CONFIDENTIAL MEDICAL REPORTDate : ___/___/____ Time : _________ (AM/PM)

File No. : _______________Family Name : ________________________________________ First Name : __________________________________ Sex : M/FDate Of Birth/Age : ____________________________________ Date Of Admission : ___________________________________Nationality : ____________________________Current Address in Bali : __________________________________________________ Phone Number : ____________________

Present Patient’s history or Complaint :________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Past Medical History : ______________________________________ Medication Currently Used : ______________________

Allergic History : __________________________________________ Treatment so far : _____________________________

Vital Signs

GCS : ________ Temperature : _______________ Respiratory Rate : _________________

Blood Pressure : _____________________ Pulse Rate : _________________ SPO2 : ___________________________

Physical Examination : _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other Examination (Radiology, Lab, ECG, CT Scan, Ultra Sound, MRI, etc.) : _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Diagnosis : ________________________________________________________________________________________________________________________________________________________________________________________________________

Differential Diagnosis : ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Treatment/Medication : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Doctor’s Recommendation :

Patient Request Repatriation : Yes No

In Doctor’s Opinion This Patient Requires Repatriation / Medical Evacuation : Yes No

Patient’s Can Be Transported : Yes No

If Yes, with :

Normal Transportation

Ambulance

Patient’s Fit To Fly : Yes No

If Yes, with :

Normal Flight

Non Escorted In Economic Class

Non Escorted In Business Class

Non Medical Escorted In Business Class

Medical Escort in Business Class

Stretcher Medical Escort Team

Charter Flight / Air Ambulance Team

Patient’s need wheelchair : Yes No

If Yes, type :

WCHC

WCHS

WCHR

Comment : _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Denpasar - Bali, _________________________

Attending Physician,

Specification/Specialist : ___________________