CLINIC THEAVY MOK M.D STAFFS GUESTS Name Card 12B

Patient Information
Khmer Name *	:		Last Name *	:		First Name *	:		Patient Code *	:
Sex	:	Male Female	Hand Phone *	:		Home Phone	:		Date of Birth / Age *	:
KHMER ID	:		KSFH ID	:		Province	:	Banteay Meanchey Battambang Kampong Cham Kampong Chhnang Kampong Speu Kampong Thom Kampot Kandal Kep Koh Kong Kratie Mondul Kiri Oddar Meanchey Pailin Phnom Penh Preah Sihanouk Preah Vihear Prey Veng Pursat Ratanak Kiri Siemreap Stung Treng Svay Rieng Takeo Tboung Khmum	District	:	Aek Phnum Andoung Meas Angk Snuol Angkor Borei Angkor Chey Angkor Chum Angkor Thum Anlong Veaeng Aoral Ba Phnum Bakan Ban Lung Banan Banteay Ampil Banteay Meas Banteay Srei Bar Kaev Baray Baribour Basedth Batheay Bati Battambang Bavel Bavet Borei Cholsar Botum Sakor Chamkar Leu Chamkar Mon Chantrea Chbar Mon Cheung Prey Chey Saen Chhaeb Chhloung Chhuk Chi Kraeng Chitr Borei Choam Khsant Chol Kiri Chong Kal Chum Kiri Dambae Damnak Chang'aeur Dang Tong Dangkao Doun Kaev Doun Penh Kaeb Kaev Seima Kamchay Mear Kampong Cham Kampong Chhnang Kampong Leaeng Kampong Leav Kampong Rou Kampong Seila Kampong Siem Kampong Svay Kampong Trabaek Kampong Trach Kampong Tralach Kampot Kamrieng Kandal Stueng Kandieng Kang Meas Kanhchriech Kaoh Andaet Kaoh Kong Kaoh Nheaek Kaoh Soutin Kaoh Thum Khemara Phoumin Khsach Kandal Kien Svay Kiri Sakor Kiri Vong Koas Krala Kong Pisei Koun Mom Kracheh Krakor Kralanh Krong Preah Vihear Krouch Chhmar Kuleaen Leuk Daek Lumphat Lvea Aem Malai Me Sang Mean Chey Memot Mondol Seima Mongkol Borei Moung Ruessei Mukh Kampul Odongk Ou Chrov Ou Chum Ou Reang Ou Reang Ov Ou Ya Dav Pailin Paoy Paet Pea Reang Peam Chor Peam Ro Pech Chreada Phnum Kravanh Phnum Proek Phnum Srok Phnum Sruoch Ponhea Kraek Ponhea Lueu Prampir Meakkakra Prasat Bakong Prasat Ballangk Prasat Sambour Preaek Prasab Preah Netr Preah Preah Sdach Preah Sihanouk Prey Chhor Prey Kabbas Prey Nob Prey Veng Puok Rolea B'ier Romeas Haek Rotonak Mondol Rovieng Ruessei Kaev Rumduol S'ang Saen Monourom Sala Krau Sambour Sameakki Mean Chey Samlout Sampov Lun Sampov Meas Samraong Samraong Samraong Tong Sandan Sangkae Sangkum Thmei Santuk Sen Sok Serei Saophoan Sesan Siem Bouk Siem Pang Siem Reab Sithor Kandal Snuol Soutr Nikom Srae Ambel Srei Santhor Srei Snam Stoung Stueng Hav Stueng Saen Stueng Traeng Stueng Trang Suong Svay Antor Svay Chek Svay Chrum Svay Leu Svay Rieng Svay Teab Ta Khmau Ta Veaeng Tbaeng Mean Chey Tboung Khmum Thala Barivat Thma Bang Thma Koul Thma Puok Thpong Tram Kak Trapeang Prasat Treang Tuek Chhou Tuek Phos Tuol Kouk Varin Veal Veaeng Veun Sai
