LISTENING

My name is Muhammad Wahyu Ikhsan, my nickname is Wahyu. I was born in (1)______ on (2)________.
I am the oldest child in my family. I live in Jln. Slamet Riyadi No. 67 Solo with my big family. My father is
a (3)_______. His name is Mr. Yunus. My mother is a housewife, her name is Mrs. Zulyana. I have two
sisters. They are Putri Nuzul Audiana and Putri Nurseha Balqis. I am in the second grade of SHS in SMA
BATIK 2 Surakarta. I like (4)________especially swimming. My favorite foods are (5)_______________.

6. Name :
7. Address :
8. School :
9. Age :
10. Family :Father’s name :
Mother’s name :
Sister’s name :
11. Hobby :
12. Favorite food :

WRITING

MEDICAL FORM

Name _______________________________________(1)____________________ Age_______(2)________

Address____________________________________(3)_________________ D.O.B______(4)____________

Phone____________________(5)_______________ Blood Type (if known)________(6)____Sex_______(7)

Doctor’s name_________________________(8)_______________ Phone___________(9)______________

EEMERGENCY CONTACT: Name__________________(10)____________ Relation ________________(11)

Allergies (list all- i.e. to medicine, food, plants or animals):________________________________________

__________________________________________(12)__________________________________________

_______________________________________________________________________________________

Health problems (list all - I.e. heart, respiratory, blood pressure, asthma, diabetes, etc….):______________

________________________________________(13)____________________________________________

_______________________________________________________________________________________

Medicine taken (please list name, dosage and how often): _______________________________________

________________________________________(14)___________________________________________

_______________________________________________________________________________________