NEHRU INSTITUTE OF MOUNTAINEERING, UTTARKASHI

MEDICAL FORM
Certificate by Medical Authority ( Put : - or + Numbers or Alphabets only)
Illness
Symptoms
Injuries
Operations
PRESENT PAST HISTORY
Allergies
Cong. Defect
Weight (kgs.)
Height (cms)
Chest (Exp)
Chest (Nrml)
GENERAL EXAM
Resp. Rate/min.
Pulse/min
Temp (0c)
B.P.(mm Hg)
Temp (0c)
Vessels
H Size
H Rate/Min
CVS
H Sounds
Rhythem
JVP
Perf Pulses
Bilat Exp. Expansion
Br. Sounds
LUNGS
Br. Holding (Sec)
Trachea
Spleen
Liver
ABDOMEN
Hernia
Abnormal Mass
Kidneys
Haemorrhoids
Testis
Bladder
URINARY SYSTEM
Hydrocoele
Prepuce
Motor F
Cranial N
CNS
Mental F
Sensory F
Abnormal MC
MC
O&G
PID
PMT
Obstertic
LMP
R
L
Near Vision
Distant Vision
EYE
R
L
Colour
I O T (mmH2O)
R
L
Hearing
Ear Drums
R
L
Tonsils
Wax
ENT
Epistaxis
Sinuses
Mucosa
DNS
Gums
Teeth (No)
DENTAL
Filling
Caries
HB (gms%)
Blood Group
CT (min/sec.)
BT (min/sec)
LAB
Spec. Gravity
Urine RE
Albumin
Sugar
Pus Cells
RBC
VACCINE
T.A.B. (dt.)
T.T (dt.)

(Certificate)

Space to write any significant finding/advice.

____________________________________________________________________________________________
Certified that I, on this date ___________ examined _________________________ age _________ sex _______
Religion ________ and found him/her medically fit to undergo_________ mountaineering course.
His/Her Blood Group is ________________
Signature of MO
Date _________________

Regd. No. & Designation

Certificate by Trainee/ Guardian

I Certify the I/ my ward did not conceal any past/present history of illness to the medical authority
Signature of Guardian ________________

Signature of Trainee/Ward_____________________

Date _____________

Dt. _________________
(To be filled by Institute MO)

1. ___________________________ was examined by me and found fit/unfit to undergo _____________________

course.
2. Opinion of specialist, Dist. Hospital, Uttarkashi has been obtained towards medically unfit candidate.
Date ________________

Medical Officer
NIM Uttarkashi (Uttarakhand)