Address 1	:		Commune	:	achar Leak Aekakpheap Akphivoadth Akreiy Ksatr Amleang Ampil Ampil Ampil Ampil Ampil Krau Ampil Pram Daeum Ampil Ta Pok Ampil Tuek Ampov Prey Andaeuk Haeb Andaung Tuek Andoung Khmaer Andoung Pou Andoung Pou Andoung Snay Andoung Thma Andoung Trabaek Angk Kaev Angk Khnaor Angk Phnum Touch Angk Popel Angk Prasat Angk Prasrae Angk Ta Saom Angk Ta Sou Angkanh Angkanh Angkaol Angkor Angk Angkor Ban Angkor Ban Angkor Borei Angkor Chey Angkor Meas Angkor Reach Angkor Sar Angkor Tret Anhchaeum Anhchanh Rung Anlong Chrey Anlong Phe Anlong Reab Anlong Romiet Anlong Run Anlong Samnar Anlong Tnaot Anlong Veaeng Anlong Vil Anlong Vil Ansa Chambak Ansaong areaks Tnaot Ba Baong Ba Srae Ba Yakha Baek Chan Bak Anlung Bak Chenhchien Bak Dav Bak Khaeng Bak Kheng Bak Khlang Bak Sna Bakong Ballangk Ballangk Ban Kam Ban Pong Baniev Banlich Prasat Bansay Reak Bansay Traeng Banteay Chakrei Banteay Chhmar Banteay Daek Banteay Dei Banteay Krang Banteay Meas Khang Kaeut Banteay Meas Khang Lech Banteay Neang Banteay Preal Banteay Stoung Bar Kham Barang Thleak Baray Baray Baray Baray Baray Barku Barong Basak Basak Basedth Bat Trang Batheay Bati Bavel Bavet Bay Damram Beng Bet Trang Boeng Boeng Bat Kandaol Boeng Beng Boeng Char Boeng Daol Boeng Kak Muoy Boeng Kak Pir Boeng Kantuot Boeng Keng kang Bei Boeng Keng Kang Muoy Boeng Keng Kang Pir Boeng Khnar Boeng Khyang Boeng Kok Boeng Krum Boeng Lvea Boeng Mealea Boeng Nay Boeng Nimol Boeng Preah Boeng Preav Boeng Pring Boeng Prolit Boeng Pruol Boeng Reang Boeng Reang Boeng Sala Khang Cheung Boeng Sala Khang Tboung Boeng Salang Boeng Ta Prum Boeng Thum Boeng Trabaek Boeng Tranh Khang Cheung Boeng Tranh Khang Tboung Boeng Tuk Boeng Tumpun Bor Bos Khnaor Bos Leav Bos Mon Bos Sbov Bos Sbov Bourei Cholsar Bu Chri Bu Sra Bung Bram Cha Ung Chaeng Mean Chey Chaeung Daeung Chak Chak Chak Chak Angrae Kraom Chak Angrae Leu Chakto Mukh Cham Chambak Chambak Chambak Chambak Chamkar Andoung Chamkar Leu Chamkar Luong Chamkar Luong Chamkar Samraong Chamlang Chamnaom Chamnar Kraom Chamnar Leu Champa Champei Champei Chamraeun Chamraeun Phal Chan Chan Mul Chan Sar Changha Changkrang Chant Saen Chantrea Chantrei Chaom Chau Chaong Maong Char Char Chhuk Chbar Ampov Chbar Ampov Muoy Chbar Ampov Pir Chbar Mon Chea Khlang Cheach Chealea Cheang Daek Cheang Tong Chek Cheung Aek Cheung Kaeub Cheung Kou Cheung Kreav Cheung Kuon Cheung Phnum Cheung Prey Cheung Roas Cheung Tien Cheung Tuek Chey Chey Chouk Chey Chumneah Chey Kampok Chey Otdam Chey Thum Cheyyou Chhaeb Muoy Chhaeb Pir Chhak Chheu Neang Chhean Laeung Chhean Mukh Chheu Kach Chheu Khmau Chheu