Biodata Pasien
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dd/mm/yyyy
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?
  Purpose
Tujuan
   
2. Do you have or have you ever had disease of :
Apakah Anda penderita atau pernah mengalami penyakit:
   
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
4. Are you allergic to anything?
Apakah Anda alergi terhadap sesuatu?
   
5. Do you have or have you ever had diabetes?
Apakah Anda penderita atau pernah menderita diabetes?
 
6. Do you have or have you ever had high blood pressure?
Apakah Anda penderita atau pernah mengalami tekanan darah tinggi?
 
7.
a.   Do you bruise easily or bleed excessively when you are injured?
  Apakah Anda mudah memar atau berdarah berlebihan saat terluka?
 
b.   Are you aware of any bleeding disorders which you might have?
  Apakah Anda mengetahui adanya gangguan pendarahan yang mungkin Anda miliki?
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?
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)
10. Do you have Hepatitis/HIV?
Apakah Anda menderita Hepatitis/HIV?
 
 
 
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.