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FORM 5: Physician’s Certificate
Your patient,
________________________________________________________________________
(Please print patient's full name)
has been accepted as a member of a high altitude mountaineering expedition.
Please ask him/her to describe the type of expedition that is planned.
This expedition involves high altitude climbing and possible cold temperatures,
along with the dangers from altitude sickness, accidents, and illness
in a remote area. Professional medical help may be days away. All participants
must be in satisfactory physical condition and be mentally stable. In
addition, we recommend that participants carry certain prescription drugs
with themselves in their personal medical kit. Possible drugs to consider
may include the following, and others:
1) Antibiotic
for upper respiratory problems; 2) Antibiotic for GI problems; 3) Diamox
for acclimatization
(125 mg tabs recommended, enough for a week); 4) Sleeping pills for jet
lag; 5) Tylenol 3 or similar for severe headaches; 6) Malaria Chemophrophylaxis,
if needed based on travel plans; 7) Asthma medication, if any history.
For serious illness
on high altitude expeditions nifedipine (for pulmonary edema) and dexamethasome
(for cerebral edema) are standard treatment protocol in association with
immediate descent.
Please assist your
patient in obtaining these or other drugs that you would advise for extended
travel in the third world away from western style medical care.
I, Doctor
____________________________________________________________________________
(Please print Doctor's full name)
have examined the above-named patient on this Date , _______________________________________
taking into consideration the activity in which he/she is going to engage
and I have conducted the types of tests that I deem necessary under the
circumstances. In my opinion, the patient is physically and mentally fit
and able to participate in the activity.
Physician’s
Comments, Reservations, Observations, if any (please use additional sheet
if necessary.)
Please list any drugs that your patient should not be given:
____________________________________________________________________________________
____________________________________________________________________________________
Signature of Physician:
_________________________________________________________________
Address: ____________________________________________________________________________
Phone(s):
___________________________________________________
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