Teal Chheu Teal Chheu Teal Chheu Teal Chheu Tom Chhloung Chhnal Moan Chhnok Tru Chhnuor Mean Chey Chhuk Chhuk Chhuk Chhuk Khsach Chhuk Sa Chhveang Chi Bal Chi Kha Kraom Chi Kha Leu Chi Khmar Chi Kraeng Chi Phat Chi Phok Chieb Chikor Chirou Muoy Chirou Pir Choam Choam Kravien Choam Ksant Choam Sangkae Choam Ta Mau Chob Chob Ta Trav Chob Veari Chol Sar Chong Ampil Chong Cheach Chong Doung Chong Kal Chong Khnies Chong Phlas Chongruk Chonloas Dai Chrach Chrak Mtes Chrang Chamreh Muoy Chrang Chamreh Pir Chranieng Chranouk Chreav Chres Chres Chres Chres Chrey Chrey Chrey Chrey Chrey Bak Chrey Khmum Chrey Loas Chrey Sema Chrey Thum Chrey Vien Chroab Chrolong Chrouy Banteay Chrouy Changva Chrouy Neang Nguon Chrouy Pras Chrouy Sdau Chrouy Svay Chrouy Ta Kaev Chrung Popel Chum Kriel Chumnik Chumnoab Chumpu Proeks Chumpu Voan Chumreah Pen Daeum Doung Daeum Mien Daeum Rues Dak Dam Dam Daek Dambae Dambouk Khpos Dambouk Rung Damnak Ampil Damnak Kantuot Khang Cheung Damnak Kantuot Khang Tboung Damnak Reang Damnak Sokram Damrei Choan Khla Damrei Phong Damrei Puon Damrei Slab Damrel Dan Koum Dan Run Dang Kambet Dang Kdar Dang Peaeng Dang Tong Dang Tong Dangkao Dar Dar Dar Dei Edth Doun Ba Doun Kaev Doun Koeng Doun Peaeng Doun Sa Doun Tei Doun Yay Doung Doung Doung Doung Khpos Hab Han Chey Han Chey Haong Samnam Hat Pak K'am Samnar Ka Choun Ka Laeng Kachanh Kaeb Kaev Poar Kahaeng Kak Kak Kak Kakab Kakaoh Kakaoh Kalai Kamboul Kamnab Kampeaeng Kampeaeng Kampenh Kampoan Kampong Ampil Kampong Bay Kampong Cham Kampong Cham Kampong Chamlang Kampong Chen Cheung Kampong Chen Tboung Kampong Chhnang Kampong Damrei Kampong hau Kampong Kandal Kampong Kdei Kampong Khleang Kampong Kong Kampong Kor Kampong Kou Kampong Krabau Kampong Kraeng Kampong Krasang Kampong Leav Kampong Lpou Kampong Luong Kampong Luong Kampong Os Kampong Os Kampong Phluk Kampong Phnum Kampong Popil Kampong Pou Kampong Pranak Kampong Prang Kampong Prasat Kampong Preah Kampong Preah Kokir Kampong Preang Kampong Reab Kampong Reab Kampong Roteh Kampong Ruessei Kampong Samnanh Kampong Samraong Kampong Seila Kampong Seila Kampong Soeng Kampong Sralau Muoy Kampong Sralau Pir Kampong Svay Kampong Svay Kampong Svay Kampong Thkov Kampong Thma Kampong Thum Kampong Trabaek Kampong Trach Kampong Trach Khang Kaeut Kampong Trach Khang Lech Kampong Tralach Kampong Treas Kampun Kamrieng Kandaek Kandal Kandaok Kandaol Kandaol Chrum Kandaol Dom Kandieng Kandieng Reay Kandoeng Kang Cham Kang Ta Noeng Kanhcham Kanhchor Kanhchor Kanhchriech Kansaom Ak Kantaok Kanthaor Khang Cheung Kanthaor Khang kaeut Kanthaor Khang Lech Kantreang