INDIAHIKES MEDICAL CERTIFICATE
PRELIMINARY INFORMATION:
Name: Height (cm):
Age: Weight (kg):
Gender: BMI:
Blood group: Waist circumference (cm):
Waist-height ratio:
PLEASE ANSWER THE FOLLOWING QUESTIONS AS HONESTLY AND SPECIFICALLY AS POSSIBLE:
(If you answer Yes to any questions, kindly mention details).
1. Do you suffer from any chronic illnesses or disease (for eg, diabetes, hypertension)?
2. Have you had any illnesses or injuries in the past month (Knee injuries, ligament tears, sprains, fractures etc)?
3. Have you ever undergone any surgeries or procedures in your life? If yes, please mention details of the
same and when you had them.
4. Are you under any medication or therapy for any physical or mental issues of any kind?
5. Do you have any history of neurological problems (eg, seizures etc)?
6. Do you have any history of lung disorders, breathlessness, asthma?
7. Do you have any history of any pre-existing heart condition?
8. Do you have any family history of heart conditions (first degree relatives)?
9. Any history of palpitations, chest pain, fainting, giddiness?
10. Any history of recent gastrointestinal infection, dysentery, jaundice?
11. Do you smoke? If yes, how many a day?
PS: Please note that smoking is strictly not allowed on any of our treks. If you are found smoking, our team will send
you back.
12. Any history of drug/food allergies, or food intolerances (eg, gluten intolerance)?
13. Have you done any high-altitude treks before? If yes: Did you have any of the following symptoms:
Headache Nausea Vomiting
Weakness Dizziness Disturbed sleep
I have elicited a detailed history and conducted a virtual/ in-person assessment of Mr/Ms
on date and found him/her fit to undergo a trekking
expedition in the high altitudes of the Himalayas.
As per the detailed history provided to me, he/she does not suffer from any ailment that can be a deterrent to a
trekking expedition.
NAME OF PHYSICIAN:
MEDICAL COUNCIL REGISTRATION NUMBER:
SEAL WITH SIGNATURE:
DISCLAIMER:
The issued certificate is a preliminary screening of health to be able to participate on the above- mentioned trek. Final
approval for the trek will be done at the base camp by the trek leader based on physical evaluation parameters.
It is not possible to predict the probability of acute mountain sickness (AMS) at high altitude. AMS does not depend on
age, sex, physical fitness or prior high-altitude exposure. No biomedical tests are available to diagnose AMS.
I, hereby declare that the above knowledge is true and
correct as per me. I declare that I have not omitted or hidden or falsified any medical history that is significant and may
possibly impact my health on a high-altitude trek.
I confirm that I am not seriously unwell and I do NOT have any of the following symptoms: chest pain, shortness of
breath, unable to swallow fluids or saliva, weakness or numbness down one side, and slurred speech. I confirm I do
not think I need to see a General Practitioner. I confirm that I am not using the certificate for any medico-legal
purposes.
I have read, understood, and agree with the information in the terms of service and consent to the use of information
in accordance with the privacy policy.
This medical certificate is not valid without your signature. The details mentioned in the medical certificate are as
per the symptoms mentioned by you during an online consultation. The medical team is not responsible for you
sharing the wrong information. You have agreed while sharing the details of your condition that you are providing
the right information, and understand the repercussions of giving false information for the medical certificate and
take full responsibility for the information shared.
This medical certificate is only valid for the date mentioned by the doctor. This medical certificate should only be
applicable to the organisation it is addressed to. This medical certificate under no circumstance can be used for any
medico-legal purposes whatsoever. Other terms and conditions apply.
