Rekam Medik

(Pasien Bekam)
Alamat: Jl. Sungai Raya Dalam Komplek Korpri Gang Bringin 5 No. 160 Telp. 085654462853
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Nama : ………………….………………………… (….Th)
Pekerjaan :……………………………..................................................
Alamat : ………………………................Telp : ...............................
Keluhan Utama : ……………………………………(Hr/Minggu/Bln/Th)
Keluhan Tambahan :...............................................................................................
Hasil Diagnosis : ..........................................................................................................
Tekanan Darah : ………… Berat Badan : ........Kg Gula Darah :........................
Syaraf :..........................................................................................................
Tangan : ……………………………………………………......…...............
Iridologi : .........................................................................................................
Tangan/Kaki : Panas/ Dingin/ Normal
Denyut Nadi : Atas/Bawah, laju/Lambat, Kuat/Lemah, Normal
Lidah : Mengembang/mengecil,Kering/Licin,Berparit/Selaput putih
Tulang Belakang: .........................................................................................................
Titik Bekam :

Anjuran/ Herba :
01 Tingkatkan ibadah kpd Allah
02 Minum air putih min 2,5 ltr/hari
03 Jus buah/sayur 3x/hari
04 Kurangi makanan berlemak segera
05………………………………….
06.....................................................
07.....................................................

Pontianak, ....., Agustus 2019

Pemeriksa

(..........……………………….)
Terapi : Bekam/ Akupunktur/Refleksi/Moksa/PTB Terapi Berikutnya tgl …………..
Akupunktur : Ten Nedle, ............................................
Moksa : ST36,SP6,CV8,GV4,BL23,..................... .....