ENGLISH TASK

ADMISSION FORM TO THE PATIENT

NAME : ASTRI WAHYUNI

NIM : 161211251

CLASS : VI B

SUPERVISOR : Ns. SUHAIMI M.Kep

S1 KEPERAWATAN

STIKes MERCUBAKTIJAYA PADANG

2018
 ADMISSION FORM TO THE PATIENT

I. Identity
Name :
Preferred name :
Place and date of birth : Day Month Year

Sex : Male Female

Religion : Islam Kong Hu Chu
Christian Budha
Hindu
Marital Status : Married Widowed
Single
Job/ Occupation :
Phone Number :
Address :
National : Indonesian
Non Indonesian
Person Incharge :
II. Health History
Chief Complaint :
Present Health History :
Family Health History : Mereditary Disease
Infection Disease
Past Health History : Disease Soffered Form
Surgery

III. Habbits
Smoking : Yes No
Times : < 3 Month > 1 Years

> 6 Month < 6 Years

A mount of Ciggareth : 1 Pack it/day 2 Pack it/day
10 Rods

Coffee : Yes No
Times : < 1 Times a day > 3 time a day
> 2 Times a day
A mount of Coffee : 1 Glass > 2 Glass
2 Glas

Drinking alcohol : Yes No

Times : < 1 Time a week > 2 Time a week
A mount Of Alcohol 1 Bottle 2 Bottle
3 Bottle
 QUESTION AND ANSWER
I. Identity
a. Name
 What is your name?
 Tell me your name, please?
 Can you tell me your name, please?
b. Place and date of birth
 Where and when were you born?
 What is your birth
 Where were your born?
 When were your born?
c. Religion
What is your religion?
d. Marital status
What is your marital status?
e. Job
What is your job?
f. Phone Number
What is your phone number?
g. Address
Where do you live?
h. Nationality
What is your nationality?
i. Person incharge
Who is your person inchange?
II. Health History
a. Chief Complaint
what is the complaint that you are feeling right now?
b. Present health history
what you feel right now?
c. Family health history
 Did your family suffer from diseases such as DM, hypertension, stroke?
d. Past health history
Have you ever suffered from other illnesses before?
Have you been hospitalized before?
III. Habbits
a. Smoking
 Are you smoking?
 How long have you been smoking?
 How many times a day do you smoking?
b. Coffee
 Do you like to consume coffee?
 When do you like to consume coffee?
 How many glasses do you consume coffee in a day?
c. Drinking alcohol
 Have you ever consumed alcohol?
 How long have you been consuming alcohol?
 How much alcohol you consume in a week?

I. Identity
a. My name is Mr. Jhon
b. I was born in Jakarta 27th February 1993.
c. My religion is Islam
d. I am married
e. My job is the trader
f. Number phone is 08231512379
g. I live in germany
h. My nationality is German
II. Health History
a. Chief Complaint
The patient came to the hospital, said the head was dizzy, pain in the legs, headache
accompanied by a neck felt tense and stiff.
 b. Present health history
The patient was hospitalized with complaints of headache, pain in the pit of the stomach,
neck and neck felt tense, the patient said it was difficult to move.
c. Family health history
My family has a history of hypertension from my mother, my mother died with a history
of hypertension.
d. Past health history
The patient was hospitalized for 4 days in 1999 with the same case, the patient was
treated and given medication for the healing process
III. Habbits
a. Smoking
 Yes
 I have been smoking since age 25 years
 I should be able to spend 1 cigarette pack
b. Coffee
 Yes
 I consume coffee 2 times a day
 I should be able to spend 2 cups
c. Drinking alcohol
No, I don't like to alcohol