PERSONAL DATA

Name :

Medical Record :

Company :

Place/Date of Birth :

Sex : Male / Female

Marital Status : Single / Married

Date of Examination : June 26th, 2019

Type of Examination : Chevron Periodic / Pre-placement

Examining Doctor : dr. Muhammad Yusuf

dr. Erman Fauzi, Sp.PD / dr. Hermadi, Sp.PD

dr. Yelvita Roza, SP.THT-KL (audiometri)

dr. Romaito Nasution, SP.P (spirometri)

dr. Harry, Sp.PK (lab)

dr. Wicak, Sp.Rad (rontgen)

Dear Mrs. Widmona, thank you for your confidence to perform your medical check-up in our
hospital. We conclude your health status / MCU result as mentioned below:

FINDINGS

 Your physical examination show blood pressure, pulse rate, respiratory rate, and
temperature are normal
 Your eye examination show …… at both eyes
 You have normal fasting blood sugar test
 You have normal lipid profile test
 Your complete blood count test show ….
 Your liver function test show …..
 You have normal urinalysis test
 You have negative stool occult blood test
 You have normal chect x-ray
 You have normal ECG Test
 Your abdominal USG is normal
 Your audiometry test is normal
 Your spirometry test is normal

SUGGESTIONS

 Your glasses are still adequate, consul ophthalmologist if you have any complain
 Consul your company doctor for further evaluation
 Consul an ENT specialist for further evaluation
 Have a low salted diet and high fiber diet. Do exercise regularly
 PERSONAL DATA

Name :

Medical Record :

Company :

Place/Date of Birth :

Sex : Male / Female

Marital Status : Single / Married

Date of Examination : June 26th, 2019

Type of Examination : Chevron Periodic / Pre-placement

Examining Doctor : dr. Muhammad Yusuf

dr. Erman Fauzi, Sp.PD / dr. Hermadi, Sp.PD

dr. Yelvita Roza, SP.THT-KL (audiometri)

dr. Romaito Nasution, SP.P (spirometri)

dr. Harry, Sp.PK (lab)

dr. Wicak, Sp.Rad (rontgen)

Dear Mrs. Widmona, thank you for your confidence to perform your medical check-up in our
hospital. We conclude your health status / MCU result as mentioned below:

FINDINGS

 Your physical examination show blood pressure, pulse rate, respiratory rate, and
temperature are normal
 Your eye examination show …… at both eyes
 You have normal fasting blood sugar test
 You have normal lipid profile test
 Your complete blood count test show ….
 Your liver function test show …..
 You have normal urinalysis test
 You have negative stool occult blood test
 You have normal chect x-ray
 You have normal ECG Test
 Your abdominal USG is normal
 Your audiometry test is normal
 Your spirometry test is normal

SUGGESTIONS

 Your glasses are still adequate, consul ophthalmologist if you have any complain
 Consul your company doctor for further evaluation
 Consul an ENT specialist for further evaluation
 Have a low salted diet and high fiber diet. Do exercise regularly