MEDICAL REPORT

GENERAL HOSPITAL OF NORTH LOMBOK

Personal statement of the candidate:

1. Name in full (in capital letters, surname first) : Adelia Permata Sari Wolfram

2 Category of Post :

3. Address : Deutsch (Germany)

4. Date of Birth : 19 June 2013

5. Married / Single : Single

6. Personal History :
A. History of Bleeding from Gastro-intestinal Track, Gastric or Duodenal Ulcers, Appendicitis,
Internal Piles, Typhoid, Jaundice, etc, Give details:
No History of Above

B. History of Asthma, Tuberculosis, Spitting of Blood, Pleurisy, Breathlessness, etc., Give details:
No History of Above
C. History of Palpitation. Fainting spells, Pain on the Chest, Breathlessness on exertion, cyanosis,
Rheumatic fever with Joint pains, Swelling of Legs, Face etc., Give details:
No History of Above

D. History of Bleeding of Urinary Tract, Painful Urination passing of stones or given in Urine
etc., Give details:
No History of Above
E. History of Fits, Paralysis, Neurasthenia, Nervous Breakdown etc., Give details:
No History of Above
F. History of Leprosy, Extensive Generalized Allergic Dermatitis, Leucoderma, Venereal Diseases
etc. Give details:
No History of Above

G. Have you suffered from defects in Hearing or Eyesight? Give details:

No History of Above

H. Details of Serious Illness / Injuries sustained by accident or otherwise, Give details

Patients came with pain and a wound caused by motorcycle accident about 30
minutes before, active bleeding from lower part of left hand (+), history of lost of
consciusness (-), history of vomitting (-).
 I. Details of Surgical Operations undergone:
No History of Above

J. Is there any other item in your Medical History which you have not already mentioned ?
No

K. Have you ever tested for HIV ? If so, what was the result ?
.............................................................................................................................................
.............................................................................................................................................

I hereby declare that the above statements are correct to the best of my knowledge and that any
incorrect, suppressed information will render me liable for termination of my services in the Bank.

PLACE: General Hospital of North Lombok

DATE : 14 April 2019 (Adelia Permata Sari Wolfram)

Signed in my presence

(dr. I Gusti Putu Yoga Kusmawan)

 REPORT OF THE MEDICAL EXAMINER
GENERAL HOSPITAL OF NORTH LOMBOK

Name of the Candidate : Thomas, Wolfram

Category of the Post :
01. General Development : GOOD........................FAIR.........................POOR.........................

Best Weight :
Any recent changes in weight : -
Height. :
Temperature :
Girth of Chest : 1. After Full Inspiration: Normal
2. After Full Expiration: Normal

02. SKIN : Vulnus Excoriatum et regio antebrachii Sinistra

03. EYES :
(a) Whether vision is Normal : Yes
If not, is it capable of being corrected to 6/6 with glasses? (Not
with Contact Lenses)
04 Ears Inspection : Normal..............................................................................................
.........................................................................................................
Hearing - Right Ear : Normal
Left Ear : Normal
05. Glands : Normal..............................................................................................
06. Conditions of Teeth : Normal......................................................................................
07. Respiratory System:

Does the physical examination reveal anything abnormal in the respiratory organs ?
No..................................................................................................................................................
......................................................................................................................................................
.. If yes, explain fully:
......................................................................................................................................................
08. Circulatory System:
a) Heart : Any Organic Lesion ? No..................................................................
Pulse Rate:
b) Blood Pressure :

09. Abdomen : Girth: Normal...................................................................................

Tenderness: No...............................................................................

10. Nervous System: Normal

11. Loco-Motor System: Any Abnormality: Normal

 X - RAY REPORT

Name :

Category of Post :

HEART :

LUNGS :
NOT PERFORMED
MEDIASTINUM :

CP ANGLES :

BONY CAGE :

INFERENCE :

Therapy:
Wound Care
Gentamicin cream for the wound 2x daily
Analgetik Paracetamol Syr (5cc/125mg) 3X250mg daily

Price: Rp 72.500,-

Place: General Hospital of North Lombok

Date: 14 April 2019 Signature of the Medical Examiner

Name: dr. I Gusti Putu Yoga Kusmawan

Designation:

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