balai pengobatan umum pusat medis trisakti unit...
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BALAI PENGOBATAN UMUM PUSAT MEDIS TRISAKTI
Unit Kampus D Trisakti JI. IKPN - Bintaro Tanah Kusir, Jakarta Selatan
Telp. 7377738
1. Fisik & Skrining Obat I Zat
2. Buta Warna
3. Fisik, Buta Warna & Skrining Keterangan Obat I Zat
I. Diisi Oleh Mahasiswa
Foto 3x4
Nama
. Keperluan
Alam at
................................................................... Umur
................................................................... Fakultas
........................................... LIP
........................................... Jurusan .
Keadaan Kesehatan :
Keluhan Sekarang : .
Kejang-kejang
Asthma
Batuk Darah
Kelainan Jantung
Sak.it Maag
YA/TIDAK Cacat Tubuh : YA/TIDAK Pemah Menggunakan Obat-obat Penenang: YA/TIDAK
YA/TIDAK Sakit Kuning : YA/TIDAK Kalau YA, sebutkan . Jenisnya .....................................................
YA/TIDAK Malaria :YA/TIDAK Pemah menggunakan Obat untuk jangka waktu lama: YAffIDAK Bila YA, sebutkan Jenisnya ..............................................................
YA/TIDAK Patah Tulang : YA/TIDAK Pemah dirawat RS. Ketergantungan obat : YA/TIDAK YA/TIDAK Peny. Syaraf : YA/TIDAK Kapan: .............................................................................................
Operasi
Olah raga
SAVA TELAH MEMBER! KETERANGAN SEBENARNYA TANPAMERAHASIAKAN SESUATU APAPUN MENGENAI KESEHATAN SAYA UNTUK KEPENTINGAN DIRI SENDIRI
Mengetahui, Orang Tua I Wali
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II. Diisi Oleh Dokter Pusat Medis Trisakti Keadaan Umum : Tensi
Mata/Buta Warna : Telinga :
Jakarta, 20 . Yang memberi pemyataan
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................. Nadi : Berat/Tinggi: .
Hi dung
Cor
Pulmo
Lien
Extrimitas
............................................................ Mulut :
......................................................................................................................................................................................
····················································································································································································· ............................................................ Hepar : .
····················································································································································································· Tanda-tanda fisik ketergantungan Obat I Zat : .
Kulit
Kesimpulan
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Catatan: Coret yang tidak perlu
Jakarta, 20 . DOTER YANG MEMERIKSA
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