Symptoms: Stable and well-controlled (either on or off medication)[ ] Yes for all of the following: Frequency of symptoms - no more than 2days per weekUse of inhaled shortacting beta agonist (rescue inhaler) o more than 2 times per weekUse of oral corticosteroidfor exacerbations - no more than2 times per yearIn the last yearo inpatient hospitalizationmore than 2 outpatient clinicurgent care visits forexacerbations (with ymptoms fully resolved).Acceptable Medications [ ] One or more of the following Inhaled - acting beta agonistInhaled shortacting beta agonist (.g.,albuterol)-Inhaled corticosteroidleukotriene receptor antagoniste.g. ontelukast [Singulair])Note: A short course of oral or IM steroids during an exacerbationis acceptable.Examiner must caution airman not to fly until course of oral steroids is completed and airman is symptom frPulmonary Function Tests (PFT)* *PFT is not required if the onlytreatment is PRN use on one ortwo days a week of a shortactingbeta agonist (e.g. albuterol).[ ] Current within last 90 days [ ]FEV1, FVC, FEV1/FVC are allequal to or greater than % predicted before bronchodilatorsAMEUSTTEinloollowing: