Medical Form

We request all the trekkers to consult a physician and conduct a medical check up before venturing in any Himalayan Trek. However this is NOT MANDATORY for all the treks, but helpful and highly advised. For certain treks this is MANDATORY (check with us for the same) and you need to submit the hard copy at the respective trek base.

Check here to DOWNLOAD the MEDICAL FORM.

MEDICAL CERTIFICATE

GENERAL REMARKS:

1. Name:

2. Gender:

3. Age:

4. Height:

5. Weight:

5. Any Previous illness, their nature and duration __________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

6. Any previous injuries, accident ______________________________________________________________

& present condition _________________________________________________________________________

7. Any operation undergone, their nature and result ________________________________________________

8. Any history of Malaria or any other fever ________________________

9. Date of last vaccination ______________________________________
10. Any previous exposure to high altitude and any problems encountered ______________________________

RESPIRATORY SYSTEM:

1. Respiratory rate at rest ______________________________________

2. Range of chest expansion ____________________________________ (Should be 5 cm or higher)

3. Any history of breathlessness _________________________________ (Should be nil)

4. Any history of chest pain ____________________________________ (Should be nil)

5. Ever suffered from Asthma or Pleurisy _________________________ (Should be nil)

CIRCULATORY SYSTEM:

1. Pulse rate at rest ________________________________________________

2. Blood Pressure _________________________________________________

3. Any history of giddiness or fainting attacks _____________________ (Should be nil)

4. Any history of palpitations __________________________________ (Should be nil)

5. Any history of chest pain ___________________________________­ (Should be nil)

6. Are the veins in any part enlarged or varicose? __________________ (Should be nil)

ALIMENTARY SYSTEM:

1. Any history of dysentery or jaundice _________________________ (Should not be recent or persisting)

2. Any history of Appendicitis. If operated, the present condition ____________________________________

3. Any history of renal or intestinal colic ________________________ (Should be nil)

NERVOUS SYSTEM:

1. Any history of Epilepsy or any other fits _______________________ (Should be nil)

BONES AND JOINTS:

1. Any injury or accident _____________________________________ (Fracture in previous six month will not be accepted) & present condition _______________________________ (Present condition should be without any complaint)

2. Any history of Rheumatism__________________________________. (Should be nil)

3. Condition of toes and feet____________________________________ (Should be healthy)

In my opinion  ____________________________________________ is medically fit / unfit to undergo a Trekking / Adventure trip in the high altitude.

Date:  ……………………                                                                         Place: ……………………

…………………………………………

Signature of the Medical Officer

Registration Number and Designation