Biodata Pasien
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Mr.
Mrs.
Ms.
dr.
Mr./Mrs./Ms./dr. /
Bpk./Ibu/Nona/Dokter
Patient's Name /
Nama Pasien
*
Date of Birth /
Tanggal Lahir
*
dd/mm/yyyy
Single
Married
Widowed
Divorced
Marital Status /
Status Pernikahan
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
Chiropractor
Dentist
Dietitian or Nutritionist
Optometrist
Pharmacist
Physician
Physician Assistant
Podiatrist
Registered Nurse
Therapist
Veterinarian
Health Technologist or Technician
Other Healthcare Practitioners and Technical Occupation
Nursing, Psychiatric, or Home Health Aide
Occupational and Physical Therapist Assistant or Aide
Other Healthcare Support Occupation
Chief Executive
General and Operations Manager
Advertising, Marketing, Promotions, Public Relations, and Sales Manager
Operations Specialties Manager (e.g., IT or HR Manager)
Construction Manager
Engineering Manager
Accountant, Auditor
Business Operations or Financial Specialist
Business Owner
Other Business, Executive, Management, Financial Occupation
Architect, Surveyor, or Cartographer
Engineer
Other Architecture and Engineering Occupation
Postsecondary Teacher (e.g., College Professor)
Primary, Secondary, or Special Education School Teacher
Other Teacher or Instructor
Other Education, Training, and Library Occupation
Arts, Design, Entertainment, Sports, and Media Occupations
Computer Specialist, Mathematical Science
Counselor, Social Worker, or Other Community and Social Service Specialist
Lawyer, Judge
Life Scientist (e.g., Animal, Food, Soil, or Biological Scientist, Zoologist)
Physical Scientist (e.g., Astronomer, Physicist, Chemist, Hydrologist)
Religious Worker (e.g., Clergy, Director of Religious Activities or Education)
Social Scientist and Related Worker
Other Professional Occupation
Supervisor of Administrative Support Workers
Financial Clerk
Secretary or Administrative Assistant
Material Recording, Scheduling, and Dispatching Worker
Other Office and Administrative Support Occupation
Protective Service (e.g., Fire Fighting, Police Officer, Correctional Officer)
Chef or Head Cook
Cook or Food Preparation Worker
Food and Beverage Serving Worker (e.g., Bartender, Waiter, Waitress)
Building and Grounds Cleaning and Maintenance
Personal Care and Service (e.g., Hairdresser, Flight Attendant, Concierge)
Sales Supervisor, Retail Sales
Retail Sales Worker
Insurance Sales Agent
Sales Representative
Real Estate Sales Agent
Other Services Occupation
Construction and Extraction (e.g., Construction Laborer, Electrician)
Farming, Fishing, and Forestry
Installation, Maintenance, and Repair
Production Occupations
Other Agriculture, Maintenance, Repair, and Skilled Crafts Occupation
Aircraft Pilot or Flight Engineer
Motor Vehicle Operator (e.g., Ambulance, Bus, Taxi, or Truck Driver)
Other Transportation Occupation
Military
Homemaker
Other Occupation
Don't Know
Not Applicable
Occupation /
Pekerjaan
Parent's Name (if it's a child) /
Nama Orang Tua
Home Address /
Alamat Rumah
Mobile Phone /
HP
*
Email /
Alamat Email
*
Bussiness Address /
Alamat Kantor
Office Phone No. /
Telepon Kantor
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.
Have you ever stayed in any hospital before?
Pernahkah Anda di rawat di rumah sakit mana pun sebelumnya?
Yes /
Ya
No /
Tidak
Purpose
Tujuan
Illness /
penyakit
Surgery /
operasi
Childbirth /
persalinan
Others, please specify /
lainnya, jelaskan ...
2.
Do you have or have you ever had disease of :
Apakah Anda penderita atau pernah mengalami penyakit:
Yes /
Ya
No /
Tidak
Heart /
jantung
Kidney /
ginjal
Liver /
hati
Others, please specify /
lainnya, jelaskan ...
Lung /
paru-paru
Asthma /
sakit nafas
3.
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
4.
Are you allergic to anything?
Apakah Anda alergi terhadap sesuatu?
Yes /
Ya
No /
Tidak
Food /
makanan
Medicine /
obat-obatan
Others, please specify /
lainnya, jelaskan ...
Metal /
logam
5.
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 ...
6.
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 ...
7.
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
8.
Do you have or have you ever had frequent head aches, neck aches, and suffer from migraine?
Apakah Anda pernah atau pernah mengalami sakit kepala, leher, dan migrain?
Yes /
Ya
No /
Tidak
9.
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
10.
Do you have Hepatitis/HIV?
Apakah Anda menderita Hepatitis/HIV?
Yes /
Ya
No /
Tidak
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
If you have any illness which is not included above, please notify us.
Jika Anda memiliki penyakit apa pun yang tidak termasuk di atas, beri tahu kami.
If you have any illness or surgery after today, please inform us before the commencement of treatment in the next visit.
Jika Anda memiliki penyakit atau operasi setelah hari ini, mohon informasikan kepada kami sebelum dimulainya perawatan pada kunjungan berikutnya.
Parents/guardians are responsible to report the child/ward's health and signature affixed above will be taken as consent to the treatment.
Orang tua / wali bertanggung jawab untuk melaporkan kesehatan anak dan tanda tangan yang tercantum di atas akan dianggap sebagai persetujuan untuk perawatan.
If there any changes in your medical history, please notify us.
Jika ada perubahan dalam riwayat medis Anda, harap beri tahu kami.