MEDICAL REPORT

Date : 9th April 2021

A. Patient Information
1. Name : Ismi Khaira
2. Birth date : 26th February 1997
3. Nationality/Race : Sundanese
4. Address & telephone : Telukpinang Ciawi, 085814142002
5. Religion : Muslim
6. Martial status : Married
7. Occupation : Teacher

Chief complaint : Mrs.Ismi said she have a headache

B. History of Present Illness

1. Date and Time Onset : 1st April 2021
2. Specific Location : Top of head
3. Type of pain : Dull and Tight

C. Mestrual History
1. Age of Menarche : 14 years old
2. Duration : 6 days
3. Last period : 1st January 2021
4. Dysmenorrhoea :-

D. Obstetric History
1. Gravida/Para : G2P1A0
2. Each Pregnancy
a. Date of Termination : 20th January 2019
b. Weeks gestation : 37 weeks
c. Place of Delivery : Hospital
d. Complication :-
e. Weight of Baby Birth : 3000 gr
f. Sex of Baby : Boy
g. Complication :-
h. Present Status of Infant : Healthy

E. Contraceptive History
1. Type : Injected Contraception
2. Side Effect : Increased weight
3. Length of time : 1 year