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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