Nama : yosi andrika putri

Nim : 161211243

Admission Form

I. IDENTITY
a. Name :
Nick name :
Family name :
b. Date of birth : ____ /____/_____
DD MM YY
c. Sex : Male □ Female □
d. Religion : □ Moeslem □ Christian □ Catholic □ Buddhism
e. Marital status : □ single □married
f. Job / Occupation :
g. Phone number :
h. Addres :
i. Nationality : □ indonesia □ not indonesia
j. Email address :

II. HEALTH HISTORY

a. Chief Complaint :

b. Present Health History:

c. Family Health History:

 - Hereditory Disease
- Infections Disease

d. Past Health History:

- Disease
- surgery

III. HABBITS
a. Smoking
□ Yes □ No
Time :
Amount of : □< 1 pack/day □>1 pack/day

b. Coffe
□ Yes □ No
Time :
Amount of : □<1 glass/day □>1 glass/day

c. Drinking alkohol
□ Yes □ No
Time :
Amount of : □< 1 bottle/day □> 1 bottle/day
 Q&A

1. IDENTITY

 Can you tell me, What is your complete name ?

my complete name ratu Amelia

 What is your nick name?

You can call me ratu

 Where and when your born ?

I was born on 16 november 1998

 What is your sex?

I’m female

 What is your region?

I am muslim

 What is your marital status ?

I’m single

 Can you tell me What is your occupation ?

I’m a student

 What is your phone number ?

my phone number is 081325267787

 Where do you live ?

I live at padang
 What is your nationality ?
I’m Indonesian

 What is your email address ?

 ratuamelia@gmail.com

2. HEALTH HISTORY

 Can you tell me What your chief complaint ?

My chief complaint tightness and location in the chest

 What is your Present health history ?

I fell tightness in the chest, the tightness came yesterday afternoon and at night I was
taken to the hospital by my parent

 What is your family health history ?

My mother has a history of hypertension
 Do you have a hereditary disease ?
No, I dont
 Do you have a infections disease ?
No, I don’t

 What is your past health history?

My disease is asthma and me never had surgery

3. HABBITS

 Do you smoking ?
I do not smoke
 How many time in one day ? -
 How many amount of in on day ? –

 Do you like drinking coffe?

 I do not like drinking coffe

 How many time in one day ? -

 Do you like drinking alkohol ? I don't like alkohol
 How many time in one day ? -