Anda di halaman 1dari 1

LABORATORIUM KLINIK

Jl. Kesambi No. 165, Kota Crebon. Jawa Barat – Indonesia


Telp. / Fax : (0231) 232275, 232276 (Fax) Email: labharapansehat@gmail.com

MEDICAL REPORT
Reg.No. HS201906120003

Name : MAS MULYANTO Fathers Name : MULYA


Sex : MALE Nationality : INDONESIA
Birth Date : 01-01-1984 Pasport No :
Address : DAMPYAK RT.003/001 Supplier : PT. SAMUEL JAYA MARITIM
KEL.DAMPYAK KEC.
KRAMAT KAB TEGAL

MEDICAL EXAMINATION
(√) Normal or (x) Abnormal
Height : 168 Cm Blood Pressure : 120/80 mmHg
Weight : 54 Kg Pulse : 76 x / mnt

Eyes : Right (√) Skin : (√) Internal Disease :


Left (√)
Abdomen : Heart (√)
Ears : Right (√) Hernia (Neg) Lung (√)
Left (√) Tumor (Neg) Liver (√)
Spleen (√)
Hematology : Imuno Serology : Kidney (√)
Hemoglobin (√) HBsAg (Neg) Thyroid (√)
Lekosit (√)
Thrombosit (√)
Hematokrit (√)
Eritrosit (√)
LED (√) Chest: X-Ray (√)

MEDICAL HISTORY
1. HIV / AIDS (No) 7. Heart Disease (No) 13. Epilepsy (No)
2. Tuberculosis (No) 8. Hypertension (No) 14. Psychiatric Problem (No)
3. Malaria (No) 9. Diabetes (No) 15. Hearing Proble (No)
4. Leprosy (No) 10. Peptic Ulcers (No) 16. Hepatitis (No)
5. Veneral Disease (No) 11. Kidney Disease (No) 17. Rheumatism (No)
6. Asthma (No) 12. Tumor (No) 18. Other State (No)

Conclusion : F I T FOR WORK Cirebon, 12 JUNI 2019


Use suggestion : 12/06/2019
12/09/2019