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Jalan Kembar Kampus Unud No.

1, Jimbaran 80361, Bali, Indonesia


Phone: +62 361 4724872 Call Center: +62 85103211012
Email: info@drromyasc.com Website: www.drromyasc.com

CONFIDENTIAL MEDICAL REPORT

Date Reported : No. : …. .OMSA.MR. …. .2019


Patient Name :
Nationality :
Date of Birth / Gender :
Address in Bali :

History of Recent Illness


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Allergy : ………………………………………….......... Past Medical History: …………………………………………………………..
Treatment so far : ……………………………………..……….......

Physical Examination
Level of Consciousness : Respiratory Rate :
Blood Pressure : Temperature :
Pulse : O2 Saturation :

General State
General Appearance :
Eye :
ENT : Ear : Nose :
Throat : Tonsil :
Cor :
Pulmo :
Abdomen :
Extrimities : warm edema

Random Blood Glucose:

Diagnosis
……………………………………………………………………………………………………………………………………
Management and Procedure
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Medication Given and Dosage


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Recommendation
………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………

Fit to Fly : Yes / No

Bali, …………………… .. 2019


The Attending Physician

Jalan Kembar Kampus Unud No.1, Jimbaran 80361, Bali, Indonesia


Phone: +62 361 4724872 Call Center: +62 85103211012 Email: info@drromyasc.com Website: www.drromyasc.com
Jalan Kembar Kampus Unud No.1, Jimbaran 80361, Bali, Indonesia
Phone: +62 361 4724872 Call Center: +62 85103211012
Email: info@drromyasc.com Website: www.drromyasc.com

(______________________)

Jalan Kembar Kampus Unud No.1, Jimbaran 80361, Bali, Indonesia


Phone: +62 361 4724872 Call Center: +62 85103211012 Email: info@drromyasc.com Website: www.drromyasc.com

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