Biodata Pasien
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Mr.
Mrs.
Ms.
Mr./Mrs./Ms. /
Bpk./Ibu/Nona
Patient's Name /
Nama Pasien
*
Date of Birth /
Tanggal Lahir
*
dd/mm/yyyy
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Cook Islands
Costa Rica
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of Congo
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia South Sandwich Islands
South Sudan
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States minor outlying islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Nationality /
Kewarganegaraan
National ID number /
NIK
*
Parent's Name (if it's a child) /
Nama Orang Tua
Home Address /
Alamat Rumah
Mobile Phone /
HP
*
Email /
Alamat Email
*
Emergency Contact /
Kontak Darurat
Referred By /
Direkomendasikan Oleh
Last Time Dental Check Up /
Terakhir Periksa Gigi
Purpose of Visit /
Tujuan Kunjungan
If you have special notes for your dentist, please specify: /
Jika Anda memiliki catatan khusus untuk dokter gigi Anda, harap jelaskan:
Please fill in the health questionnaire below
1.
Are you expecting baby?
* If you are likely to be pregnant whenever you see us, let us know immediately
Apakah Anda sedang mengandung bayi/sedang menjalani program kehamilan? *mohon beritahu kepada kami
Yes /
Ya
No /
Tidak
2.
Are you allergic to anything?
Apakah Anda alergi terhadap sesuatu?
Yes /
Ya
No /
Tidak
Medicine /
obat-obatan
Please specify /
Jelaskan ...
3.
Do you have or have you ever had diabetes?
Apakah Anda penderita atau pernah menderita diabetes?
Yes /
Ya
No /
Tidak
If you are under any medication, please specify ...
Jika Anda sedang menjalani pengobatan apa pun, sebutkan ...
4.
Do you have or have you ever had high blood pressure?
Apakah Anda penderita atau pernah mengalami tekanan darah tinggi?
Yes /
Ya
No /
Tidak
If you are under any medication, please specify ...
Jika Anda sedang menjalani pengobatan apa pun, sebutkan ...
5.
a.
Do you bruise easily or bleed excessively when you are injured?
Apakah Anda mudah memar atau berdarah berlebihan saat terluka?
Yes /
Ya
No /
Tidak
b.
Are you aware of any bleeding disorders which you might have?
Apakah Anda mengetahui adanya gangguan pendarahan yang mungkin Anda miliki?
Yes /
Ya
No /
Tidak
6.
Do you have or have you ever had epileptic fits?
Apakah Anda penderita atau pernah menderita epilepsi?
(Epileptic : A disorder in which nerve cell activity in the brain is disturbed, causing seizures)
Yes /
Ya
No /
Tidak
7.
Do you have Hepatitis/HIV?
Apakah Anda menderita Hepatitis/HIV?
Yes /
Ya
No /
Tidak
8.
For our publication/ SosMed purpose, we will take some photos and record our activities of doctors and staffs while serving patients. We will make sure to keep our patient's privacy by not showing patient's face. However, if it is not convenient for you, please inform us accordingly
Untuk keperluan publikasi / sosial media, kami akan menggambil foto/ merekam beberapa aktifitas tim dokter / staff kami saat melakukan pelayanan kepada pasien.
Selama melakukan kegiatan tersebut, kami akan memastikan
untuk tetap menjaga privasi pasien dengan tidak menampakkan wajah pasien
Namun apabila anda merasa kurang nyaman dengan kegiatan tersebut mohon utk diinformasikan kepada kami
No,
I am not convenient /
Tidak,
saya tidak nyaman
By Submitting this form, I've declared that all the questions above are answered correctly and under a sober circumstance
Dengan mengisi dan mengirim formulir ini, saya menyatakan bahwa semua pertanyaan di atas dijawab dengan benar dan dalam keadaan sadar
Submit /
Kirim