Date reported 10 February 2020

Patient’s name Toru Ogata

Patient’s age
GLOBAL ASSISTANCE & HEALTHCARE
5th floor, CIBIS NINE Tower (CIBIS Business park)
Treating Doctor’s name Dr. Sukartono-Internist
Jl. Raya Cilandak KKO, Jakarta 12560. Hospital Budi Rahayu Hospital Pekalongan
Alarm Centre : + 62 (21) 299 78 999 Reference
Administration : + 62 (21) 299 78 997
Fax : + 62 (21) 299 78 955
Email: ops@Global-Assistance.Net

Patient Medical History Present condition :

With date of first complaint, date of
hospitalization, past individual and family history

Physical examination Significant physical findings :

As reported by treating doctor

Vital signs Level of consciousness GCS E M V

Temperature ºC
Pulse rate bpm Blood Pressure mmHg
Respiration rate rpm SaO2
Investigations Lab and radiology result :
Blood test, bacteriology, imaging,…

Diagnosis

Treatment

Treating doctor’s What is the treatment plan ?

recommendation and plan
Does he needs another follow up review date?

Is the patient fit to return to work ?

Is there any restriction relate to his work duty?

Is he fit to travel with commercial flight without medical escort?

Date of next treatment

Report by Dr Reviewed by Dr. (GAH doctor)
Date, time, signature