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Petunjuk Pengisian: G/OHI/017-02/0318
Petunjuk Pengisian: G/OHI/017-02/0318
PETUNJUK PENGISIAN
NO :
APPLICATION FORM
A. IDENTITY
Name : Ahmad Gunawan
Front Title :Ns Gender*) : Male / Female Height(cm)/Weight (kg) : 161 /58
End Title :S.Kep Marital Status*) : Married / Single BPJS Kes Number :
Nick Name :Gun Phone : BPJS TK Number :
Birth Place :Karwang Mobile Phone : 085778872752 NPWP Number :
B. FAMILY
Name Age Number of KK Education Occupation
Father
Mother
Brother / Sister - 1
Brother / Sister - 2
Brother / Sister - 3
Brother / Sister - 4
Brother / Sister - 5
Brother / Sister - 6
Brother / Sister - 7
C. SPOUSE
Name Age Number of KK Education Occupation
Husband / Wife
1 st Child
2 nd Child
3 rd Child
D. FAMILY IN LAW
Name Age Number of KK Education Occupation
Father in law
Mother in law
Brother / Sister in law - 1
Brother / Sister in law - 2
Brother / Sister in law - 3
Brother / Sister in law - 4
E. EDUCATION
Name Place Major Finish (Year)
Elementary School
Junior High School
Senior High School
Diploma
University S1
University S2
*) choose one that appropriate
Page 2 of 2
F. ORGANIZATIONAL EXPERIENCE
Year Name Position
G. WORKING EXPERIENCE
Company Name
Industry Position :
Start / End Salary :
Job Description
Company Name
Industry Position :
Start / End Salary :
Job Description
Company Name
Industry Position :
Start / End Salary :
Job Description
H. EMERGENCY CALL
Emergency Contact Name :
Emergency Contact Phone :
Emergency Contact Address :
Emergency Contact Relation :
I. OTHERS
Current Salary :
Expected Salary :
Preference Work Place : Outer island of Java / On the island of Java / Others : __________________________
Reason :
*) choose one that appropriate
Page 3 of 2
G/OHI/017-02/0318
Apakah Anda berencana memasukan anggota keluarga Anda (Istri/Suami dan anak
2 pertama s.d ketiga yang diakui secara sah oleh negara) di dalam BPJS Kesehatan?
(Ya/Tidak)
Jika Ya, mohon diisi data-data berikut :
(sesuai dengan Kartu Identitas)
No Nama lengkap Suami/Istri/Anak JK No. KK No. Kartu BPJS Tanggal Lahir
1
Healthy History
Fill with (X) symbol in Yes Colom fir those conditions you've experienced during this last 3 months
Berikan tanda (X) dibawah kolom Yes bila Anda pernah /sering menhalamo gangguan di bawah ini pada 3 bulan terakhir
1. Medical History
Disease / Condition Yes No Disease / Condition Yes No Disease / Condition Yes No
Respiratory / Saluran Napas Saluran Cerna Joints & Bones / Sendi & Tulang
Diptheria Typus Radang Sendi / Reumatik
Sinusitis Muntah darah Penyakit lainnya
Bronchitis Sulit buang air besar Alergi makanan
Batuk Darah Sakit lambung / maag Makanan :
TBS Penyakit kuning Alergi Obat
Radang paru Penyakit kantung empedu Obat :
Asthma Gangguan Menelan Tetanus
Sesak Nafas Inskontinensia Alvi Pingsan
Ginjal & Saluran kemih Kulit / Kelamin Pelupa
Sulit buang air kecil Cacar air Sulit KOnsentrasi
Saluran kemih Jamur kulit Gangguan penglihatan
Penyakit ginjal Penyakit kelamin Gangguan pendengaran
Kencing baru Jantung Sakit pinggang
Inskontinesia Urin Nyeri dada Tumor ganas / kanker
Jaringan Saraf Rasa berdebar Penyakit jiwa
Radang Selaput Otak Tekanan darah tinggi TBC kulit
Gegar Otal Oembuluh darah TBC tulang dan lainnya
Polio Ambeien / wasir Campak
Ayan/Epilepsi Varises Malaria
Stroke/Lumpuh Kelenjar Diabetes
Sakit kepala Penyakit gondok / Thyroid Gangguan tidur
2. Vaccination History
Vaccination Yes No Vaccination Yes No Vaccination Yes No
HEPATITIS A DPT BCG
HEPATITIS B MEASLES POLIO
TYPHOIS TETANUS LAIN2
3. Others
Have you ever had an accident? Apakah Anda pernah mengalami kecelakaan?
Have you ever hospitalized? Apakah Anda pernah dirawat di Rumah Sakit?
(Bila ya, jelaskan kapan, berapa lama dan karena apa?)
Have you ever had surgery? Apakah Anda pernah dioperasi?
(Bila ya, jelaskan kapan dan operasi apa?)
Which kind of Sports do you like to exercise? Apakah Anda suka berolahraga?
(Bila ya, jelaskan olah raga apa dan berapa kali seminggu?)