Form Mcu Basic Dwi Jainuddin 2016.doc

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. . . . . . . . . . . RUMAH SAKIT AGUNG

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AUTHORIZATION / SURAT KUASA I certify that the above answer are true and correct, it is further understood and agreed that if my application for employment is accepted and it discovered that I had concealed or whittled any known history of physical mental infirmity, the company may Immediately there after terminate my employment for cause, if my application for employment is accepted I here by authorize Agung Hospital release all information concerning the result of this medical exam. Photo static copy if this authorization shall be considered as effective and valid as the original. Saya menyatakan bahwa semua jawaban diatas adalah benar, Saya juga mengetahui dan menyetujui bahwa bila permohonan saya untuk menjadi karyawan diterima dan ternyata saya menyembunyikan atau menutupi hal – hal tentang sejarah penyakit saya, maka perusahaan yang menerima saya dapat memberhentikan saya tanpa alasan lain. Bila saya diterima menjadi karyawan maka saya memberikan kuasa kepada pihak Rumah Sakit Agung untuk memberitahukan pihak lain semua hasil pemeriksaan saya. Foto copy dari surat kuasa ini dapat dianggap sama dengan yang asli.

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Jl. Sultan Agung No. 67, Manggarai, Jakarta Selatan 12970 Telp. 021 – 829 4955 (Hunting), Fax : 021 – 830 5791

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. . . . . . . . . . . RUMAH SAKIT AGUNG

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TO WHOM IT MAY CONCERN This Medical Report of Name Nama

: Mr. Dwi Jainuddin

Sex : Male Kelamin

Age / Date of Birth Umur

: 41 Tahun

Nationality Kebangsaan

: Indonesia

Address Alamat

: Cipinang Lontar No.16 Rt 14 / 6 Jatinegara

On

: Jakarta Timur Which Was Performed on

Keluhan Utama Chief complaint & Present Illness -

Pro MCU

Riwayat Penyakit Past History -

Tidak Ada

Kebiasaan & Riwayat Operasi Habit & Operation -

Tidak Ada

Riwayat Keluarga Family History -

Tidak Ada

Allergy Bronchial Asthma Bleeding tendency Cancer Diabetes Heart disease Hypertension C.V.A Kidney

( - ) *) (-) (-) (-) (-) (-) (-) (-) (-)

F F F F F F F F F

M M M M M M M M M

B B B B B B B B B

S S S S S S S S S

*) Father (F) Mother (M) Brother (B) Sister (S) Other (O)

Jl. Sultan Agung No. 67, Manggarai, Jakarta Selatan 12970 Telp. 021 – 829 4955 (Hunting), Fax : 021 – 830 5791

O O O O O O O O O

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. . . . . . . . . . . RUMAH SAKIT AGUNG

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PEMERIKSAAN FISIK PHYSICAL EXAMINATION Tinggi Badan Height

:

160 cm

Berat Badan Weight

:

48 kg

Berat Ideal Ideal Weight

:

Suhu temperatur

:

36

ºC

Nadi / Pulse Rate :

80

Min

kg

Frekuensi pernafasan : Respiration rate

20

Min

Tekanan Darah / Blood Pressure - Berbaring / Lying - Duduk / Sitting - Berdiri / Standing

: ……………………………… 120 / 70 ….………... ……………… mm Hg : ……………………………………………………………………………. mm Hg : ……………………………………………………………………………. mm Hg

Keadaan Umum General Appearance

: Normal

Kepala & Leher Head & Neck

: Normal

Kelenjar getah bening Lymph nodes

: Normal

Dada / Chest

: Normal

Jantung / Heart

: Normal

Perut / Abdomen

: Normal

-

Hati / Liver Limpa / Spleen Ginjal / Kidney

Lain – lain / Others Tulang punggung / Spine

Not Palpable : Normal : Normal

Anggota gerak / Extremities : Normal Refleksi / Reflexes Sensibilitas / Sensibilities : Normal Jl. Sultan Agung No. 67, Manggarai, Jakarta Selatan 12970 Telp. 021 – 829 4955 (Hunting), Fax : 021 – 830 5791

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Alat Kelamin / Genital

: Normal

Anus

: Normal

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HEMATOLOGI HEMATOLOGY - Hb : 12,5 g% ( 13 – 15 ) - Ht : 40,5 % -BSR: 10 mm / jam ( 0 – 20 ) - Leucocytes : 13.800 / mm3 ( 5000 – 10.000 ) - Eritrosit : - Malaria : …………………………………………………………………………………………………………….. - Diff Count : Leucocytes : Basofil Eosinofil Batang Segmen Limfosit Monosit Erythrocyte : Size : Shapes : Stain chr : Thrombocyte decrease /

: : : : : :

85 11 -

413.000

% % % % % %

( 0 – 0,5 ) (2–4) (1–5) ( 51 – 67 ) ( 20 – 30 ) (2–6)

/ul

PEMERIKSAAN MATA EXAMINATION OF THE EYES Visual Equity Kanan / Right : 6/6 Kiri / Left : 6/6 Koreksi / Correction : No Correction -

Tio

: -

Anterior segment (Slit Lamp)

-

Funduscopie

-

Buta warna Colors Blind test

Diagnose Therapy

: : : No Colors Blindness

: (-) : (-)

Jl. Sultan Agung No. 67, Manggarai, Jakarta Selatan 12970 Telp. 021 – 829 4955 (Hunting), Fax : 021 – 830 5791

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. . . . . . . . . . . RUMAH SAKIT AGUNG

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URINALYSIS Protein / Albumin Glukosa Urobilinogen Keton Bilirubin Darah Samar Nitrit Sediment Leucocytes Type Erythrocyte Cast Type Crystals Type Ephitel Others Bakteri

: (-) : (-) : 0,1 : (-) : (-) : (-) : (-) : : 1-2 : -----------------------------------------------------: 0-1 : : : (-) : : (+) : : (-)

p.h : 6,0 S.g : 1.020 pos

/lpb /lpb /lpb /lpb /lpb /lpb /lpb

PEMERIKSAAN RONTGEN X – RAY EXAMINATION Didalam paru tidak tampak tanda-tanda kelainan Ukuran Jantung normal Sinus dan diafragma baik Kesan : Normal,Tidak ditemukan kelainan

Jl. Sultan Agung No. 67, Manggarai, Jakarta Selatan 12970 Telp. 021 – 829 4955 (Hunting), Fax : 021 – 830 5791

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. . . . . . . . . . . RUMAH SAKIT AGUNG

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KESIMPULAN SUMMARY This is certify that physical examination was given to : Mr. Dwi Jainuddin

age : 41 years

He is found to be -------------- for duty as a Fitness category : a.

Physically perfect

b. Physically fit with minor correctible defect c. Mayor Physically defect but fit Physically limited duty in specific and selected assignment d. Un fit for duty

ANJURAN SUGESTION

Date : Tanggal

14 Maret 2016 Koordinator

dr . Rosita Vivayani SIP : 1.1.01.3171.1745/42007/07.16.1

Jl. Sultan Agung No. 67, Manggarai, Jakarta Selatan 12970 Telp. 021 – 829 4955 (Hunting), Fax : 021 – 830 5791

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