BIMC Hospital Kuta

PATIENT STICKERS

………………………………… ASSESSMENT REPORT

Patient Complain / Medical History

Allergy :
Past Medical History

Physical Examination
Level of Consciousness : ………. Respiration rate : ……….x/min Temperature : ……….0C
Blood Pressure : …………mmHg Pulse : ……….x/min O2 Saturation : ……% on ……
Other Examination Findings :

Investigations

Assessment / Diagnosis

Treatment / Management

Recommendation / Doctor’s Note

Travel Recommendation (if applicable)

Patient is fit to fly ? □ Yes □ No
Patient need □ Ordinary seat □ wheelchair assistance □ stretcher case □ business class / extra leg space
Patient can travel □ unescorted □ with non medical escort □ with medical escort
Patient ask repatriation □ Yes □ No □ no choice In Doctors Opinion Is This Medically Necessary ? □ Yes □ No
Treating Doctor’s Name : Signature :

Date : Time :