KLAYAN PERTAMINA HOSPITAL

CIREBON
Patra Raya Street Klayan Phone (0231) 2512116 Facs (0231) 209328 Cirebon

IDENTITY
Name : XXXXX
Sex : Female
Date of birth : March 10, 1984
Marital status : Not married
Religion : Islam
Nationality : Indonesia
Address : xxxxxxxxxxxxxx

MEDICAL HISTORY
History of present illness :
No paticular complaint
Past medical history :
None
Family history :
None

PHYSICAL EXAMINATION
Bp 100/70 mmHg; Pulse rate 78 bpm, reguler; Respiratory rate 18 x/min
Height 161 cm; Weight 54 kg
Others : Within normal limit

Eyes : winthin normal limit, color blindness : no

Ear : perforasi auricular dextra
Nose & Throat : within normal limit
Dental screening :
x
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
v o o v

(x = Missing, o = Caries, v = Root rest )

Vision : within normal limit (without glasses)
Color Blindness : negative
Neck : within normal limit
Chest : Heart and Lungs normal
Abdomen : within normal limit
Extremities : within normal limit
Skin and Nails : within normal limit
Central Nervous System : Pathologic reflex -/- , Tremor [ - ], Romberg [ - ]

LABORATORY FINDING (Routine Hematology and Urine) : within normal limit

CHEST X-RAY : mild chronic bronchitis, cor normal (No. Photo xxx)

RESULT

The above named person physically : Fit for duty as a House Keeper

Cirebon, March 26, 2003

Dr. Sugiantoro