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Previous KTAT Treks:

KIRAT TREKS BACKGROUND INFORMATION FOR PHYSICIAN AND APPLICANT
Kirat Treks, Adventure Travel operates its treks in a variety of conditions, some in isolated wilderness areas. Occasionally, a Kirat Treks can be days from modern medical facilities. Trips vary in length from two weeks to four weeks. Depending on the specific type of trek, the applicant may be carrying a pack of 5-35 pounds at altitudes up to 20,000 feet. Participants will often sleep outdoors, and are expected to take care of themselves. Weather conditions can be extreme, with temperatures ranging from -5 degrees F. to +80 degrees F. Prolonged storms, high winds, and/or intense sunlight is possible. Kirat Treks can be physically demanding. Prior physical conditioning is strongly recommended.
In the interest of the personal safety of both the applicant and the other trek members, please consider the above description carefully when completing the Medical Form. A "YES" answer does not cancel an applicant's enrollment, but we do need the information. The physician completing this form may not be a relative of the applicant.
APPLICANT: The following medical information as completed by the physician is complete and true to the best of my knowledge. I recognize that falsification or omission of information is grounds for my removal from the trek.

Applicant Signature:
Date:

PHYSICIAN'S EXPLANATION OF ALL "YES" ANSWERS - BE SPECIFIC
Question Number and Explanation / Attach extra paper if necessary.
PHYSICAL EXAMINATION (Please type or print legibly) Applicants over 60 years of age and applicants over 40 years of age with a history of cardiovascular disease, obesity, or high blood pressure are required to have a stress electrocardiogram. We also recommend this for individuals with a sedentary lifestyle or those without frequent physical exercise (three times weekly).

1. Knee, ankle, back, or any other joint problems including sprains, injuries or operations? (what and when?) YES NO
2. Respiratory problems? YES NO
3. Gastrointestinal disturbances? YES NO
4. Eating disorders? YES NO
5. Disorders of the urinary tract? YES NO
6. Hypertension? YES NO
7. Liver dysfunction? YES NO
8. Arthritis? YES NO
9. Neurological problems? YES NO
10. Epilepsy or seizures? YES NO
11. Treatment or medication for abdominal cramps?
Menstrual cramps? Please specify. YES NO
12. Treatment or problems associated with drug/alcohol/chemical abuse or dependency?
YES NO
13. Psychiatric/psychological treatment or counseling? YES NO
14. Thyroid problems? YES NO
15. Cardiac problems? YES NO
16. Physical disability? YES NO
17. Is s/he a diabetic? YES NO
18. Has s/he ever had frostbite? Describe symptoms and treatment. YES NO
19. Has s/he ever had symptoms of Acute Mountain Sickness? YES NO
20. Any other disease? YES NO
21. Is s/he allergic to any medications? To iodine? Be specific. YES NO
22. Is s/he allergic to any foods, insects, plants, etc. Please specify. YES NO
23. Is s/he currently taking any medications? Please specify dose. YES NO
24. Is s/he on a medically prescribed diet? YES NO
25. Does the person see a specialist of any kind? YES NO
26. Is there any additional information we would want to know? YES NO

PHYSICIAN'S EXPLANATION OF ALL "YES" ANSWERS - BE SPECIFIC
Question Number and Explanation / Attach extra paper if neccessary

PHYSICAL EXAMINATION (Please type or print legibly) Applicants over 60 years of age and applicants over 40 years of age with a history of cardiovascular disease, obesity, or high blood pressure are required to have a stress electrocardiogram. We also recommend this for individuals with a sedentary lifestyle or those without frequent physical exercise (three times weekly).

1. Blood Pressure:
   Pulse:
   Last DT series:
2. General Appearance:

3. Physical Examination:

4. General Impressions:

5. On the basis of the background information at the beginning of this form and your examination, do you feel that this individual can participate in this KTAT trek?
(Check One) YES NO

Comments:


NAME: , M.D.
ADDRESS:
PHONE:
PHYSICIAN'S SIGNATURE:
DATE:

PLEASE RETURN TO:
Kirat Treks
37702 Rushing Wind Court
Murrieta, CA 92563