Kantueu Muoy Kantueu Pir Kantuot Kantuot Kantuot Kaoh Andaet Kaoh Anlong Chen Kaoh Chek Kaoh Chen Kaoh Chiveang Kaoh Chouram Kaoh Chraeng Kaoh Chum Kaoh Dach Kaoh Kaev Kaoh Kapi Kaoh Khael Kaoh Khnhaer Kaoh Khsach Tonlea Kaoh Mitt Kaoh Oknha Tei Kaoh Pang Kaoh Peak Kaoh Pir Kaoh Pong Satv Kaoh Preah Kaoh Reah Kaoh Roka Kaoh Roka Kaoh Rung Kaoh Sampeay Kaoh Sampov Kaoh Samraong Kaoh Sdach Kaoh Snaeng Kaoh Soutin Kaoh Sralay Kaoh Ta Suy Kaoh Thkov Kaoh Thum Ka Kaoh Thum Kha Kaoh Tontuem Kaoh Touch Kaoh Trong Kaong Kang Kat Phluk Kbal Damrei Kbal Kaoh Kbal Romeas Kbal Trach Kbal Tuek Kdanh Kdei Doung Kdei Run Kdoeang Reay Kdol Kdol Tahen Ke Chong Kear Khchas Khchau Khcheay Khang Cheung Khcheay Khang Tboung Khlong Popok Khmuonh Khnach Romeas Khnang Phnum Khnaor Dambang Khnar Chhmar Khnar Pou Khnar Sa Khnar Sanday Khnar Totueng Khnat Khon Rang Khpob Khpob Khpob ateav Khpob Ta Nguon Khsach Andaet Khsam Khsem Khsan Khsuem Khtum Krang Khun Ream Khvav Khvav Khvav Khvet Thum Khyang Kien Chrey Kien Sangkae Kiloumaetr Lekh Prammuoy Kiri Chong Kaoh Kiri Voan Klaeng klaing Rmeas Klang Hay Koas Krala Koh Dach Kok Lak Kokir Kokir Kokir Kokir Saom Kokir Thum Kokir Thum Kokor Komar Reachea Kong Chey Kong Noy Kor Kor Kou Khchak Kou Loab Koub Kouk Ballangk Kouk Banteay Kouk Chak Kouk Doung Kouk Kakthen Kouk Khmum Kouk Khpos Kouk Kong Kaeut Kouk Kong Lech Kouk Mon Kouk Pou Kouk Prech Kouk Pring Kouk Roka Kouk Romiet Kouk Rovieng Kouk Srok Kouk Thlok Kouk Thlok Kraom Kouk Thlok Leu Kouk Trab Koul Koul Koun Kriel Koun Satv Koy Maeng Koy Trabaek Krabau Krabei Riel Kracheh Kraek Krakor Krala Kralanh Krang Ampil Krang Ampil Krang Chek Krang Dei Vay Krang Leav Krang Leav Krang Lvea Krang Mkak Krang Pongro Krang Sbov Krang Skear Krang Snay Krang Svay Krang Ta Yang Krang Teh Krang Thnong Krang thnong Krang Yov Kranhung Kraol Kou Krapeu Pir Krapum Chhuk Krasang Krasang Krava Kraya Kraya Krouch Krouch Chhmar Krouch Kor Kruos Ksetr Kuleaen Cheung Kuleaen Tboung Kumru Kus Kuttasat L'ak L'ang La Bang Muoy La Bang Pir Labansiek Laming Lbaeuk Leach Leang Dai Leay Bour Leuk Daek Lngieng Lolok Sa Longveaek Lum Choar Lumchang Lumhach Lumpong Lumtong Lung Khung Lve Lve Lvea Lvea Lvea Lvea Lvea Krang Lvea Leu Lvea Sa Lveaeng Ruessei Malai Malik Me Bon Me Mang Me Pring Me Sa Thngak Me Sar Chrey Me Tuek Meakprang Mean Cheay Mean Chey Mean Chey Mean Chey Mean Chey Mean Chey Mean Ritth Mean Ritth Melum Memong Memot Mesa Prachan Meun Chey Mien Mien Mittakpheap Mkak Mkak Mlu Prey Muoy Mlu Prey Pir Moha Khnhoung Moha Leaph Moha Ruessei Moha Sang Monourom Monourom Monourom Monourom Mor Rokort Moung Moung