ADMISSION TASK

Compiled to fulfill one of the assignment for english courses

Dosen Pengampu:

Aris Puji Utami., SST., M.Kes

Disusun oleh:

1. Violeta Dity Virginia Khoir (21025029028)

2. Wahyu Nur Aminah (21025029029)

PRODI S1 KEBIDANAN

FAKULTAS KEPERAWATAN DAN KEBIDANAN

INSTITUT ILMU KESEHATAN NAHDATUL ULAMA

TUBAN 2022
 ASYIFA
MEDICAL CLINIC

MEDICAL HISTORY
Date: Tuban, 14 Juni 2022
Please complete this history form. This will allow us to best serve your health needs. The
information contained herein is stricly confidential and will not be released unless you
authorize us to do soo.
Name : Mrs. Intan _ Birth Date : 21 Juni 994 Location : Surabaya
Address : Anggrek street Home : - Business : -
Blok F No.04 Malang
Occupation : Teacher Retired (Yes/No) Year
Marital Status : Married Religion : Moslem
Previous Physycian : Dr. Andrian Location : Diponegoro Street, Malang_

FAMILY Sex Ag General Health Age at Death Cause of Death

e
Father 55 ✓
Mother 50 ✓
Brother/Sister M F
M F
M F
Husband/Wife M F 34 ✓
Son/Daughter M F 7 ✓
M F
M F
Do you have any immediate family with the following? (Indicated relationship)
High Blood Pressure Epilepsy
Heart Attack Asthma
Stroke Bleeding Problems
Diabetes Thyroid Problems
Tuberculosis Mental Illness
Cancer, Leukemia Kidney Disease _

HABITS
Yes No Do you smoke? Cigarettes, Pipe, Cigar?
Packs/day___Years_____
Yes No Have you stopped smoking? When _______________________
Yes No Do you drink coffee? Regular How much/day
_______2x______
Yes No Do you drink alcohol?
1 oz./day 2 oz./day 3 oz./day More
Beer: 1 btl/day 2 btl/day 4 btl/day More
Dialog

Nurse : Hello good morning miss, anything I can help?

Mrs. Intan : Good morning nurse, I will check my disease
Nurse : Okay ma’am, before checking may I ask a question to fill out the form
Mrs, Intan : “Yes, You may”
Nurse : “What is your name?
Mrs. Intan : “my name is intan”
Nurse : “when were you born”
Mrs. Intan : “ I was born on June 21 1994”
Nurse : “Where were you born?”
Mrs. Intan “ I was born in Surabaya”
Nurse : “ Where is your home address or business address?”
Mrs. Intan : “My Address is anggrek Street, Blok F, No.04, Malang”
Nurse : “what is your occupation?
Mrs. Intan : “I am a theacher”
Nurse : “ Are you married or still single?”
Mrs. Intan : “ I’m married”
Nurse : “sorry to disturb privacy may I know your religion?”
Mrs. Intan : “I’m moslem”
Nurse : “where have you checked before?”
Mrs. Intan : “ Dr. Andrian”
Nurse : “Where's the location of dr. Andrian?”
Mrs. Intan : “At the Diponegoro street, Malang”
Nurse : “Sorry, are your parents still alive?”
Mrs. Intan : “Yes nurse”
Nurse : “How old is your father dan your mother”
Mrs. Intan : “My dad is 55 years old and my mom is 50 years old”
Nurse : “Do you have brother or sister?”
Mrs. Intan : “No, I’m an only child”
Nurse : “How old is your husband?”
Mrs. Intan :” He is 34 years old”
Nurse : “Do you have son/daughter?”
Mrs. Intan : “Yes, I have a daughter”
Nurse: “How old is your daughter?”
Mrs. Intan : “She is 7 years old”
Nurse : “okay mam. Did you have any previous illness?”
Mrs. Intan : “yes I have a history of stroke”
Nurse : “Do you smoke,ma’am?”
Mrs. Intan : “ No, I'm not”
Nurse “Do you drink a coffee?”
Mrs. Intan : “yes, I drink coffe, I drink 2x a day”
Nurse : “Do you drink alcohol?”
Mrs. Intan : “No, I'm not”
Nurse : “Okay Mrs. Intan thankyou for the information, you can wait here, I’ll call the
dokter “
Mrs. Intan : “Okay, Nurse.you are welcome.”