oe Medic Centre Your Trusted Partner In Health Sumame Fisivane Tidde name] Sox [ Age] Weight | Grade ofthe of ’ SUSeT YO Heol ove 67 Ag ‘Medal Fisory- Do any of he medical condlionTated apply? Inaiate adeltenal comments below ‘Yes. No Yes No] Yes No | 4. Loss ofvision 6. Hypertension | 13. Eplepey v 2 Color bindness J] |7. chest pain 12, Kidney disease 3. Seizures YJ | 8 Diabetes |. Venereal disease 4. Frequent headaches 8. _Shoriness of breath | 14. Narcotics history 5. Heart difficulties 10. Tuberculosis: | 18. Other illness: “J as | Circa Evaluation Neral Neral Yes. "'No Yes." No 16. Head, face, neck : 20. Genitourinary (Hematuria, Pyuria), 17, Chest and kings 21, Rectal (Blood. Masses) 18. Vascular system | 22. Lower extremities (varicoses) 19. Abdomen and viscera ~ (23. Appearance & mental state. 7 Vision 2. Gol PereaHIOn 76. eating Theorected | —Corecied rere Right Eye aoa. 20/22 | Book Lanter, Right Ear _ DP Left Eye 20140 2026 | Yetow oma! Reg Aora sea Botheyes 20 20 | Green ZEP™ Blue —Arrmal | Lettear _ Avrmal WF Blood pene 2B. Respiratory 7 Pe Yes No. ‘Systolic al Rate _20 tp Rate 0. bpm, regular Diastolic Ea Tabata Finding 30. Chest Raiography Report aii] Revegen ec clipemviagn Tanda tap AeA Ta Tan Xr Bis “ER ck a Veneta “penuatet ‘sakta Jan cerg 31 Urinalisis "Specie gravy Protein ‘Sugar, a EBsat ir BBs) soohi_TPHAL Positive negative Overall eumimary barr Anamnesis clan Pemeriesoun Foie tidak di kmvlean adanyer tarda -tanete lekiinan atau Peryauct yung akan nenghalane — Pelerzoan Thave examined and fnd Rinvher fitfor duty unfit for duty The present medical cereal vald unt Thereby cory a he above i corech Date 04 AbvsrvUs 2o0/b Physician's name an. Amnatieh : 3 a Address Tansung Bota karimen, (eowesta INTRI Signature a Kepulauan Riau