KLAYAN PERTAMINA HOSPITAL

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

IDENTITY
Name : A. KHARISMA SATRIA KESUMA
Sex : Male
Date of birth : January 25, 1987
Marital status : Not married
Religion : Islam
Nationality : Indonesia
Address : Setrayasa Raya Street no. 14 Cirebon

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

PHYSICAL EXAMINATION
Bp 110/70 mmHg, Pulse rate 78 bpm, reguler
Height 173 cm, Weight 66 kg
Others : Within normal limit

Eyes : winthin normal limit, color blindness : no

Ear, Nose & Throat : within normal limit
Dental screening : DMF 0/0/0 ( D : Dental cavity, M : Missing, F : Filling )

RESULT

I certify that I have this day examined the above-named, that He is found to be Fit

Cirebon, February 17, 2003

Dr. Sugiantoro
 KLAYAN PERTAMINA HOSPITAL
CIREBON
Patra Raya Street Klayan Phone (0231) 2512116 Facs (0231) 209328 Cirebon