Medical Clearance for Pilgrimage
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Passport/ID Number
Contact Number
Address
Medical History
Chronic Illnesses
Allergies
Current Medications
Past Surgeries
Other Relevant Information
Doctor's Assessment
Physical Examination Findings
Are there any medical conditions that may affect this individual's ability to perform pilgrimage?
Recommendations/Restrictions
Physician Details
Physician Name
License Number
Contact Information
Date
Signature