Medical and personal information

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All participants to any outdoor activities or trip to the Himalayas organized by Himalayan Ecotourism must fill in and submit this form.

Email *

Group name (the first name of the person who contacted us in the first place) *

Name of participant *

Gender *

Date of birth *

YYYY

Height (cm) *

Weight (kg) *

Food habits *

Non-vegetarian

Eggtarian

Vegetarian

Other:

Mobile number

Have you ever participated in a multi-day trek ? If yes where, for how many days and the altitude gained ? *

Did you encounter any altitude related problems on your previous travel/treks ? *

Yes

Maybe

Fitness rating table

0 to 20 You have a sedentary way of life. A little physical effort will leave you out of breath. You know you have a weak stamina.
20 to 40 You have a sedentary way of life but you know that you have some physical potentials. Your body is not used to prolonged physical effort but you don't mind walking for about 2 hours on easy paths with gentle slopes.
40 to 60 You may still have a sedentary way of life but you are physically fit. You don't miss an occasion to go on foot or by cycle. You can run for 10 minutes without problems and you can challenge a lift by climbing on foot a three story stairs with speed. You are not in the best shape but you feel confident in most of the situations where your body will be challenged. In short you have an average fitness.
60 to 80 Even if you work in an office you regularly do sport. Physical activities are an important part of your life. You like to surpass yourself by participating in a race, for instance. Prolonged physical efforts in harsh conditions do not scare you.
80 to 100 You are very sporty. You have already tested your body capacities in a challenging mountain environment for several days, at a high altitude. You are confident that you have a very strong stamina to face the unpredictable.

How will you rate your physical fitness on a scale from 0 to 100 ? *

Do you suffer from any allergy to food/medicines/other? If yes please mention. *

Do you have chronic illness like diabetes, asthma, epilepsy, heart problems, etc.? If so, please give the details. *

Please mention any previous illness, injuries or any operation undergone during the past 6 months. *

Please mention any other information related to your health that would be useful to us to plan your trip or in the case of emergencies.

Emergency contact information

Please share the details of the person to contact in case of emergency.

Name of contact *

Relationship *

Mobile number *

Send me a copy of my responses.

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