FORMULIR PENGAJUAN BPJS

POLINDES : PANDEMAN
BULAN : SEPTEMBER 2022

PEMERIKSAAN FISIK TEKANAN DARAH

NO TANNGAL NO.BPJS NIK NAMA UMUR ALAMAT DIAGNOSA RR NADI SUHU ALERGI
TB BB LP SISTOL DIASTOL
1 9/1/2022 0000782320904 3529245506900003 Maimuna 30 th Pandeman Luka Bakar (T23) 150 56 86 100 70 20 80 36.1 tdk ada
2 0000782331682 3529248807800002 Suhairiyah 40 th Pandeman Kekurangan Vit.Lain (E56) 154 57 91 110 70 24 84 37.9 tdk ada
3 9/2/2022 0000782261673 3529245401710001 Saminah 49 th Pandeman Kekurangan Vit.Lain (E56) 149 50 89 100 60 24 80 36.1 tdk ada
4 0000782302623 3529244107670715 Nuliyah 54 th Pandeman Demam (R50) 155 60 90 100 60 24 80 36.4 tdk ada
5 9/3/2022 0000782302342 3529240107671181 Suldan 53 th Pandeman Kekurangan Vit.Lain (E56) 170 65 91 90 60 20 80 36.3 tdk ada
6 0000782242896 3529244205700000 Marwiya 50 th Pandeman Rematik (M06) 150 52 86 100 90 24 84 36.3 Tdk ada
7 9/5/2022 0002618268366 3529246810900001 Martina 30 th Pandeman Kekurangan Vit.Lain (E56) 152 50 87 100 70 24 80 36.5 Tdk ada
8 0000200316442 3529245304790009 Jannati 41 th Pandeman Diarea (A09) 150 45 96 100 60 24 80 36.1 Tdk ada
9 9/6/2022 0002161841995 3529245007910006 Lusmiati 29 th Pandeman ISPA (J06) 146 55 65 120 70 20 80 37.9 Tdk ada
10 0002161842028 3529240210090003 Ainur Rahman 11 th Pandeman Alergi (L23) 130 24 56 100 60 24 84 36.2 Seafood
11 9/7/2022 0002161842017 3529244107520392 Buaton 68 th Pandeman Kekurangan Vit.Lain (E56) 149 58 89 110 70 24 80 36.1 tdk ada
12 0002161841984 3529242505650001 Herman 55 th Pandeman Kekurangan Vit.Lain (E56) 172 62 90 120 60 20 80 36.3 tdk ada
13 9/8/2022 0001040353391 3529240107600516 Mahruan 60 th Pandeman Rematik (M06) 169 53 80 120 70 20 80 36.1 tdk ada
14 0001049354638 3529244107920506 Suhriya 28 th Pandeman Kekurangan Vit.Lain (E56) 148 48 85 90 80 20 80 36.1 Tdk ada
15 9/9/2022 0001049354616 3529240107511181 Muhnin 69 th Pandeman ISPA (J06) 160 40 76 90 70 24 84 38.2 Tdk ada
16 0002161842186 3529246809980002 Nur Halifah 30 th Pandeman Alergi (L23) 150 50 86 90 70 24 80 36.2 Seafood
17 9/10/2022 0002161842197 3529241009030001 R Bayu Agung 17 th Pandeman Demam (R50) 168 59 87 100 70 20 80 36.1 Tdk ada
18 0002161842096 3529242710020003 Widan Al Asul 18 th Pandeman ISPA (J06) 171 70 96 100 60 24 80 36.1 Tdk ada
19 9/12/2022 0001049353841 3529244505050007 Qonita R 15 th Pandeman Alergi (L23) 153 54 88 90 60 20 80 36.4 Seafood
20 0002618268535 3529241903100003 Danis FR 7 th Pandeman Demam (R50) 78 14 47 100 60 20 84 36.6 Tdk ada
21 9/13/2022 0002618269334 3529241703180002 Qoid FR 3 th Pandeman Alergi (L23) 103 11 49 100 60 20 84 36.7 Seafood
22 0002161842039 3529241105910000 Saiful Bahri 29 th Pandeman ISPA (J06) 174 67 92 120 60 20 84 36.3 tdk k ada
23 9/14/2022 0001049354313 3529246604860008 Yanti 34 th Pandeman Luka Bakar (T23) 153 54 88 90 60 20 80 36.4 Tdk ada
24 0000763370060 3529244107670069 Nursiya 53 th Pandeman Kekurangan Vit.Lain (E56) 168 70 95 170 80 24 84 36.4 Tdk ada
