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Waktu Pemeriksaan :

Tanggal :
Jam :

Identitas pasien :
Nama :
Umur :
Alamat :

Jenis kelamin :
Pekerjaan :
Suku :
Agama :
Jumlah saudra :
Anak ke :

Keluhan Utama :
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Telaah :
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Riwayat Penyakit Terdahulu:


1.
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3.
4.
5.
Riwayat Pemakaian Obat :
1.
2.
3.
4.
5.
6.
Pemeriksaan Fisik:

Vital Sign :
Tekanan Darah :
Pernapasan :
Suhu :
Nadi

Berat Badan :

Inspeksi :

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Palpasi :

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