COMPULSORY HEALTH CERTIFICATE

Please paste
FOR SHRI AMARNATHJI YA TRA 2023 one recent
passport size
photograph
here

PART A: JTO BE FILLED BY APPLICANT)

1. Name. ______________S/o;D/o; W/o, _________________
2.. Address
3. Date of Birth / / AadhaarNo. / / ,Blood Group:____

4. _Identification marK:,
Age limit:
a) For Yatri : Should not b less than 13 years or more than 70 years old
b) Women with pregnancy should not be pregnant for more than 6 weeks, are allowed to perform,Yatra pilgrimage

5. DECLARATION : Have you suffered from or have history of any of the following
S. NO CONDITIONS YES NO S.NO CONDITIONS YES NO

A) Breathlessness B) Diabetes
C) Respiratory/ lung ailment D) High Blood pressure
E) Blood disorder F) Asthma
G) Bleeding tendencies H) Epilepsy
I) Heart ailment J) N ervous breakdown
K) Joint Pains L)
High altitude/mountain sickness

M)
Discharge from ear N) History of stroke/ paralysis
Are vou preqnam:
0) Are you a smoker P)
. . . (applicable to female Yatris)
q) History of Heart Attack; if yes, please specify____________________
r) History of sudden death in family members; if yes, please specify______________
s) Any major injury in the past; if yes, please specify___________________
t) Any other ailment; if yes, please specify_______________________
u) History of surgery; if yes, please specify______________________
v) Are you under any medication; if yes, please specify__________________
w) Are you allergic to drugs, foods and chemicals; if yes, please specify____________

I hereby declare that the particulars given above are true to the best of my knowledge and belief, and nothing has been concealed.

Date____ (Signature/ thumb impression of the Yatri)

PART B: (TO BE FILLED BY AUT HORISED MEDICAL AUTHORITY)

O n the basis of infor mation furnished by the applicant, detailed examination and the necessary investigations, it is cer tified that
Mr/Ms/Mrs _______________________________________________is fit to undertake the journey to the Shri Amarnathji Holy Cave Sh rine.

Details of any specific test conducted before issuing the certificate: _______________

Name of the Doctor _____ _

Designation: _______ Signature and seal of Authorized Medical Authority
Date of issue: ________ MCI/ State Medical Council Registration No: _______