High-Altitude Nepal Pilgrimage Health & Readiness Intake

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Section 1: Personal Information

Full Name(Required)

First Last

Email(Required)

Preferred Name(Required)

Date of Birth(Required)

Gender & Preferred Pronouns(Required)

Nationality(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

In case of emergency, first notify: Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Relationship to Participant(Required)

Primary Physician Name(Required)

Physician Phone(Required)

Have you discussed it with your physician?(Required)

Choose One

Yes

No

Does your physician know that you will be participating in this trek?(Required)

Choose One

Yes

No

Have you received approval from your physician?(Required)

Choose One

Yes

No

Section 2: Passport Information (Required for Trekking Permits)

Passport Number(Required)

Passport Country of Issue(Required)

Passport Expiration Date(Required)

Please attach or submit a copy/photo of your passport identification page.(Required)

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB.

Section 3: Previous High Altitude Experience

Have you traveled above 3,000m / 10,000 ft before?(Required)

Yes

No

If Yes, did you arrive there via flight, or did you arrive at this elevation by foot / hiking?(Required)

If yes, where and when?(Required)

Have you experienced altitude illness symptoms? Describe.(Required)

History of AMS (Acute Mountain Sickness), HAPE (High Altitude Pulmonary Edema), or HACE (High Altitude Cerebral Edema)? Please explain.(Required)

Section 4: Physical Health History

List any current or past medical conditions.(Required)

Do you wear a Medic-Alert Tag or any marker of a medical condition?(Required)

Were you hospitalized in the last two years?(Required)

Cardiovascular conditions (heart disease, hypertension, etc.) Have you had a heart attack of any kind? Have you been told you have high blood pressure, a heart murmur, or heart disease?(Required)

Respiratory conditions (asthma, COPD, etc.) or any kind of breathing condition?(Required)

Neurological conditions (seizures, migraines, etc.) or trouble with headaches?(Required)

Musculoskeletal injuries (knees, back, joints)(Required)

Do you have hemophilia or any other issue that impairs blood-clotting?(Required)

Do you have hypoglycemia or diabetes?(Required)

Have you had a recent tetanus or rabies shot?(Required)

Other relevant medical conditions(Required)

Section 5: Medications & Allergies

List all current medications and dosages. Please include daily medications, occasional medications (prescription) as well as supplemental medicines with their indicated use.(Required)

Drug allergies and reaction(Required)

Food allergies and reaction(Required)

Dietary restrictions or preferences(Required)

Environmental allergies and reaction(Required)

Have you ever had a life-threatening allergic response? Do you carry an Epi Pen?(Required)

Do you carry emergency medications (inhaler, EpiPen, insulin, etc.)?(Required)

Medication Disclosure Clause: Participants must disclose all medications they are currently taking, including prescription drugs, over-the-counter medications, herbal supplements, and psychiatric medications. Certain medications may affect altitude tolerance, hydration, sleep, or respiratory function. Trek leaders may request further medical clarification if necessary for participant safety.

Section 6: Physical Fitness

How often do you exercise per week?(Required)

Types of exercise you perform(Required)

Longest hike in the past year(Required)

Are you able to walk 10 km (6.5 mi) in a day with a pack?(Required)

Yes

No

Describe your trekking experience.(Required)

Do you have any concerns regarding your fitness level or ability to participate in a high-altitude trek for 16 days? Is there anything we should know?(Required)

Section 7: Mental & Emotional Health

Have you been diagnosed with depression, anxiety, PTSD, OCD, bipolar disorder, or panic disorder? Do you experience anxiety, depression, panic, OCD, suicidal ideation, or any other mental / emotional symptoms that have not been diagnosed? (Please explain)(Required)

Are you currently seeing a mental health professional? If so, please explain this relationship.(Required)

Are you taking psychiatric medication? For what purpose are these medications prescribed?(Required)

Have you experienced severe anxiety, panic attacks, or major depression in the past year? Please elaborate.(Required)

If the answer is yes, do you feel stable now?(Required)

Enter N/A if not applicable.

Section 8: Psychological Preparedness

How do you typically respond to stress or discomfort? What tools do you have to successfully navigate stress (physical, emotional, mental?)(Required)

Experience with meditation retreats or spiritual intensives?(Required)

Comfort level with silence and introspection?(Required)

Section 9: Group Readiness

Are you comfortable with shared lodging and limited facilities? (Yes/No) ***The facilities in Nepal and the Himalayas are quite rustic. We may not have hot water, comfortable beds, or Western luxuries along the way.(Required)

Any concerns about remote group travel, including small airplanes, buses, remote jeep travel, etc.?(Required)

Section 10: Travel Insurance & Evacuation Coverage

Travel insurance is required for the trip. If you already have a provider, please include the information here.

Do you have travel insurance?(Required)

If yes, enter the provider and policy number below

Yes

No

Travel insurance provider

Policy number

Insurance emergency contact phone

Evacuation Insurance Requirement: All participants must carry travel insurance that covers high‑altitude trekking above 5,000 meters and emergency helicopter evacuation in Nepal. Participants are financially responsible for evacuation costs if not covered by insurance.

Section 11: Final Reflection

What physical or mental/emotional challenges or concerns do you anticipate?(Required)

Anything else the leadership team should know?(Required)

Participant Acknowledgment

Guide Authority Clause:
Trek leaders and guides retain full authority to make safety decisions during the pilgrimage, including altering the itinerary, requiring additional rest days, requiring descent for altitude illness, or removing a participant from the trek if necessary for safety.

I confirm that the information provided above is accurate to the best of my knowledge and that I understand the physical and psychological demands of participating in a high‑altitude pilgrimage trek.

Signature(Required)

Date(Required)