You are on page 1of 2

SURAT RIWAYAT KESEHATAN

1. Nama .....................................................................................................................................................
2. Jenis kelamin …………………………………………………………………………………………..
3. Usia ......................................................................................................................................................
4. Tinggi badan .........................................................................................................................................
5. Berat badan .........................................................................................................................................
6. Alamat tempat tinggal di Malang ……………………………………………………………………...
7. Riwayat Penyakit :
a. Dahulu : …………………………………………………………………………………………….
.............................................................................................................................................................
.............................................................................................................................................................
b. sekarang : ……………......................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
c. cara penanganan : ……………………………………………………………………………………
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
d. obat yang sedang dikonsumsi : ……………………………………………………………………...
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
e. Terakhir menderita penyakit pada bulan………………………………………….…tahun…………
f. Penyakit berat yang pernah dialami : ..………………………………………………………………
.............................................................................................................................................................
g. Kelainan pada organ : ……………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
h. Operasi yang pernah dijalani :……….………………………………………………………………
……………………………………………………………………………………………………….
i. Keluhan kesehatan yang sering dialami : …………………………………………………………...
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
8. Riwayat Alergi
a. obat : ……………………………………………………………………………………………….
b. makanan : …………………………………………………………………………………….…….

1

. jika iya sebutkan : ………………………………………………... Cara menangani jika terjadi alergi :………………………………………………………………. ……………………………………………………………………………………………………… 10... Olah raga yang sering dilakukan : …………………………………………………………………. Dampak jika terjadi alergi : ……………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… e. lain – lain : …………………………………………………………………………………………. 12. 11. ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 9. d. Apakah Anda pernah naik gunung. Nomor penting yang bisa dihubungi (Keluarga / Wali ) ……………………………………………….. ……………………………………………………………………………………………………… b. …………………………………………………………………………………………………………... Apakah anda memerlukan perhatian khusus yang perlu diperhatikan oleh panitia sehubungan dengan kesehatan anda ? ya / tidak ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. c. ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… 2 . Riwayat Olahraga a. …………………………………………………………………………………………………………. Intensitas olahraga : ……………………………………………………………………………….