Himalayas 2022

MEDICAL FORM

ACN (Registration Number):

Full Name:

1. MEDICAL SCREENING

As the Himalayan Sojourn involves trekking at an altitude of 13,000 feet, participants are required to undergo
the following medical tests. These tests must be taken within a period of 6 months from the date of your
Himalayas sojourn.

● Himalayas Medical Form

Please complete and sign the Declaration and have the Fitness Certificate completed and signed by a
registered Medical Doctor (M.D Physician).

● Medical Reports
Please upload the digital copy of the reports as provided from the hospital.

MANDATORY
❏ 1. Complete Haemogram with TC, Differential Count, Hb, and Platelet Count
❏ 2. Fasting Blood Sugar & HbA1c
CONDITIONAL
❏ 3. ECG - Required for those above age 30 only
❏ 4. TMT / Exercise Stress Test (Summary and all Graphs)
Required for anyone with: hypertension, diabetes, elevated cholesterol, thyroid issues or BMI of 30
and above (irrespective of age).

❏ Please note, we cannot accept TMTs with poor exercise tolerance, so it is best to attempt it after 2 weeks
of regular brisk walking.

Please Note

● If Isha's medical team deems it necessary, they may ask for additional test reports.
● High blood pressure, diabetes and other chronic ailments must be under control to be considered for the
journey. Please ensure these are taken care of before submitting your medical documents.
● If you have low haemoglobin levels, please request your doctor to clarify the reason for anaemia (iron
deficiency, Thalassemia or other causes).
● This sojourn is NOT advised for pregnant women and those suffering from chronic health problems
such as uncontrolled blood pressure, diabetes and asthma or epilepsy, obesity, heart ailments, chronic
infections, physical disabilities or psychological problems.
● In case of any ailment, if you have consulted any specialist, it is mandatory to submit a medical
clearance certificate from the concerned specialist.

1/4
 2. FITNESS CERTIFICATE
2.1 Participant Details

This form must be filled by a registered Medical Doctor (M.D Physician) after reviewing the applicant’s health
information, conducting a physical examination and evaluating lab results and medical reports. Please ensure
all fields of this form are filled, as incomplete forms cannot be accepted.

Applicant Name: Gender:

❏ Male
❏ Female

Age: Height (cm): Weight (kg): BMI:

Pulse Rate (per min): Respiratory Rate (per min): BP (sitting):

Significant history of present/past ailments (including details of treatment):

Medications taken at present/past (including name, dosage and duration of treatment):

History of Covid related illness (including dates and details of severity, treatment and complications):

2.2 Examination & Assessment by the Doctor

Physical Exam Normal Abnormal (Describe)

Cardiovascular ☐

Lungs ☐

Abdomen (incl. hernia) ☐

Neurological ☐

Psychological ☐

Musculoskeletal ☐

Other ☐

2/4
 2.3 Lab Data & Medical Screening Results

Abnormal (Describe)

Complete Haemogram:

TC: Total White Blood Cells / Leukocytes:

Haemoglobin (Hb) (g/dL): Platelet Count:

Blood Sugar Fasting: HbA1c:

ECG - Required for anyone above the age of 30

TMT / Exercise Stress Test (Graph) - Required for anyone with

hypertension, diabetes, elevated cholesterol or BMI of 30 (irrespective of
age)

Any other tests recommended by certifying physician:

RECOMMENDATIONS: Include precautions, medications and prophylaxis, if required.

This is to certify that Mr / Ms / Mrs ____________________________________________________________ is at:

☐ LOW RISK ☐ MODERATE RISK ☐ HIGH RISK ☐ UNFIT

to undertake the Himalayas Sacred Walks to 13,000 feet altitude.

Date: Doctor’s name in BLOCK letters:

Place:

Registration No: Doctor’s Signature & Stamp:

Phone No:

Email:

Please ensure the doctor stamp is included above and kindly note that forms signed by

Nurse Practitioners / Physician Assistants / Ayurveda Doctors cannot be accepted.

3/4
 3. DECLARATION

I, _____________________________________ , as an applicant for Himalayas Sacred Walks have been

requested by Isha to complete the medical formalities mentioned here to qualify my physical and
psychological fitness for the forthcoming high altitude trek. I confirm that I have shared my medical
history as requested on all medical forms and have not withheld any information regarding past and
present history of illness and medications taken. I confirm that all information provided is true and
accurate and agree to it being shared with Isha. I acknowledge Isha’s terms and conditions specifying
that a qualified doctor must complete and sign the Isha Sacred Walks Fitness Certificate, which has
been provided. If anything changes with my health condition or if I undergo any medical procedure prior
to the journey, I will inform the Isha Sacred Walks team immediately.

I have fully read all the pages of the ‘Medical Form’. I have understood the contents and I have had this
translated and read to me in a language that I fully understand.

Place: Date: Applicant Signature:

4/4