Hospital : Margono Soekarjo Hospital Ward / Clinic : dahlia ward

Contact Number for enquiries : (0281) 390234

Name of Nurse making referral : Nurse Tanu seherly Signed :

District Number : 53318

GP Name and surgery address: Doctor Abdul Hadi and Mersi st number 05

Date of discharge : April 20rd 2011

First Visit Requested For : he was convalesce stage

Patient’s Name and Full Home Address including Post Code :

Mr. bejo and kocar, binanguCilacap, 53281

Telephone Number : 085747313933

Date of Birth : January 30st 1970

Does the patient live alone? No, he doesn’t

Name of main career and telephone number : Mr. bejo and 085365588436

Discharge address if different : -

Name and Address of Temporary General Practitioner :

Doctor Abdul H and Mersi st number 05

Reason for admission :

He is hepatitis.

Diagnosis : Intolerance activity related to decrease of power with manifested patients ,

SD : Patient said that he feel tired, anorexia, diarrhea, cramp abdomenOD : Patient look so pale and fever, abnormal function of liver, and color brown of feces

Date and nature of recent surgery : -

Is the patient / family aware of Diagnosis / Prognosis : Yes / No / Not Sure