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Medical Certificate Format

This document is a medical certificate from the Youth Hostels Association of India. It requests information about the applicant's name, father/spouse's name, date of birth, address, city, and state. It asks whether the applicant has any infectious disorders, unknown allergies to drugs or foodstuff, hypertension, bronchial asthma, diabetes mellitus, epilepsy, heart disease, or has a history of taking drugs for chronic diseases. For those over 45, it requests blood pressure, ECG report, and blood sugar report. It states that the doctor examined the applicant on a given date and found them medically and mentally fit to undergo adventure/trekking expeditions in high altitude areas

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iamketul6340
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530 views

Medical Certificate Format

This document is a medical certificate from the Youth Hostels Association of India. It requests information about the applicant's name, father/spouse's name, date of birth, address, city, and state. It asks whether the applicant has any infectious disorders, unknown allergies to drugs or foodstuff, hypertension, bronchial asthma, diabetes mellitus, epilepsy, heart disease, or has a history of taking drugs for chronic diseases. For those over 45, it requests blood pressure, ECG report, and blood sugar report. It states that the doctor examined the applicant on a given date and found them medically and mentally fit to undergo adventure/trekking expeditions in high altitude areas

Uploaded by

iamketul6340
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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YOUTH HOSTELS ASSOCIATION OF INDIA

(ISO 9001:2015 Certified Organization)


5, Nyaya Marg, Chanakyapuri New Delhi 110021
[email protected] | 7827 999 000
Medical Certificate

Name ………………………………………………………………………………………………………………………….…..

Father / Spouse Name ……………………………………………………………………………………………………..


DOB …………………………………….

Address ……………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………..
City ………………………………….Pin………………………………………………State……………………………………

Present illness / Past illness / Physical


Is the Applicant suffering from
Disability
Any Infectious
Yes No
Disorder
Any unknown allergy to Drugs / Foodstuff Hypertension Yes No

Bronchial Asthma Yes No

History of taking drugs for Chronic Disease Diabetes Mellitus Yes No

Epilepsy Yes No

Heart Disease Yes No

Above 45 years Blood Sugar


BP ECG Report
Male / Female Report
Female HB

I have medically examined Mr /Ms_______________________________________


on (Date)__________________________and found him / Her medically / Mentally
fit to undergo any Adventure / Trekking expedition in high altitude areas & in the
mountains and as per history and clinical examination he/she is not suffering from any
chronic disease.
Name of Dr __________________________Degree ____________ Reg No______

Signature & Seal

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