Nama : Cicilia Aditya Melinda (170103016)

Ray Hannif Fadillah (170103072)

Kelas : Elementary 4A

N : Roy

P : Cicilia

ADMISSION FORM

N : Good Morning

P : Good morning nurse

N : my name is Roy, who’ll be looking after you. I’d like to ask you about your personal
data

P : OK Nurse

N : What is your surname, Mrs?

P : My surename is Melinda

N : What is your first name?

P : My first name is Cicilia

N :

P :

N : When were your born?

P : 16th of January 2000

N : So you are 19 now, right?

P : Yes, that’s right

N : Where do you live?

P : I live in Purwokerto

N : What is your job?

P : I am a singer

N : Are you single?

P : Yes

N : Who is your of kin?

P : Mrs. Chintya, she is my mom

N : Can I have her phone number?

P : Yes, 085783895296

N : Well, I think that is enough. Thank you.

P : Ok, thank you nurse

N :Okay, wait a minute, next I will check your Blood pressure and Pulse.

Okay Mrs, I will check your blood pressure now. I will take about five minute

P : Sure nurse

N : Your back is supported? Good, are your legs crossed?

P : No

N : I am gonna slide up your sleeve, so I can wrap this cuff around

P : Yes
N : Okay Mrs I will continue to check your pulse

P : Ok

N : Give me your right hand, I am going my three fingers an your wrist.

P : yes

N : OK, all done, mrs cicil, your blood pressure is 110/80 mmHg, it is normal. And your
pulse is eighty beats per minute. It is normal.

P : Okey, nurse thank you

PATIENT’S MEDICAL HISTORY FORM

N : Cicilia

P : Roy

N : good morning Mr. Roy

P : good morning, nurse.
N : my name is Cicil, I am a nursing student. I’d like to ask you about history of present and
past illness.
P : Ok, nurse
N : I just need to take a look at your ID bracelet. Ok thanks. What do you feel now?
P : I don’t feel well
N : what’s the matter?
P : I have a headache
N : what did you do before it happened?
P : I just teach as usual
N : have you ever got headache before?
P : no, I haven’t
N : did you consume any medication?
P : no, I just lie down when I have headache.
N : have you been hospitalized?
P : no, I haven’t nurse
N : do you have any drug, food or airborne allergy?
P : I am allergic to cold temperature
N : do you smoke?
P : no
N : well, I think that is the last question. Thank you.
P : you are welcome
N : Okay wait a minute, next I will check your Temperature and your condition.
P : Ok, nurse
N : Unbutton your shirt please and I am going to put this thermometer into your armpit.
And then I will put this object on your stomach for just a moment okey? Ready? Start!
P : okay
N : okay, all done. Your temperature is 37 C. it is normal Mr.
And Your respiratory rate eighteen breats per minutes. It is normal. Ok great thank you
P : thank you nurse
N : you are welcome. Do you have any questions before I leave?
P : nothing
N : ok. Bye-bye