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Biodata Mahasiswa
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* Indicates required question
Nama
*
Your answer
NIM
*
Your answer
Tempat Lahir
*
Your answer
Tanggal lahir
*
MM
/
DD
/
YYYY
Agama
*
Choose
Islam
Kristen Protestan
Katolik
Hindu
Budha
Kong Hu Cu
Jenis Kelamin
*
Choose
Laki-laki
Perempuan
Usia (tahun)
*
Your answer
Berat Badan (kg)
*
Your answer
Tinggi Badan (cm)
*
Your answer
Gol Darah
*
O
A
B
AB
Nama Ayah
*
Your answer
Nama Ibu
*
Your answer
Alamat Asal
*
Your answer
Alamat di Malang
*
Your answer
No Telp/HP
*
Your answer
Email
Your answer
WALI DI MALANG YANG DAPAT DIHUBUNGI
Nama Wali
*
Your answer
Alamat Wali
*
Your answer
No Telp/Hp Wali
*
Your answer
RIWAYAT PENYAKIT LALU
Jika tidak ada jawab -
1. Penyakit
*
Jantung
Sesak Napas
Vertigo
Maag Akut
Patah Tulang
Epilepsi
Tidak Ada
Other:
Required
2. Saat Usia (tahun)
*
Your answer
4. Apakah Anda Pernah Pingsan
*
Ya
Tidak
5. Jika Ya, Apa penyebabnya?
*
Your answer
RIWAYAT PENYAKIT SEKARANG
Jika tidak ada jawab -
1. Penyakit
*
Jantung
Sesak Napas
Vertigo
Maag Akut
Patah Tulang
Epilepsi
Tidak Ada
Other:
Required
2. Saat Usia (tahun)
*
Your answer
ALERGI
Jika tidak ada jawab -
1. Alergi Obat obatan
*
Your answer
2. Alergi Makanan
*
Your answer
3. Alergi Minuman
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Your answer
4. Alergi Lainnya
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Your answer
5. Obat yang biasa digunakan
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