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CATATAN PENGOBATAN PASIEN

APOTEK
JL.

DATA PRIBADI
NAMA : ..........................................................................
JENIS KELAMIN :...........................................................................
TANGGAL LAHIR/USIA : ..........................................................................
ALAMAT :...........................................................................
NO. TELP :...........................................................................
GOLONGAN DARAH :...........................................................................
BERAT BADAN :...........................................................................
TINGGI BADAN :...........................................................................
RIWAYAT ALERGI
MAKANAN :...........................................................................
OBAT :...........................................................................
LAINNYA :...........................................................................
RIWAYAT PENYAKIT
ASMA :...........................................................................
DIABETES :...........................................................................
JANTUNG :...........................................................................
HIPERTENSI :...........................................................................
LAINNYA :...........................................................................
RIWAYAT EFEK SAMPING OBAT
NAMA OBAT EFEK SAMPING
PROFIL PENGOBATAN DENGAN RESEP
TGL DOKTER NAMA OBAT ATURAN PAKAI LAMA PENGOBATAN CATATAN APOTEKER

PROFIL PENGOBATAN TANPA RESEP (OBAT OTC,VITAMIN ATAU SUPLEMEN)


TGL DOKTER NAMA OBAT ATURAN PAKAI LAMA PENGOBATAN CATATAN APOTEKER

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