Form Medik MIPA Bersatu 2015

A. Data Diri
Nama Lengkap

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Nama Panggilan : ....................................

TTL

No. HP

: ...................................

: ..................................., ...................................................................

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NPM

: .....................................

Prodi

: ...................................

Jenis Kelamin

: .....................................

Gol. darah

: ...................................

Berat badan

: .....................................

Tinggi badan : ...................................

B. Riwayat Kesehatan
a. Penyakit yang pernah dialami (beri tanda ceklis pada kolom kosong yang disediakan)
Asma

Sakit mata

Cacar

Hemophilia

Migraine

Campak

Patah tulang

Maag

HIV

Kanker
Hepatitis

Jantung
Hipertensi

Tivus
Kolera

Diabetes

Ginjal

TBC

Depresi

Hipertermia

Hipotermia

Anemia
Sakit gigi
Arthritis

Ginjal
Usus buntu
Sakit kepala

Malaria
DBD
Pneunomia

Penyakit lain :
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b. Apakah Anda mempunyai alergi? ( ya / tidak )*
Jika ya, sebutkan dan jelaskan keluhan serta cara penangannya
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c. Apa penyakit yang anda derita, jelaskan keluhan serta cara penangannya
Selama 6 bulan terakhir

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Selama 3 bulan terakhir

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d. Apakah Anda pernah dirawat di rumah sakit? ( ya / tidak )*

Jika ya, apa penyebabnya
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e. Apakah Anda pernah menjalani operasi ( ya / tidak )*
Jika ya, apa penyebabnya
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Apa pantangan setelah operasi
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a. Keluarga yang dapat dihubungi dalam keadaan darurat
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Nama

: .............................................................................................

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Alamat

: .............................................................................................

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No. HP
: ...............................................................................................
Hubungan kekerabatan
: ...............................................................................................
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Nama

: .............................................................................................

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Alamat

: .............................................................................................

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No. HP
: ...............................................................................................
Hubungan kekerabatan
: ...............................................................................................