HEALTH REPORT
Whereof the undersigned, docter
of PUSKESMAS Sukolilo Surabaya, Indonesia, declares that:
Gender : Female
Age : 18 years old
Address : Jln. Pulau Sambit no. 915 RT. 05
Tanjung Redeb kab. Berau
Has been examined carefully and this Health Report is used for fulfilling the requirement in
continuing the study in Turkey.
Height/weight :
170kg/55
Blood pressure :
Pulse :
Blood type :
O
Color Blindness :
Yes/No
Surabaya,
April 2017.
dr.
………………..
NIP.
………………………
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