Name SRN Day / date Room

: : : :

Thursday, August 29th 2013 Kemuning Ward ( Ear Nose Throat)

A. ASSESSMENT 1. Clients Identity Name Gender Age Address Education Occupation Merital Status Religion Ethnicity/Nation Date Of Entry Medical Diagnose : : : : : : : : : : : Mr. A Male 37 years old Paringin, Balangan Elementary School Farmer Married Islam Javanese / Indonesian August 22th, 2013 Corpus Alienum (Dental) of esophagus 1-06-24-20 August 29th, 2013

Medical Record Number : Date Of Assessment :

2. Next Of Kin Identity Name : Mrs. R

Gender Age Occupation Address Relation With Client

: : : : :

Female 34 years old House wife Paringin, Balangan Clients wife