Full Name

Joko Tri Purnomo

Department
System Support Dept
Position
System Support Manager
Sex
Male
Place/Date of Birth
Klaten, 4 March 1981
Blood Type
A / B / AB / O
Height (CM)
155
Weight (Kg)
50
Home Address
Pondok Ungu Permai Sektor V Blok N2 No. 12A Bekasi

Do you still in the Medical Treatment or Recovery Term? ...NO........ If the answer is YES, please write
down your medical treatment list!

Please give the names of any drugs you may be taking during training, with the dosage and times to
be given!

Have you ever been in the hospital in the last one year? If the answer is YES, Please fill this form
below:
MM/DD/YYYY Hospital Kind of Treatment

If you are NOW or HAVE BEEN in this one of this situations or symptoms below, PLEASE, mark it
with circle in the word “YES”, and underlined the situation/symptoms. If your answer is “NO”,
mark it with circle in the word “NO”.
YES NO Often to Lost Conscious, Dizzy, Migraine, Headache
YES NO Injury to: Muscle, Shoulder, Backbone, Waist, Elbow, Neck, Wrist, Hip, Ankle
YES NO Dislocate to: Muscle, Shoulder, Backbone, Waist, Elbow, Neck, Wrist, Hip, Ankle
YES NO Fracture: Muscle, Shoulder, Backbone, Waist, Elbow, Neck, Wrist, Hip, Ankle
YES NO Phobia: of Height, Narrow Places, Dark/Secret, Crowd, Water
YES NO Kinds of : Depression, Anxiety, Hysteria
YES NO Cough, Bronchitis, TBC, Asthma, Epilepsy, Diabetes

Ø Do you have any medical report/note from your doctor? Or Allergies of Something?

Ø Do you wear glasses or contact lens? YES / NO? Myopic / Hypermetropic / Astigmatic?

Signature of Participant : ___JOKO TRI PURNOMO____________________

Place/Date : __Jakarta_31_March 2017

®
ADVENTURE INDONESIA – Head Office
Jl. Guru Serih No.38 Cijantung, East Jakarta, Indonesia - 13790
Phone : (+ 62 21) 293 833 01 (Hunting)
Fax : (+ 62 21) 877 11 271
Email : info@adventureindonesia.co.id
Website : www.adventureindonesia.co