Medical Checkup Form (Attachment 3)

Applicant Name: SYAMSUL BAHRI __

Date of Birth 17 / 06 / 1984 Sex: □✔ Male □ Female

Current Address: DYANDARA RACIDENCE A.6 WESABBE TAMALANREA, MAKASSAR

1. Weight: 67 Kg
2. Height: 168 Cm
3. Internal Examination: Within normal limit
4. X-ray: Normal chest X-ray
5. Chest Problem: Shortness of breath (-), cough (-)
6. Eyesight With glasses: Left (-) Right (-)
Without glasses: Left 6/6 Right 6/6
7. Color Blindness: Normal
8. Blood Pressure: 100/80 mmHg
9. Urine Test: Microscopic and macroscopic urine within normal limits
10. Hearing: Normal Hearing
11. Blood Sedimentation: Blood Sedimentation rate is within normal limits
12. Tuberculin Reaction: □ Positive □✔Negative
13. Past Illnesses: Gastritis (+), DM (-), Hypertension (-)
14. Chronic Illnesses: Gastritis (+), DM (-), Hypertension (-)
15. Allergies: Allergies of foods (egg and shrimp)
16. Dietary restrictions: No restriction
17. Blood type: O
18. Other: (-)

19. Do you drink alcohol? □✔No □ Yes (If yes, drinks per day/week/month)
20. Do you smoke? □✔No □ Yes (If yes, cigarettes per day/week/month)

I hereby certify that the above details are true and correct.

Name of Physician: dr. Asti Trianawati

Physician Signature:

Date: 14 / 02 / 2022

Hospital: PELAMONIA HOSPITAL

Address: Jalan Jenderal Sudirman No. 27 Makassar, South Sulawesi Province.