New Patient Registration

Medical History

Patient's information

Nama Pasien [Patient's Name]
Nama Pasien [Patient's Name]
Nama Depan [First Name]
Name Tengah [Middle Name]
Nama Keluarga [Family Name]
Alamat di Bali [Address in Bali]
Alamat di Bali [Address in Bali]
State/Province
Kode Pos
Alamat di luar Bali [Address Outside of Bali]
Alamat di luar Bali [Address Outside of Bali]
City
State/Province
Zip/Postal
Country

Emergency Contact

Name Kontak Darurat [Emergency Contact Name]
Name Kontak Darurat [Emergency Contact Name]
Nama Depan [First Name]
Nama Depan [Last Name]

Riwayat Medis/ Medical History

**Masalah Alergi terhadap Makanan/Food Allergies**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)
Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)
Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Masalah Alergi terhadap Obat/Drug Allergies**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Masalah Jantung/Heart Problem**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Masalah Pernapasan/Respiratory Problem**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Masalah Ginjal/Kidney Problem**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Masalah Otot, Sendi, atau Saraf/Muscle, Joint, or Nerve Problem**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Diabetes**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Hipertensi/Hypertension**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Pengobatan Saat Ini/Current Medications**

Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)
Apakah Anda memiliki alergi terhadap makanan? (Do you have any allergies to food?)

**Operasi Sebelumnya/Previous Surgeries**

**Gangguan Pembekuan Darah/Blood Clotting Disorders**

**Kehamilan/Menyusui (untuk pasien wanita) /Pregnancy/Breast feeding (for female patients) **

**Riwayat Medis/Medical History**

**Riwayat Medis Keluarga/Family Medical History**

**Kesehatan Mental/Mental Health**

**Merokok / Smoking**

**Konsumsi Alkohol / Alcohol Consumption**

Section

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