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ANEXO N° 16A

MEDICAL EVALUATION FOR ASCENT TO HIGH ALTITUDES


(Greater than 2,500 masl)
1. PERSONAL DATA
Surname:
Passport Number:
Birthdate:
Age:
Employer: Colorado School of Mines
Activity to be carried out: Tour – 1 day

VITAL FUNCTIONS

FC ______ x min, PA ___/___ mmHg, FR ______ x min, IMC ______ kg/m2, Sat. O2______%

He / She presents or has presented in the last 6 months the following:


YES NO
Recent major surgery
Disorders of coagulation, thrombosis, others
Diabetes mellitus
Arterial hypertension
Pregnancy
Neurological problems: epilepsy, vertigo, others
Recent infections (moderate to severe)
Obesity
Cardiac problems: pacemaker, coronary heart disease, others
Respiratory problems: asthma, COPD, etc
Ophthalmological problems: retinopathy, glaucoma, others
Digestive problems: digestive bleeding, hepatitis, liver cirrhosis, others
Sleep apnea
Allergies
Another important medical condition

Use of current medication: _________________________________________________________

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:

Signature & stamp:

1
GUIDELINES FOR THE EXAMINING DOCTOR

I. PHYSICAL EXAMINATION AND AUXILIARY EXAMINATIONS

• Physical examination of the cardiovascular system and the lungs.


• Hemoglobin and hematocrit must be done to everyone.
• Electrocardiogram should be done to all those who are 45 years old or older.
• Basal glucose and glycosylated hemoglobin should be taken by all diabetics.
• In case of clinical suspicion of any pathology that could endanger the health of the patient
that must ascend to 2500 masl or more, request a consultation with the corresponding
specialist.

II. CLINICAL CONDITIONS THAT MERIT ONE OR MORE ADDITIONAL STUDIES TO


DETERMINE THE APTITUDE:

• 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

III. ABSOLUTE CONTRADICTIONS TO RISE TO HEIGHT GREATER THAN OR EQUAL TO 2500


meters above sea level

• IC functional class III or higher


• Functional class III valve or greater
• IMA in the last 3 months
• ACV in the last 3 months
• Presence of unstable angina
• Epilepsy
• Pregnancy (week 28 and up)
• Moderate anemia*
• Severe COPD
• BMI greater than or equal to 40 Kg / mt2
• Presence of pacemaker
• Diabetes mellitus not controlled
• History of cerebral venous thrombosis
• Recent major surgery
• Obstructive hypertrophic cardiomyopathy
• Hepatic cirrhosis
• Deep vein thrombosis (last 6 months)

* Consider the values of the World Health Organization