NAME : NAME :

PASSPORT NUMBER : PASSPORT NUMBER :

ADDRESS : ADDRESS :
KLOTER / ROMBONGAN : KLOTER / ROMBONGAN :
PHONE NUMBER : +62 PHONE NUMBER : +62

LIST OF DRUGS TAKEN (Daftar obat yang dibawa) : LIST OF DRUGS TAKEN (Daftar obat yang dibawa) :

NO JENIS OBAT (THE DOSIS JUMLAH NO JENIS OBAT (THE DRUGS) DOSIS JUMLAH
DRUGS) (DOSAGE) (AMOUNT) (DOSAGE) (AMOUNT)
1 Amlodipin 10 mg 42 tablet 1 Adalat Oros 30 mg 42 tablet
2 Diamicron MR 60 mg 42 tablet 2 Amlodipin 10 mg 10 tablet
3 Metformin 500 mg 130 tablet 3 Furosemid 40 mg 30 tablet
4 Micardis 80 mg 42 tablet 4 Micardis 80 mg 42 tablet
5 Simvastatin 20 mg 42 tablet 5 Simvastatin 20 mg 42 tablet
6 Beneuron 15 tablet 6 Beneuron 10 tablet
7 Ferrovit 25 kapsul 7 Ferrovit 25 kapsul
8 Akita 30 tablet 8 Akita 10 tablet
9 Paracetamol 500 mg 20 tablet 9 Paracetamol 500 mg 20 tablet
10 Masflu 20 tablet 10 Masflu 20 tablet
11 Cetirizine HCl 10 mg 20 tablet 11 Dextaf 20 tablet
12 Ambroxol 30 mg 30 tablet 12 Ambroxol 30 mg 30 tablet
13 Cefadroxil 500 mg 20 kaplet 13 Cefadroxil 500 mg 20 kaplet
14 Domperidone 10 mg 20 tablet 14 Spironolacton 25 mg 20 tablet
14 Ramolit 25 sacchet 15 Betahistine Mesilate 6mg 30 tablet
15 Masker 25 pcs 16 Ranitidine HCl 150 mg 20 tablet
16 Betadine cair 5 ml 17 Salbutamol 2 mg 30 tablet
17 Alkohol swab 20 pcs 18 Ramolit 25 sacchet
18 Kasa steril hidrofil 16x16cm 16 lembar 19 Masker 25 pcs
20 Betadin zalf 5 gr 1 tube
21 Nebulizer mask for adult 1 pcs
WAJIB MINUM : WAJIB MINUM :
Metformin 3x1 sesudah makan Adalat oros 1x1
Diamicron 1x1 Simvastatin 1x1
Simvastatin 1x1 Micardis 1x1
Amlodipin 1x1
Micardis 1x1 Demam/pusing: paracetamol 500mg 3x1
Pilek : masflu 3x1
Demam/pusing: paracetamol 500mg 3x1 Batuk : ambroxol 3x1
Pilek : masflu 3x1 Mencret : akita 3x1
Batuk : ambroxol 3x1 Mual : ranitidin 2x1
Mencret : akita 3x1 Muntah : domperidon 3x1
Mual : ranitidin 2x1 Gatal2 : cetirizine 2x1 atau dextaf 3x1
Muntah : domperidon 3x1 Antibiotik : cefadroxil 2x1
Gatal2 : cetirizine 2x1 atau dextaf 3x1 Vertigo :betahistin 2x1
Antibiotik : cefadroxil 2x1 Vitamin: beneuron dan ferrovit
Vertigo :betahistin 2x1 Sesak nafas : salbutamol 2x1 + dextaf 2x1
Vitamin: beneuron dan ferrovit Kaki bengkak : furosemid 1x1 pagi + spironolacton 1x1 pagi
Sesak nafas : salbutamol 2x1 + dextaf 2x1
Kaki bengkak : furosemid 1x1 pagi + spironolacton 1x1 pagi