KUESIONER HAMIL / PREGNANCY QUESTIONNAIRE

*) Harus diisi oleh Dokter yang merawat/ Must be filled by physician

**) Bila kolom penjelasan tidak cukup, mohon memberikan penjelasan pada kertas lain/ If the columns
are not sufficient, give answers in separate paper

Nama Tertanggung/ Tanggal lahir/ No. SPAJ/ Polis

Name of Proposed Insured Date of birth App./ Polis No.
_______________________ ____________________ _______________
(tgl/bln/th-dd/mm/yy)

1. Status obstetric (GPA)?/ Obstetric state (GPA)?

…………………………………………………………………………………………………..

2. HPHT/ First day of last mestruation :…………………………………

Usia kehamilan/ Gestational age :………………………………………

3. Pemeriksaan fisik/ Medical examination :

a. Tinggi dan berat badan/ Height and weight :……………………
b. Tekanan darah/ Blood pressure :……………………

4. Riwayat kehamilan terdahulu?/ Previous history pregnancy?

…………………………………………………………………………………………………..
…………………………………………………………………………………………………..

5. Kondisi kehamilan saat ini?/ Present pregnancy condition?

…………………………………………………………………………………………………..

6. Komplikasi kehamilan?/ Pregnancy complication?

…………………………………………………………………………………………………..
…………………………………………………………………………………………………..
7. Hal-hal lain yang perlu diketahui/ Other conditions we need to know
……………………………………………………………………………………………………………….…………………………………………

______________________________
Tempat dan Tanggal/ Place and Date :

____________________
Nama lengkap dan Tandatangan Dokter yang merawat/
Doctor’s name and signature

85152-V001201404