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IH Medical Form

This medical certificate document contains fields to record a trek participant's personal medical details such as name, age, height, weight, blood group, and BMI. It includes sections for the examining doctor to provide comments on the participant's chronic illnesses, medications, respiratory rate, blood pressure, and overall physical fitness. The doctor must sign to state whether the participant is medically fit to undertake trekking in the high altitude Himalayas. A separate personal medical record form requires the participant to provide details on any previous illnesses, injuries, operations, medications, allergies, altitude experience, breathing issues, chest pains, asthma, fainting, epilepsy, palpitations, digestive issues,

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643 views2 pages

IH Medical Form

This medical certificate document contains fields to record a trek participant's personal medical details such as name, age, height, weight, blood group, and BMI. It includes sections for the examining doctor to provide comments on the participant's chronic illnesses, medications, respiratory rate, blood pressure, and overall physical fitness. The doctor must sign to state whether the participant is medically fit to undertake trekking in the high altitude Himalayas. A separate personal medical record form requires the participant to provide details on any previous illnesses, injuries, operations, medications, allergies, altitude experience, breathing issues, chest pains, asthma, fainting, epilepsy, palpitations, digestive issues,

Uploaded by

shrey13488
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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MEDICAL CERTIFICATE

To be filled in and signed by a registered medical practitioner only


Submit to your Indiahikes Trek Leader at the base camp

Participant’s Name: Height:


Age: Weight:
Blood group: BMI:

Medical Details Comments

Does the participant suffer from any chronic illness?


If yes, please mention details

Is the participant under medication of any kind?


If yes, please mention details

Respiratory rate at rest

Blood pressure reading

Overall physical fitness

Any drug allergies

Any other information related to the health of the


participant that would be useful in emergencies.

I have medically examined Mr /Ms_______________________________________________ on


(Date)__________________________and found him/her fit to undergo a trekking expedition in the high
altitudes of Himalayas.
As per history and clinical examination he/she is not suffering from any chronic disease or any other
ailment that can be a deterrent to a trekking expedition.

Doctor’s Name:
Degree: Signature and Seal
PERSONAL MEDICAL RECORD
This document has to be filled in, signed and handed over to your Indiahikes Trek Leader at the base camp

Medical Details Comments

1 Any previous illness - past 3 months ⟥ Yes ⟥ No


If yes, mention the nature and duration of illness

2 Any previous injuries – past 6 months (accident / sprain / fracture ⟥ Yes ⟥ No


etc. If yes, what is the present condition?

3 Any operation undergone – past 6 months ⟥ Yes ⟥ No


If yes, mention the nature and result of the operation

4 Are you under medication of any kind? ⟥ Yes ⟥ No


If yes, please mention details & medicines being taken

5 Do you have any drug or food allergies? ⟥ Yes ⟥ No


If yes, please mention details

6 Do you have any experience with high altitude treks? ⟥ Yes ⟥ No


(If yes, please mention the name of the trek and altitude gained)

7 Did you encounter any altitude related problems on your ⟥ Yes ⟥ No


previous trek? If yes, please mention details

8 Do you have any history of breathlessness ⟥ Yes ⟥ No

9 Do you have any history of chest pain ⟥ Yes ⟥ No

10 Have you ever suffered from Asthma or Pleurisy ⟥ Yes ⟥ No

11 Any history of giddiness or fainting attacks ⟥ Yes ⟥ No

12 Any history of Epilepsy or any other fits ⟥ Yes ⟥ No

13 Any history of palpitations ⟥ Yes ⟥ No

14 Any history of dysentery or jaundice ⟥ Yes ⟥ No

15 Any history of recurring pain in the abdomen ⟥ Yes ⟥ No

16 Any other information related to your health that would be


useful to us in the case of emergencies

I (name)__________________________________ certify that the information mentioned above is true


and correct to the best of my knowledge. I have not hidden any medical condition and have disclosed
all my medical information to Indiahikes which will be useful to them in the case of an emergency.

Signature: Place: Date:

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