Moung Riev Mream Mroum Msar Krang Muk Ra Mukh Da Mukh Paen Nam Tau Nang Khi Loek Nareay Neak Loeang Neang Teut Ngan Nhaeng Nhang Nhang Nhor Ni Pechr Nimitt Nirouth Nitean Nokor Pheas Nokor Thum Norea Otdam Souriya Ou Ou Ambel Ou Andoung Ou Bak Roteh Ou Bak Roteh Ou Bei Choan Ou Buon Leu Ou Char Ou Chrov Ou Chum Ou Da Ou Dambang Muoy Ou Dambang Pir Ou Kanthor Ou Krasar Ou Krieng Ou Mal Ou Mlu Ou Mreah Ou Oknha Heng Ou Prasat Ou Rai Ou Ruessei Ou Ruessei Ou Ruessei Bei Ou Ruessei Buon Ou Ruessei Kandal Ou Ruessei Muoy Ou Ruessei Pir Ou Rumduol Ou Sampor Ou Samrel Ou Sandan Ou Saom Ou Saray Ou Smach Ou Sralau Ou Svay Ou Svay Ou Svay Ou Ta Ki Ou Ta Paong Ou Tavau Ou Treh Oulampik Ovlaok Pa Kalan Pa Tang Pailin Pak Nhai Pal Hal Paoy Char Paoy Paet Pate Pea Ream Peak Snaeng Peam Peam Aek Peam Bang Peam Chhkaok Peam Chi Kang Peam Chileang Peam Kaoh Sna Peam Krasaob Peam Mean Chey Peam Montear Peam Oknha Ong Peam Prathnuoh Peam Reang Peam Ro Pean Roung Peang Lvea Peani Pech Changvar Pech Chenda Pech Sar Pechr Muni Peuk Peus Muoy Peus Pir Ph'av Ph'av Phan Nheum Phat Sanday Phdau Chum Pheakdei Pheari Mean Chey Pher Phkoam Phleung Chheh Roteh Phlov Meas Phlov Tuk Phluk Phnhi Meas Phniet Phnom Penh Thmey Phnum Bat Phnum Dei Phnum Den Phnum Kok Phnum Kong Phnum Lieb Phnum Penh Phnum Proek Phnum Sampov Phnum Tbaeng Muoy Phnum Tbaeng Pir Phnum Touch Phnum Touch Phong Phsar Phsar Chas Phsar Chhnang Phsar Daek Phsar Daeum Kor Phsar Daeum Thkov Phsar Depou Bei Phsar Depou Muoy Phsar Depou Pir Phsar Kandal Muoy Phsar Kandal Pir Phsar Thmei Bei Phsar Thmei Muoy Phsar Thmei Pir Phteah Prey Phteah Rung Phum Thmei Phum Thum Phum Thum Pir Thnu Pneay Pnov Pnov Ti Muoy Pnov Ti Pir Pong Tuek Pong Tuek Pong Tuek Pongro Pongro Pongro Pongro Pongro Pongro Kraom Pongro Leu Ponhea Lueu Ponhea Pon Ponhea Pon Ponley Ponley Ponley Ponsang Popeaek Popel Popel Popel Popel Popok Popueus Pot Sar Pou Pou Pou Angkrang Pou Chamraeun Pou Mreal Pou Rieng Pou Rumchak Pou Ta Hao Pou Ti Pou Treay Pouthi Ban Pouthi Reach Pralay Pralay Pralay Meas Pram Yam Pramaoy Prambei Mom Prambei Mom Prame Praphnum Prasat Prasat Prasat Prasat Prasat Prasat Prasneb Prasout Prateah Lang Pratheat Preaek a Chi Preaek Aeng Preaek Ambel Preaek Ampil Preaek Anhchanh Preaek Anteah Preaek Bak Preaek Changkran Preaek Chrey Preaek Chrey Preaek Dach Preaek Dambang Preaek Dambouk Preaek Hour Preaek Kak Preaek Kampis Preaek Khsach Preaek Khsay Ka Preaek Khsay Kha Preaek Kmeng Preaek Koy Preaek Koy Preaek Krabau Preaek Krabau Preaek Kroes Preaek Lieb Preaek Luong Preaek Luong Preaek Meas Preaek Norint Preaek Phtoul Preaek Pnov