KLINIK PRATAMA PIKA MEDIKA

JL. RAYA SINGAKERTA, UBUD, GIANYAR

082341676096 / pikamedikaubud@gmail.com

CONFIDENTIAL MEDICAL REPORT

Medical Record Code
Medical Record Number :
Reg. Date :

Patient Identity
Name :
Sex :
Date of Birth :
Nationality :
Address in Bali :
Phone number in Bali :

Medical information
Type of service : come to clinic/on call/home visit
History :

Physical :Vital sign Conciousness : Respiration rate :

examination Body
Blood pressure : :
temperature
Pulse rate : O2 saturation :

Gen. Physical Examination

Diagnosis :

Treatment :

Recomendation :

Attending physician

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