DISASTER MEDIS COMITE (DMC)

RUMAH SAKIT ISLAM KENDAL

Jl. Ar Rahmah No. 17 Ngasinan TELEPON : (0294) 641870
Kecamatan Weleri Kabupaten Kendal (0294) 643756
Email : rsimuhkendal@yahoo.com FAX : (0294) 644150

FORMULIR PEMERIKSAAN KESEHATAN DASAR

Hari, Tanggal Pemeriksaan :______________________________________________________________

Nama Kegiatan :_____________________________________________________________

IDENTITAS PESERTA

Nama :____________________________________________________________________

Jenis Kelamin:Wanita / Laki-laki*

Tempat, Tanggal Lahir/ Umur : ___________ , ______________________ / _____ Tahun

Alamat :______________________________________________________________________________

No. Tlp/ HP :____________________________________________________________________

HASIL PEMERIKSAAN

Tekanan Darah : ____________________________________________________________________

Nadi : ___________________________________________________________________

Nafas : ___________________________________________________________________

Riwayat Penyakit/Kesehatan :

1. _______________________________________________________________________________

2. _______________________________________________________________________________

3. _______________________________________________________________________________

4. _______________________________________________________________________________

Rekomendasi : _____________________________________________________________________

_____________________________________________________________________

Pemeriksa

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