YPIB Medical Clinic

MEDICAL HISTORY
Date :

Please complete this history form. This will allow us to best serve your health needs. The information contained
herein is strictly confidential and will be released unless you authorize us to do so.

Name : Dandi Risnandar D.O.B : 23 March 1998 Location : No

Address : Sumedang Home : Sumedang Business : Playing game
Occupation : Collag student Retired : (yes / no) Year :
Marital status : Un Merried Religion : Islam
Previous physician : Nothing Location : Nothing

FAMILY Sex Age General health Age at death Cause of death

Father 53 No No No
Mother 49 No No No
Sibling M F No No No
M F
M F
M F
M F
Husband/wife M F
Son/daughter M F
M F
M F
M F
M F
Do you have immediate family with the following? (indicated relationship)
High blood pressure Epilepsy
Heart attack Asthma
Stroke Bleeding problems
Diabetes Thyroid problems
Tuberculosis Mental illness
Cancer, Leukaemia Kidney disease
Habits
Yes No Do you smoke?
Yes No Have you stopped smoking? When?
Yes No Do you drink coffee? How much per day?
Yes No Do you drink alcohol?