FORMULIR SURAT KETERANGAN DOKTER FORMULIR SURAT KETERANGAN DOKTER

NAMA LENGKAP :.................................................................................... NAMA LENGKAP :....................................................................................

JENIS KELAMIN :.................................................................................... JENIS KELAMIN :....................................................................................

TEMPAT TANGGAL LAHIR : ................................................................................... TEMPAT TANGGAL LAHIR : ...................................................................................

PENDIDIKAN TERAKHIR : ................................................................................... PENDIDIKAN TERAKHIR : ...................................................................................

PEKERJAAN : .................................................................................... PEKERJAAN : ....................................................................................

ALAMAT : .................................................................................... ALAMAT : ....................................................................................

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PERMINTAAN KIR UNTUK KEPERLUAN : PERMINTAAN KIR UNTUK KEPERLUAN :

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1. PEMERIKSAAN
a. Visus : ...................................................................................
b. Warna : ...................................................................................
c. Penciuman : ...................................................................................
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5. PEMERIKSAAN
f. Visus : ...................................................................................
g. Warna : ...................................................................................
h. Penciuman : ...................................................................................

2. PEMERIKSAAN FISIK 6. PEMERIKSAAN FISIK

a. Tensi Darah : .................. MmHg d. Tensi Darah : .................. MmHg
b. Tinggi Badan : .................. Cm e. Tinggi Badan : .................. Cm
c. Berat Badan : .................. Kg f. Berat Badan : .................. Kg

3. PEMERIKSAAN LABORATORIUM 7. PEMERIKSAAN LABORATORIUM

a. HB : ..................Gr % c. Urine –Alb: .................. c. HB : ..................Gr % c. Urine –Alb: ..................
b. Golongan Darah : .................. - Red: .................. d. Golongan Darah : .................. - Red: ..................
4. PEMERIKSAAN GIGI : 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 8. PEMERIKSAAN GIGI : 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 76 5 4 3 21 1 2 3 4 5 6 7 8 8 76 5 4 3 21 1 2 3 4 5 6 7 8
d. OH – IS : ................................................................................... i. OH – IS : ...................................................................................
e. Lain-lain : ................................................................................... j. Lain-lain : ...................................................................................