Form Konseling Obat.xlsx

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FORMULIR KONSELING OBAT PASIEN Tanggal Nama Pasien Alamat No. Telp Resep

Nama Dokter Diagnosis BB/TB pasien Usia

Riwayat Alergi

Tidak

Riwayat Penyakit

Tidak ada penyakit lain

Ya, terhadap

Ada penyakit lain Riwayat Pengobatan Kondisi Khusus Hasil Pemeriksaaan Laboratorium Informasi dan Saran

Hamil trisemester

Menyusui

Anak

Lansia

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