EVALUATION FORM FOR SPEAKING ASSESSMENT

RSUP. Dr. M. DJAMIL PADANG HOSPITAL

I. IDENTITY

a. Name :

b. Place and date of birth/ Age: / Years old

c. Gender : Male Female

d. Last Education : Elementary School

Junior High School

Senior High School

University

e. Occupation/ Job :

f. Marital Status : Single Married

Widow Divorced

g. Religion : Moeslim Christian

Hindu Buddha

h. Phone Number :

i. Address :

II. HEALTH HISTORY

a. Chief Complaint (Reason for admission hospital)

b. Present Health History

c. Past Health History

 Disease suffered from :

 History of hospitalization : Yes No
Years :
Length of time:

 History of surgery : Yes No

Years :
Kind of surgery:

d. Family Health History : Yes No

Hypertension

Diabec Mellitus

Asthma

Other

e. Infection Disease : Yes No

Kind Of Disease : HIV AIDS

TBC

Hepatitis

III. HABBITS

a. Smooking : Yes No

 Length of time : Month Years

 A month of cigarette :
 Kind of cigarette :

b. Drinking Coffe : Yes No

 Length of time : Month Years

 A month of glasses :
c. Drinking Alcohol : Yes No

 Length of time : Month Years

 A month of glasses :
 Kind of alcohol :