Tugas PSI PART III

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Medical History Form

Date : ____/__/__ (yyyy/mm/dd)

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A.   Private Data

       Name                    : ______________________________        

Age                       : (  )(  )

       Address                : ______________________________

       Phone                   : (  )(  )(  )(  )-(  )(  )(  )(  )(  )(  )(  )(  )(  )
       Zip Codes             : (  )(  )(  )(  )(  )

       Insurer                  :______________________________

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B.
        Employer           : ______________________________
        Office                 : ______________________________
        Address              : ______________________________
        Phone                 : (  )(  )(  )(  )-(  )(  )(  )(  )(  )(  )(  )(  )(  )
     

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C.    Medical Data
       Have you ever been hospitalized?(if yes,)

•        When : ____/__/__ Until____/__/__ (yyyy/mm/dd)
•        Why   :______________________

       Have you ever a surgery?(if yes,)

•        When : ____/__/__(yyyy/mm/dd)
•        Why   : _____________________

      a.   Medical History   (Check)

                                         I Have Had                         Family History

     
           Diabetes                      (  )                                           (  )
           Heart Trouble              (  )                                           (  )
           Cancer                         (  )                                           (  )
           Seizure                        (  )                                           (  )
           Fainting                       (  )                                           (  )
      b.  Medical Status
           When is you last exam ?

•  ____/__/__ (yyyy/mm/dd)

           Who refered you?

• ______________

          Are you currently having paint?(often/seldom)

• ______________ 

         How long does it last?

• ______________    

Signature Patient,



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