Laboratorium Klinik GORAMataram

HIMPUNAN PEMERIKSA KESEHATAN TENAGA KERJA INDONESIA

(HIPTEK)
Jl. R.A. Kartini no 77 Monjok _ Mataram

MEDICAL REPORT
Name : SYAMSUL RIJAL Date Issue :
Date Of Birth : Passport No :
Sex : MALE Supllier :
Nasionality : INDONESIA MR :

PHOTO Status :
Put Mark (v) Normal Put Mark (x) Abnormal

History of any sign nature past illness including :

1. Psyciatric and neurologic disorders ( epilepsy, depression) (v)
2. Allergy (v)
MEDICAL EXAMINATION

EYES X-RAY : Chest (v) OTHERS

Vision Right Eye (v) Weight : Hernia (v)
Left Eye (v) Height : Voricose Veins (v)
Others Right Eye (v)
Left Eye (v) SYSTEMIC EXAMINATION SKINS (v)
EARS Blood Pressure (v)
Right Ear (v) Heart (v) VENERAL DISEASES
Left Ear (v) LABORATORY
Lungs INVESTIGATION
(v) Clinical (v)
Abdomen (v) Temperature (v)

URINE BLOOD BLOOD CHEMISTRY

* Sugar (v) * Haemoglobin (v) * FBS (v)
* Albumin (v) * Malaria Film (v) * SGOT (v)
* Bilharziasis (v) * Others (v) * SGPT (v)
* Others (v) * ALKALI PHOS (v)
STOOL SEROLOGY
* Helminthes (v) * HIV (v) RENAL FUNCTION TEST
MICROBIOLOGY * HBsAg (v) * Creatinine (v)
* Salmonella (v) * VDRL (v) * Urea (v)
* Shigella ( v ) * TPHA
Notes about medical and laboratory investigation : (v)
* Vibrio Cholera (v)
Dear Sir,
Mentioned above is the medical report Mr.
He is F I T / U N F I T for mentioned Job.
Expired Date :
Chief Physician,

dr. I MADE RIASTANA, Sp.PD