Preaek Pou Preaek Pra Preaek Prasab Preaek Preah Sdach Preaek Rey Preaek Roka Preaek Ruessei Preaek Ruessei Preaek Rumdeng Preaek Saman Preaek Sambuor Preaek Sdei Preaek Slaeng Preaek Ta Kov Preaek Ta Meak Preaek Ta Nong Preaek Ta Sar Preaek Ta Sek Preaek Ta Teaen Preaek Thmei Preaek Thmei Preaek Tnaot Preaek Tonloab Preah Andoung Preah Bat Preah Bat Choan Chum Preah Damrei Preah Khae Preah Khleang Preah Netr Preah Preah Nipean Preah Phos Preah Ponlea Preah Ponlea Preah Pralay Preah Prasab Preah Putth Preah Rumkel Preah Sdach Preah Srae Preah Theat Preak Dak Preal Prei Prek Chik Prek Phnov Prey Ampok Prey Angkunh Prey Char Prey Chas Prey Chhlak Prey Chhor Prey Chhor Prey Chruk Prey Daeum Thnoeng Prey Kabbas Prey Kandieng Prey Kanlaong Prey Khla Prey Khla Prey Khmum Prey Khnes Prey Khpos Prey Kmeng Prey Kokir Prey Krasang Prey Kri Prey Kuy Prey Lvea Prey Mul Prey Nheat Prey Nhi Prey Nob Prey Phdau Prey Phkoam Prey Pnov Prey Poun Prey Puok Prey Rumdeng Prey Rumdeng Prey Rumduol Prey Sa Prey Sloek Prey Sniet Prey Sralet Prey Svay Prey Ta Ei Prey Ta Hu Prey Thnang Prey Thum Prey Thum Prey Tonle Prey Totueng Prey Touch Prey Tralach Prey Tueng Prey Veaeng Prey Vihear Prey Yuthka Pring Chrum Pring Thum Prongil Pteah Kandal Puk Ruessei Puok Putrea Rasmey Songha Reab Reach Montir Reaks Chey Reaksa Reaksmei Reaksmei Sameakki Ream Ream Andaeuk Reang Kesei Reang Til Reathor Reay Pay Reul Rieb Roy Rik Reay Roang Roang Robas Mongkol Robieb Rohal Rohas Rohat Tuek Roka Roka Roka Roka ar Roka Chonlueng Roka Kandal Roka Kaoh Roka Kaong Muoy Roka Kaong Pir Roka Khnaor Roka Khpos Roka Knong Roka Koy Roka Krau Roka Po Pram Roka Thum Rokat Rolea B'ier Roleab Roleang Chak Roleang Kaen Roleang Kreul Roluos Roluos Roluos Roluos Mean Chey Romeang Thkaol Romenh Romonea Romoniy Romtom Ronak Ser Roneam Rotanak Rotanak Roung Damrei Roung Kou Rovieng Roya Ruessei Chrouy Ruessei Chrum Ruessei Kaev Ruessei Kaev Ruessei Krang Ruessei Kraok Ruessei Lok Ruessei Sanh Ruessei Srok Ruessei Srok Ruessei srok Khang Kaeut Ruessei Srok Khang Lech Rumchek Rumchek Rumchek Rumchek Rumdaoh Rumdaoh Srae Rumlech Rumlech Run Ta Aek Rung Rung Chrey Rung Roeang Rung Roeang Rung Roeang Ruos Roan S'ang S'ang Phnum Sa Kream Saeb Saen Dei Saen Monourom Saen Sokh Sak Sampov Sala Kamraeuk Sala Krau Sala Visai Sam Rong Sam'ang Sambatt Mean Chey Sambok Sambour Sambour Sambour Sambour Sambuor Sambuor Sambuor Sambuor Sambuor Sambuor Sambuor Sambuor Meas Sambuor Meas Sameakki Sameakki Sameakki Sameakki Samkhuoy Samlanh Samlei Samlout Sampong Chey Sampou Lun Sampov Lun Samprouch Samraong Samraong Samraong Samraong