Medical Record Code
Medical Record Number
Registered Date
Time
Date of Birth
Customer Name
Phone
Address In Bali
Nationality
Email
Allergies
(please tick if yes)
Do you have any of following allergies listed below?
Diabeter
Hepatitis A B C
Arthritis
HIV Virus
Pulmonary Vasular Disease
High Blood Pressure
Anemia
Asthma
Kidney Disease
Pregnancy
Cancer
Epilepsy
Hepatitis
Other
Allergies
(please tick if yes)
Do you have any of following allergies listed below?
Rubbing Alcohol
Pollen or Dust
Latex or Adhesives
Any Foods
Peanuts
Medications
Please list any medications you are currently taking
Treatments
Symptoms
(Please tick)
Headache
Nausea
Vomitting
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