YAYASAN KESEHATAN GPM Nomor RM : ………………………………….

RUMAH SAKIT SUMBER HIDUP Nama : ………………………………….

JL. ANTHONI RHEEBOK NO. 11 Tanggal Lahir : …………………...…Umur…….
TELP (0911) 352373-351654 Jenis Kelamin :L/P

Tanggal Kunjungan :
ASESMEN AWAL RAWAT JALAN/INAP Pukul :
Klinik/Poli :
LembarFormulir Rawat Jalan/Inap
Layanan Kedokteran Fisik dan Rehabilitasi

I.Diisi oleh Pasien Peserta : .........................................................................................

Nama Pasien : .........................................................................................
Tanggal Lahir : .........................................................................................
Alamat : .........................................................................................
Telp /HP : .........................................................................................
Hubungan dengan tertanggung : .........................................................................................

II. Diisioleh DokterSpKFR

Tanggal Pelayanan : .........................................................................................
Anamnesa :.......................................................................................
PemeriksaanFisik dan UjiFungsi: .........................................................................................
Diagnosis Medis (ICD-10) : .........................................................................................
DiagnosisFungsi (ICD-10) : .........................................................................................
Pemeriksaan Penunjang : .........................................................................................
TataLaksanaKFR (ICD9 CM): .........................................................................................
.........................................................................................
Anjuran : .......................................................................................
.........................................................................................
Evaluasi : ........................................................................................
SuspekPenyakitAkibatKerja : Ya(.......................................................................)
Tidak

Tempat &Tanggal
TandaTangan Pasien Cap dan TandaTangan dr. SpKFR

(.........................................................) (.................................................................)
 YAYASAN KESEHATAN GPM Nomor RM : ………………………………….
RUMAH SAKIT SUMBER HIDUP Nama : ………………………………….
JL. ANTHONI RHEEBOK NO. 11 Tanggal Lahir : …………………...…Umur…….
TELP (0911) 352373-351654 Jenis Kelamin :L/P

Tanggal Kunjungan :
ASESMEN AWAL RAWAT JALAN/INAP Pukul :
Klinik/Poli :
Permintaan Terapi :

TTD
PROGRAM TANGGAL
PASIEN DOKTER TERAPIS
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Tempat &Tanggal
Cap dan TandaTangan dr. SpKFR

(.................................................................)