BAKTI SOSIALJAGE KASTARE FOUNDATION

Lombok Tengah, 14 Juni 2014

LEMBAR ANAMNESIS

Nama : Umur : Jenis Kelamin :Alamat : No.Reg : Tanggal :

AnamnesisKeluhan Utama :____________________________________________________________________________________________________Riwayat Penyakit :_____________________________________________________________________________________________________________________________________________________________________________________________________________________Vital Sign

Denyut Nadi :________x/menit Tekanan Darah :________mmHg Pernapasan :________x/menit Suhu :________OC

Diagnosis __________________________________________________________________________________________________________________

R/

Catatan : _________________________________________________

BAKTI SOSIALJAGE KASTARE FOUNDATION

Lombok Tengah, 14 Juni 2014

LEMBAR ANAMNESIS

Nama : Umur : Jenis Kelamin :Alamat : No.Reg : Tanggal :

AnamnesisKeluhan Utama :____________________________________________________________________________________________________Riwayat Penyakit :_____________________________________________________________________________________________________________________________________________________________________________________________________________________Vital Sign

Denyut Nadi :________x/menit Tekanan Darah :________mmHg Pernapasan :________x/menit Suhu :________OC

Diagnosis __________________________________________________________________________________________________________________

R/

Catatan : _________________________________________________