25 9/15/2022 0001048354526 3529240110810003 Arsani 39 th Pandeman Diarea (A09) 167 58 85 110 70 24 84 36.4 tdk ada
26 0001049353402 3529244107620541 Misna 38 th Pandeman Kekurangan Vit.Lain (E56) 155 50 87 100 70 20 80 36.4 tdk ada
27 9/16/2022 0000781890153 3529245907060001 Refindi J 14 th Pandeman ISPA (J06) 134 26 65 90 60 24 80 36.3 tdk ada
28 0000781869115 3529243112330000 Muhat 87 th Pandeman Rematik (M06) 157 38 67 130 70 24 80 36.2 Tdk ada
29 9/17/2022 0000782331434 3529240107781168 Moh Samri 44 th Pandeman Alergi (L23) 168 59 88 120 70 24 80 36.2 Seafood
30 0001040353391 3529240107600516 Mahruan 60 th Pandeman Rematik (M06) 169 53 80 120 70 20 80 36.1 tdk ada
31 0001049353402 3529244107620541 Misna 38 th Pandeman Kekurangan Vit.Lain (E56) 155 50 87 100 70 20 80 36.4 tdk ada
32 0000781924037 3529240506540002 Idrat 66 th Pandeman ISPA (J06) 167 50 86 90 70 24 80 36.2 tdk ada
33 9/20/2022 0000781869892 3529246603930001 Nur Astina 30 th Pandeman Kekurangan Vit.Lain (E56) 148 48 85 90 80 20 80 36.1 Tdk ada
34 9/21/2022 0000783368335 3529245007670002 Muiyah 53 th Pandeman Diarea (A09) 149 40 76 90 70 24 84 38.2 Tdk ada
35 9/22/2022 0002161841692 3529240107600473 Misrawi 60 th Pandeman Rematik (M06) 169 59 88 90 70 24 80 36.1 Tdk ada
36 0002161841736 3529244107950511 Milawati 26 th Pandeman Alergi (L23) 148 57 90 120 60 20 80 36.4 Seafood
37 9/23/2022 0002161841725 3529240107020369 Firfanto 18 th Pandeman Kekurangan Vit.Lain (E56) 169 67 92 120 60 20 84 36.3 tdk k ada
38 0001049353839 3529245606980005 Lifa Karlina 22 th Pandeman Diarea (A09) 150 40 82 100 60 20 84 36.6 Tdk ada
39 9/24/2022 0001049355033 3529244505790006 Pi'ati 41 th Pandeman Demam (R50) 155 56 89 100 60 20 84 36.7 Tdk ada
40 0000781890153 3529245907060001 Refindi J 14 th Pandeman Demam (R50) 134 26 65 90 60 24 80 36.3 tdk ada
41 9/26/2022 0000781889826 3529240107780788 Moh Fadli 43 th Pandeman Kekurangan Vit.Lain (E56) 170 53 85 110 60 20 80 36.2 tdk ada
42 0000782303545 3529246812900002 Indayani 30 th Pandeman Demam (R50) 152 52 86 110 70 24 80 36.5 Tdk ada
43 9/27/2022 0001049354144 3529240107431160 Busaddik 77 th Pandeman Hipertensi (I10) 168 70 95 150 80 24 84 36.4 Tdk ada
44 0002161842085 3529241709060001 Miftahul A 14 th Pandeman ISPA (J06) 146 35 65 120 70 20 80 37.9 Tdk ada
45 9/28/2022 0002161842074 3529241410130000 Achmad B 7 th Pandeman ISPA (J06) 120 18 50 120 60 24 80 36.2 Tdk ada
46 0000783369999 3529240107550296 Buidan 65 th Pandeman Hipertensi (I10) 170 55 87 150 90 24 80 36.2 Tdk ada
47 9/29/2022 0001049353828 3529240107681299 Rahmani 52 th Pandeman ISPA (J06) 168 59 87 100 70 20 80 36.1 Tdk ada
48 0002161841714 3529244107950510 Suhartini 25 th Pandeman Diarea (A09) 153 54 56 100 60 24 84 36.2 tdk ada
49 9/30/2022 0002161842006 3529243112490023 Sahrain 61 th Pandeman Rematik (M06) 169 59 88 90 70 24 80 36.1 Tdk ada
50 0000782354902 3529241105860004 Abdul Rakip 34 th Pandeman Demam (R50) 170 61 90 90 70 24 84 36.1 tdk ada

Pandeman, 30 september 2022

FITRIYATI
NIP : 198403012017042008