cOMPULSORY HEALTH CERTIFICATE FOR

SHRI AMARNATHJI YATRA 2023

PART A TO BE EILLED DY APPLICANT)
1. Name TAYESH So. DO, WO KAL CuIARANJ
2 Adtms RASULAUR LobDHRULI RasT tn0BRA ETAH
3. Data of Bm ß 1 999 Aashaar No26.1s1422S Blood Group
4 ntfcake Mak

Ttn o t be es than 11 Years er more the 70 Years eld

No laty th more than & werk preonancy wilt be registered for the Yatra 2Bzs
5. DECLARATION Have you sufered from or have history of any of the tlloeing

Condition Ye No 5 No Conditkon Yes No

Diabetes
BreaeseS
D High Ekood Pressure
CL Respiratoytug rt
F Asha
Biood dsorder
G Bleming ensencien H Epkpsy
Nevcus breakdomn
Heart alment
K
Hgh alliludemourtain Sickness
Jont Pans

Dschag ron car History ct sirokal parayis

to female
Are you a smcker
P) Ae you pregnant (Applicable

tiotony of Hoart Attock, f yos sacase socity

Hiatory of audden death n faty menter, it yes pase specty Ma

Any mjor injury n Ihe past. yes piease speaty

Any othie aient, fyes please specity NO

Hstory of surgery, yes peare spety

Are you under any edkcaton, it yes please npecty NO
Ae you allergc o drugs, oods and chencas, it yes pse spocity
the best of my knowledge and behl, and nothing has beon concealed.
Ihereby declare that the paticulars given above are true to

(Signature/thumb impressibn of the Yatri)

Date 02lose3
PART B:TO BE FILLED BY AUTHORISED MEDICAL AUTHORITY)
amialon and he neceusary imstgatns, ks ceted that Me M/ Mis
On the bosis of intormaton hmised by te applat, etailed
is ftt to udertak te umey to t St Anaratj Holy Cave Shrie
issuing the certifkcate:
Detaka of any specifle test conducted before
Name of the Doctor AaandSsh Signature and seal of uvorsedieatuuhority
Designation MCU State Medical CounclRegistration No: 513
Data of h s