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Annexure II Compulsory Health Certificate For Kumbh Mela Haridwar - 2021

This document contains a health certificate form for the Kumbh Mela in Haridwar, India in 2021. The form has two parts: Part A collects health information from the applicant, including any history of medical conditions like respiratory issues, diabetes, high blood pressure, asthma, etc. as well as COVID-19 testing details. The applicant must declare the information is true. Part B is filled by an authorized medical authority. After examining the applicant and any necessary tests, the authority will certify if the applicant is medically fit to undertake the journey to Kumbh Mela Haridwar 2021. The certificate includes the doctor's details.

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Shrasti Soni
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223 views1 page

Annexure II Compulsory Health Certificate For Kumbh Mela Haridwar - 2021

This document contains a health certificate form for the Kumbh Mela in Haridwar, India in 2021. The form has two parts: Part A collects health information from the applicant, including any history of medical conditions like respiratory issues, diabetes, high blood pressure, asthma, etc. as well as COVID-19 testing details. The applicant must declare the information is true. Part B is filled by an authorized medical authority. After examining the applicant and any necessary tests, the authority will certify if the applicant is medically fit to undertake the journey to Kumbh Mela Haridwar 2021. The certificate includes the doctor's details.

Uploaded by

Shrasti Soni
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Annexure II

COMPULSORY HEALTH CERTIFICATE FOR


KUMBH MELA HARIDWAR - 2021 Affix cross-
signed
(by Yatri)
recent
photograph
PART A: (TO BE FILLED BY APPLICANT)
1. Name S/o;D/o; W/o
Address
2. Date of Birth Identification mark: Blood Group:
3. DECLARATION: Have you suffered from or have history of any of the following:
a) Breathlessness Yes No b) Diabetes Yes No
c) Respiratory/ lung ailment Yes No d) High Blood pressure Yes No
e) Blood disorder Yes No f) Asthma Yes No
g) Bleeding tendencies Yes No h) Epilepsy Yes No
i) Heart ailment Yes No j) Nervous breakdown Yes No
k) Joint Pains Yes No l) History of stroke/ paralysis Yes No
m) Are you a smoker Yes No n) Are you pregnant: Yes No
(applicable to female Yatris)

o) History of COVID-19 Infection Yes No, if Yes date of COVID-19 Positive Report________
p) History of Heart Attack; if yes, please specify
q) History of sudden death in family members; if yes, please specify
r) Any major injury in the past; if yes, please specify
s) Any other ailment; if yes, please specify
t) History of surgery; if yes, please specify
u) Are you undergoing under any medication; if yes, please specify
v) Are you allergic to drugs, foods and chemicals; if yes, please specify
w) Date of Latest COVID-19 Testing result. Date___________ Positive Negative
4. I hereby declare that the particulars given above are true to the best of my knowledge and belief, and nothing
has been concealed.

Date (Signature/ thumb impression of the Applicant)

PART B: (TO BE FILLED BY AUTHORISED MEDICAL AUTHORITY)


On the basis of information furnished by the applicant, detailed examination and the necessary
investigations, it is certified that
Mr/Ms/Mrs is fit to undertake the journey to the KUMBH MELA
HARIDWAR 2021.

Details of any specific test conducted before issuing the certificate:

Name of the Doctor

Designation: Signature and seal of Authorized Medical Authority


Date of issue: MCI/ State Medical Council Registration No:

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