CONFIDENTIAL MEDICAL REPORT

Date : ___/___/____ Time : _________ (AM/PM)

File No. : _______________

Family Name : ________________________________________
First Name :
__________________________________ Sex : M/F
Date Of Birth/Age : ____________________________________
Date Of Admission :
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Nationality : ____________________________
Current Address in Bali : __________________________________________________ Phone Number :
____________________
Present Patients history or Complaint :
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Past Medical History : ______________________________________
Medication Currently Used :
______________________
Allergic History : __________________________________________
_____________________________

Treatment so far :

Vital Signs
GCS : ________
_________________

Temperature : _______________

Blood Pressure : _____________________ Pulse Rate : _________________

___________________________

Respiratory Rate :

SPO2 :

Physical Examination :
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Other Examination (Radiology, Lab, ECG, CT Scan, Ultra Sound, MRI, etc.) :
____________________________________________
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Diagnosis :
_______________________________________________________________________________________________
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Differential Diagnosis :
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Treatment/Medication :
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Doctors Recommendation :
Patient Request Repatriation :

Yes

No

In Doctors Opinion This Patient Requires Repatriation / Medical Evacuation :

Patients Can Be Transported :

Yes

Yes

No

No

If Yes, with :
Normal Transportation
Ambulance
Patients Fit To Fly :

Yes

No

If Yes, with :
Normal Flight
Non Escorted In Economic Class
Non Escorted In Business Class
Non Medical Escorted In Business Class
Medical Escort in Business Class
Stretcher Medical Escort Team
Charter Flight / Air Ambulance Team
Patients need wheelchair :

Yes

No

If Yes, type :
WCHC
WCHS
WCHR
Comment :
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Denpasar - Bali,
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Attending Physician,

Specification/Specialist :
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