FORMULIR POLIKLINIK RAWAT JALAN

IDENTITAS PASIEN
No. RM : .......... - .......... - .......... BB : ....................Kg
Nama Pasien : ....................................................................................................................
Tanggal Lahir : ....................................................................................................................
Jenis Kelamin : ....................................................................................................................
Alamat : ....................................................................................................................
No Tlp/HP : ....................................................................................................................
Jaminan : ...................................................................................................................
Poliklinik : ....................................................................................................................
RIWAYAT KEBIDANAN RIWAYAT IMUNISASI
HPHT : □ BCG □ DPT □ Polio □ Campak
Taksiran Partus : □ Hep □ TT □ Lain-lain
G : ........... P : ............ A : ........ H : ............

RIWAYAT ALERGI RUJUKAN

□ Tidak □ Ya, sebutkan ....................... □ Tidak □ Ada, sebutkan dari ................

No. Tanggal Keluhan dan Pemeriksaan Diagnosis Terapi dan Paraf

fisik Tindakan

Kode Formulir : 003/Yan-med/I/16/Rev.01

Kode Formulir : 003/Yan-med/I/16/Rev.01