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ASESSMEN MEDIS OBSTETRI

Anamnesa : ................................................................................................................................................
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Pemeriksaan Dokter Jam:..................


Status Lokalis
Abdomen : .................................................................................................................................................................
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Genitalia : ................................................................................................................................................................
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Pemeriksaan Dalam ( Vaginal Toucher / Rectal Toucher / Inspeculo )

Diagnosa : ................................................................................................................................................
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Rencana Tindakan / Terapi :..............................................................................................................................................


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Tulungagung, ................................ Jam : ........


Dokter

( ........................................................)
Tanda Tangan & Nama Terang

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