HIMALAYAN MOUNTAINEERING INSTITUTE

JAWAHAR PARBAT, DARJEELING - 734101

Medical Certificate

1	Any signification past medical history (Fits) :
2	Chest...........................................cm (range of expansion should be more than 5 cm)
3	Height..........................................cm
4	Weight.........................................kg (only + 15% accepted)
5	Respiratory Rate........................per minute.
6	B.P. ............................................mm of Hg.
7	Eye Distant vision RE.......................................................... (Power of glass, if any) .................................................... Any history of night blindness :
8	Systematic Examination (specially CVS and Respiratory) :
9	Any other significant observation :
	Certified that I have examined Mr./Ms........................................................................................... on ............................................... and found him/her medically fit/unit to undergo Basic/Advance/Adventure Course. It is also certified that the individual has been immunised against tetanus.
	Place : ...................................................................... Date : ........................................................................	Signature of Medical Officer
		Registration No. & Designation
	Note : Trainee will again be medically examined before joining the course by the Institute Medical Officer.

	IMPORTANT : Along with the Full Course Fee add Rs. 50 (Two Dollars incase of Foreign Nationals) in favour of Principal, Himalayan Mountaineering Institute, without which it will be rejected. **Read the online instructions before filling up the form. Do not change or edit anything on this form.
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