Scribd
Upload
64 views1 page

DK Application

The document is a compulsory health certificate for participants of the Shri Amarnathji Yatra 2022, requiring personal information and a declaration of medical history. It includes a series of health-related questions to assess the applicant's fitness for the journey. The certificate must be filled out and signed by an authorized medical authority after conducting necessary examinations.

Uploaded by

kshreyanshkp6914
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
64 views1 page

DK Application

The document is a compulsory health certificate for participants of the Shri Amarnathji Yatra 2022, requiring personal information and a declaration of medical history. It includes a series of health-related questions to assess the applicant's fitness for the journey. The certificate must be filled out and signed by an authorized medical authority after conducting necessary examinations.

Uploaded by

kshreyanshkp6914
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

COMPULSORY HEALTH CERTIFICATE FOF

SHRI AMARNATHJI YATRA 2022

PARTAR ALR AC SoDe Wa OmAakcah ehda


AdressV&PNaltkedQ VLST:JHATAPUR MP PAN 46S UU Biood Group
2 Date of Brth ldentilication mark
have history of any of the following:
3. DECLARATION: Have you suffored from
or

a) Breathlessness Yes No b) Dlabetes Yes No


o) Respiratory/ lung alment Yes CNo d)HighBlood pressure Yes No
e) Blood disorder Yes No Asthma Yes No
g) Sleeding tendencies YesNo h)Epiepsy Yes p No
Yes No ) Nervous breakdown Yes No
Heart alment
k)Jaint Pains
Yes a No )HighaltudelmountainsicknessYes pNo
m) Discharge from ear Yes p No n) History of stroke' paralysis Yes No
o) Are you a smoker
Yes pNo p)Areyou pregnant e s pNo
(agplieabie to female Yatris)
No
Q) History of Haart Atack i yes, please
specity
members: Yyes. please specity No
Hstory of sudden death in family
f please specfy NO
s) Any major injury in the past: yes, NO
specfy
1) Any other alment; f yes, please
if please specify
No
u) Histary of surgery, yes, NO
under any medicaion: il yes. please specily
v) Are you
foods and chemicals: if yes, pleasespeciy Q
w) Are you allergc to drugs, of my knowledge and beliai.and nothing
has been
above are true to the best
particulars given
I hereby dec iare that the e L n
concealed
the Applicamt)
Signaturelthumb jmpresslon of
DatS0>-uo2
AUTHORISED MEDICAL AUTHORITY)
BY
PARTB:(TO BE FILLED and the necessary
imvestigations, t i s
information furnished by the apRlicant, detaled axamination Shri Amarnath
On the basis of undertake the journay to the
et EtActad is t to
certified that MriMs/Mrs t
DwAAA LAC
Holy Cave Shrine.

test conducted
belore issuing the
certificate: one
Detalls of any specific
cwey odhidar
NameoftheDoctor Authorized MedicalAkherity
Signature and seal of
Designaton
SmO State Medical Council Registration Nox_
Dr.SANJAY PATIDAR
ohauMCU
Dateof issue:O5 M.B.B.S. MD
SENOIR MEDICAL OFFICER
WELLNESS CENTER AJMER
CGHS

You might also like