RINGKASAN RIWAYAT POLIKLINIK No.RM: 90-05-05 NAMA (Pakai huruf cetak) Bunga Cir VeTRRI ALAMAT / TELEPON > UL Taman Kencana Tl - (anggenny : 6993125 TEMPAT & TANGGAL LAHIR/UMUR | STATUS PERKAWINAN | _JENIS KELAMIN AGAMA Jakarta, 93 - 10- 1954 Osx @k Ov Oo Ol &pP (slam PEKERJAAN NAMA TEMPAT PEKERJAAN ‘ALAMAT TEMPAT PEKERJAAN Pedagang a _ NAMA AYAH UMUR PEKERJAAN : [NaMaiBu UMUR PEKERJAAN DOKTER YANG MENGIRIM de. Pern Sp. Ot, ALAMAT / TELEPON : tM (Olrdanan PERUBAHAN ALAMAT \ - u TANGGAL | POLI YANG DIAGNOSIS TINDAKAN/OPERASI | TANOATANGAN | KODE KUNJUNGAN] —DIKUNJUNGI DoKTER — | DIAGNOSIS’ OPERAS! 30/509 | dewasn Wearensa _ 4 _ Benegal rsdn 100.01) PERJALANAN-RENYAKIT, | --PERINTAH DOKTER DAN PENGOBATAN Namal ; “tae Cha hestari = Poli Dowasa, NOuRM 11 ' eet ee Hele Umi): wa IP | TEU | JAM AOA \ PERINTAH H RESORT YTINDAKAN | TT & NAMA seRRON DOKTER 90/8 | ton aang (4), posren butobut Pugakan Poli ebidanan Kenta hpertenee be polk (ebidanan irr Mongobaty Merofause CFlone.ug), beblea dcner D= BO/10 runtig . Rx didlingnosa| herr de. febidanan + dibbke poli (widanan Ay det Nordadh Wa + tua. & rwongayrolaan abt Selamh tovan (aly Stop sencliei arena murse, beigan. 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ReMODIO HP] | TELA GREE SUIT AR BER Ode HATHIS " PERINTAH FENG AA AKAN | JAM} | PERACANAN FERYART. | yal DERN NS TDOKTER Pas] - px —e ambit dah - ¥Y ponalibion bia enh @ 0 obat poretttan foes Tes sanfa, Pada. Wnyungen Salanyidinge | ~ Clk om Lotus tan é. Yo | Rass Wo dln. U Ptnen amends Ee dln Celampie) Friee blues © ella > opel kingusen) 2.Subject’s Initial : B CL Site Number : 00 Enrolment Number: | J [ SCREENING VISIT - Visit 1 Date of Visi > 30 - MAY -& 0 09 (adimmmyyyyy Date of Informed Consent :3 0. -M AY - 200 J (ddimmmiyyyy) Date Of Birth: 23 -V OV -1.4 6 4 (ddimmmiyyyy) Sex : Male Female Date of I diagnosed as Hypertension: 3.0 -M AY -2 0.09 (ddimmmyyyy) Frillwith the closest data evalable Hypertension Classification : Essential C Non- Essential : (underlying cause) Nicotine use : Smoking (1 Non- Smoker O Ex-Smoker Occasional Smoker K Habitual Smoker Previous Related Medical History (fill with the closest date available) ret, From To No Condition/Disease aammmiyay Tmaminyy 1 | Diqbetes Melliivs 2 | Pppendicins SE_195F [3 Gasnets = 4 3 TESH Study ~CRF Version 1.1 Pg 1 of 5Subject’s Initial: B EL Site Number : JQ 2 Enrolment Number: 1 Q 1 SCREENING VISIT — Visit 1 Hypertension Therapy History (fill with the closest date available. ) No Drug/Therapy From To (Brand Name) dd/mmm/yyy3 dd/mmm/yyyy i Hct Xt_Feb 200F Zt hpe 204 2 3 + 5 icant Familial Medical History (fill with the closest date available) Condition/Disease Physical Examination 130 - MAY -2 0 O 4 (ddimmmyyyy) Weight: {0 Kg Height: 4@0_cm Waist Circumferen Date of Examin: Respiratory Rate: 48 x/min Blood Pressure I (systolic/diastolic): 40) M0 Pulset: 2 x/min Blood Pressure Il (systolic/diastolic):_ 1@5_/ M0 _ mmHg Pulse W: 68 x/min Note: please refer to protocol for correct procedure of Blood Pressure measurement. Make sure subject has 10 minutes rest prior to measurement and 5 minutes rest period between 1" and 2" Examination. TESH Study ~CRF Version 1.1 Pg 2 of 5Subject’s Initial : 6 Site Number : Enrolment Number : ( L 4 2 | josic SCREENING VISIT - Visit 1 Other Significant Physical Examination : NA ECG Result Date of ECG: 3 0 - MAY -20 0 4 (ddimmmiyyyy) Normal 1 Abnormal (please describe) ‘TESH Study ~ CRF Version 1.1 Pg 3 of SSubject’s Initial: BC L Site Number: A2BZB ID/ Enrolment Number : JQ. 2 SCREENING VISIT - Visit 1 ‘Yes [No Inclusion c1 1. Men or women 40 years or older x 2. Systolic blood pressure > 160 mm Hg and < 210 mmHg x 3. Diastolic blood pressure > 100 mm Hg and < 115 mmHg x Exclusion criteria 1. Pregnancy and lactation bee, 2.__ Hypersensitivity to ARBs or t Evidence of orthostatic hypotension (a decrease in sitting SBP ‘of >20 mm Hg and/or a decrease in sitting DBP of >10 mm Hg on standing) or malignant hypertension ~< 4. History of transient ischemic attack or cerebrovascular accident within the preceding 6 months; Evidence of a secondary type of hypertension Overt heart failure or a history of heart failure; History of myocardial infaretion within the preceding 6 months; Percutaneous transluminal coronary angioplasty or coronary artery bypass grafting within the preceding 6 months 9. Angina pectoris; clinically relevant arthythmia; clinically significant valvular heart disease 10. Evidence of hepatic disease L1,_Abnormal serum potassium level 12, Evidence of renal impairment (serum creatinine level >1.5 times the upper limit of normal); % Pe [os] aq [PS PSPS Ps | >< 13, Type-1 or type-2 diabetes mellitus with poor glucose control (persistent fasting blood glucose >200 mg/dL) or peripheral xK neuropathy or autonomic neuropathy; 14, Patient involved in other experimental treatment in the past 3 x months ‘TESH Study ~CRF Version 1.1 Pg 4 of 5Subject’s Initial Site Number Enrolment Number : BN ISIC Its SCREENING VISIT - Visit 1 All Inclusion criteria must be answered yes and exclusion Criteria must be No Does the patient Eligible for the study ?: {Yes 0.No Date of Next Visit: 95 -JU M-20 8 J (ddimmmiyyyy) Investigator Declaration I, Principal Investigator of Site declare that all the data in the previous pages and this page are correct and accurate. TESH Study — CRF Version 1.1 Pg 5 of 5