: ___________________________
RM
Tanggal Lahir : ___________________________
NO: Jenis Kelamin : ___________________________
Alamat : ___________________________
ANAMNESIS
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Perawatan Sebelumnya_______________________________________________________________________________________
Vital Sign:
Tekanan darah:______mmHg Nadi:______x/m R.Rate:______x/m Temp:______OC
Penyakit Jantung :
Diabetes :
Haemophilia :
Hepatitis :
Penyakit Lainnya :
Alergi Obat-obatan :
Alergi Makanan :