REPORT of DRUGS TESTING

No :
To whom it may concern,
By signing below, I :
Name
Employee ID
Position
Department

:
:
:
: Department of Psychiatry

Certify that :
Name
Medical Record Number
Place and date of Birth
Gender
Address

:
:
:
:
:

Based on the examination on .........................., .................................. with result :

1. Anamnesis
Found / No found symptoms of drug user
2. Physical Examination
Found / No found signs of drug user
3. Laboratorium examination : urine sample , on .........................., ..................................
(result was attached)
Methamphetamine
Reactive / Non Reactive
Opiate / Morphine
Reactive / Non Reactive
Marijuana
Reactive / Non Reactive
Amphetamine
Reactive / Non Reactive
Cocaine
Reactive / Non Reactive
Benzodiazepine
Reactive / Non Reactive
This report is provisional and used for.........................................................
Bandung,...................................

(...........................................)

REPORT of HIV TESTING

No :

To whom it may concern,

By signing below, I :
Name

Employee ID

Position

Department

: Department of Psychiatry

Certify that :
Name

Medical Record Number :

Place and date of Birth

Gender

Address

Based on the examination on .........................., .................................. with result:

1. Anamnesis
Found / No found symptoms of HIV infection
2. Physical Examination
Found / No found signs of HIV infection
3. Laboratorium examination : blood sample , on
attached)
Anti HIV

(result was
Reactive / Non Reactive

This report is provisional and used for.........................................................

Bandung,...................................

(...........................................)