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VITAL FUNCTIONS
FC ______ x min, PA ___/___ mmHg, FR ______ x min, IMC ______ kg/m2, Sat. O2______%
I declare that the answers given in this document are true and I am aware that hiding or falsifying
information can cause me harm, so I am fully responsible for it.
…………………………………………..
Patient Signature & Fingerprint
According to the declarations of the patient I certify that he/she is …………………… (able/not able)
to ascend to high altitudes (greater than 2,500 masl), however, I do not assure the performance
during the ascent or during its permanence.
Observations: ___________________________________________________________________
2. PHYSICIAN’S DATA
Surname Name:
Address:
CMP: Date:
1
GUIDELINES FOR THE EXAMINING DOCTOR
• Mild anemia*
• Heart failure CF I and II
• Valvulopathy CF I and II
• Uncontrolled hypertension
• Poliglobulia with plethora
• Patients with coronary revascularization or stent placement
• COPD
• Pulmonary hypertension
• BMI between 35 and 39.9 Kg / mt2
• Other cardiac pathologies (controlled and certified by Cardiologist)
• Heart rhythm disorders
• Pneumonectomy
• Restrictive spirometric pattern of any cause