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  • Inap 2

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    Nikita Putri
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    Rumah Sakit Mata Fatma is an eye hospital located in Sidoarjo, Indonesia. The document provides a medical checkup form for a patient, including fields for patient name, gender, date of birth, date of checkup, checkup time, and examinations of the right and left eyes. The form includes boxes to note observations of the eyes such as vision, prescription needs, eye movement, eyelids, conjunctiva, cornea, pupil, iris, lens, vitreous, fundus, intraocular pressure, and color blindness test results. It concludes with spaces for the doctor's conclusion and recommendations.

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    FORMULIR RAWAT INAP

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    INAP 2

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    Rumah Sakit Mata Fatma is an eye hospital located in Sidoarjo, Indonesia. The document provides a medical checkup form for a patient, including fields for patient name, gender, date of birth, date of checkup, checkup time, and examinations of the right and left eyes. The form includes boxes to note observations of the eyes such as vision, prescription needs, eye movement, eyelids, conjunctiva, cornea, pupil, iris, lens, vitreous, fundus, intraocular pressure, and color blindness test results. It concludes with spaces for the doctor's conclusion and recommendations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    16 views1 page

    Inap 2

    Uploaded by

    Nikita Putri
    Rumah Sakit Mata Fatma is an eye hospital located in Sidoarjo, Indonesia. The document provides a medical checkup form for a patient, including fields for patient name, gender, date of birth, date of checkup, checkup time, and examinations of the right and left eyes. The form includes boxes to note observations of the eyes such as vision, prescription needs, eye movement, eyelids, conjunctiva, cornea, pupil, iris, lens, vitreous, fundus, intraocular pressure, and color blindness test results. It concludes with spaces for the doctor's conclusion and recommendations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    RUMAH SAKIT MATA FATMA

    Jl. Raya Kalijaten No. 40, Taman, Sidoarjo


    Telp. 031-7879857,Fax. 031-788 1302
    Website : rsmatafatma.com
    Email : info@rsmatafatma.com
    MEDICAL CHECK UP
    NAMA PASIEN : NO RM :
    JENIS KELAMIN : ALERGI :
    TGL LAHIR : TEMPELKAN LABEL ALERGI :
    TGL MRS :
    JAM MELAKUKAN MCU :

    OD OS

    ______________________________ Visus
    ______________________________ Koreksi
    ______________________________ Adisi
    ______________________________ Gerakan bola mata
    ______________________________ Kedudukan
    ______________________________ Palpebra
    ______________________________ Conjunctiva
    ______________________________ Cornea
    ______________________________ COA
    ______________________________ Pupil
    ______________________________ Iris
    ______________________________ Lensa
    ______________________________ Vitreous
    ______________________________ Fundus
    ______________________________ T.I.O
    ______________________________ Campus

    Test Buta Mata  Normal


     Red Green Deficiency
     Buta Warna Total

    Kesimpulan :

    Anjuran :

    Dokter

    (……..……..)

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