The Medical Declaration Form is a crucial document used in Indonesian healthcare settings to collect and verify patient medical information while ensuring compliance with national healthcare regulations. This form is typically required before medical procedures, hospital admissions, or when establishing new patient relationships with healthcare providers. It serves multiple purposes: documenting patient medical history, recording current health status, capturing informed consent, and establishing a legal record of disclosed medical information. The document must comply with Indonesian healthcare laws, including Law No. 36 of 2009 on Health and specific regulations regarding medical records (Minister of Health Regulation No. 269/MENKES/PER/III/2008). It is designed to be comprehensive yet clear, ensuring accessibility for patients while maintaining legal validity.
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1. Personal Information: Patient's full name, date of birth, ID number (KTP/Passport), contact details, and emergency contact information
2. Medical History: Current medical conditions, past surgeries, chronic illnesses, and existing medications
3. Family Medical History: Relevant hereditary conditions and significant family health issues
4. Current Symptoms: Description of present health complaints or symptoms, if any
5. Allergies and Reactions: List of known allergies to medications, foods, or other substances
6. Declaration of Truth: Patient's confirmation that all provided information is true and accurate
7. Consent and Authorization: Patient's agreement to share medical information with relevant healthcare providers
8. Signature Section: Space for patient's signature, date, and witness signature if required
1. Vaccination History: Details of previous vaccinations - included when relevant for specific medical procedures or hospital admissions
2. Travel History: Recent travel information - particularly important during infectious disease outbreaks or pandemic situations
3. Lifestyle Information: Information about smoking, alcohol consumption, exercise habits - included when relevant for specific medical assessments
4. Insurance Information: Details of health insurance coverage - included when the form is used for insurance-related purposes
5. Specific Condition Declaration: Detailed questions about specific conditions - included when the form is for specialized medical services
6. Pregnancy Status: Declaration of pregnancy status - included for female patients of reproductive age when relevant for treatment
7. Mental Health History: Information about mental health conditions - included when relevant for psychological or psychiatric services
1. List of Medications: Detailed list of current medications, dosages, and frequency of use
2. Previous Medical Records: Copies of relevant previous medical records or test results
3. Vaccination Records: Copies of vaccination certificates or immunization records
4. Specific Condition Questionnaire: Detailed questionnaire for specific medical conditions if applicable
5. Privacy Notice: Detailed information about how the patient's medical information will be used and protected
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Patient Administration
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