Samraong Samraong Samraong Samraong Samraong Samraong Samraong Knong Samraong Kraom Samraong Kraom Samraong Leu Samraong Leu Samraong Saen Samraong Thum Samraong Tong Samraong Yea Samrong Samyaong San Kor Sandaek Sandan Sandan Sandar Sangkae Sangkae Muoy Sangkae Pir Sangkae Satob Sangkat Bei Sangkat Buon Sangkat Muoy Sangkat Pir Sangkhoar Sangvaeuy Sanlung Sanlung Santepheap Santepheap Santreae Saob Saom Saom Thum Sarh Ruessei Sarikakaev Sarongk Sasar Sdam Satv Pong Sdach Kong Khang Cheung Sdach Kong Khang Lech Sdach Kong Khang Tboung Sdaeung Chey Sdau Sdau Sdau Sdau Sdau Kaong Sdok Sdok Pravoek Seang Khveang Seda Seda Sedthei Seena Reach Otdam Sekong Serei Maen Cheay Serei Mongkol Sesant Setbou Seung Siem Bouk Siem Reab Siem Reab Sithor Skuh Sla Sla Kaet Sla Kram Sla Kram Slaeng Spean Smach Mean Chey Smaong Smaong Cheung Smaong Tboung Sna Ansa Snam Krapeu Snam Preah Snao Snao Snay Anhchet Snoeng Snuol Snuol Sochet Soea Soeng Soengh Sokh Dom Sokh Sant Sopoar Tep Sou Young Soupheas Souphi Souphi Sour Kong Sour Saen Soutip Spean Mean Chey Spean Sraeng Spean Thma Spean Tnaot Spueu Spueu Ka Spueu Kha Srae Ambel Srae Ampum Srae Angkrong Srae Chaeng Srae Char Srae Chea Khang Cheung Srae Chea Khang Tboung Srae Chhuk Srae Chis Srae Huy Srae Khtum Srae Khvav Srae Knong Srae Kor Srae Krasang Srae Nouy Srae Preah Srae Ronoung Srae Ruessei Srae Sambour Srae Samraong Srae Sangkom Srae Sdok Srae Thmei Sraeung Srah Chak Srah Chik Srah Reang Srak Sralab Sralau Srama Sranal Srang Srangae Srangae Srangae Srayang Srayov Sro Em Stueng Chhay Stueng Chhay Stueng Kach Stueng Kaev Stueng Mean Chey Stueng Traeng Stueng Trang Stueng Veaeng Sung Suong Svay Svay Ampear Svay Angk Svay Antor Svay at Svay Chacheb Svay Chek Svay Chek Svay Chek Svay Chreah Svay Chrum Svay Chrum Svay Chrum Svay Chrum Svay Chuk Svay Dangkum Svay Doun Kaev Svay Khleang Svay Kravan Svay Leu Svay Luong Svay Pak Svay Pao Svay Phleung Svay Phluoh Svay Pou Svay Prateal Svay Rieng Svay Rolum Svay Romiet Svay Rumpea Svay Rumpea Svay Rumpear Svay sa Svay Sa Svay Sach Phnum Svay Ta Yean Svay Teab Svay Thum Svay Toea Svay Tong Khang Cheung Svay Tong Khang Tboung Svay Yea Sya Ta Aek Ta an Ta Ang Ta Baen Ta Ches Ta Kaen Ta Kao Ta Kdol Ta Khmau Ta Kong Ta Krai Ta Kream Ta Lam Ta Lat Ta Lav Ta Loas Ta Lon Ta Lou Ta Mau Ta Meun Ta Nuon Ta Ong Ta Ou Ta Phem Ta Phou Ta Pon Ta Prok Ta Pung Ta Saen Ta Sal Ta Sanh Ta Saom Ta Sda Ta Siem Ta Suos Ta Tai Kraom Ta Taok Ta Tey Leu Ta Veaeng Kraom Ta Veaeng Leu Ta Yaek Tang Doung Tang Krang Tang Krasang Tang Krasang Tang Krasang Tang Krasau Tang Krouch Tang Samraong Tang Sya Tang Yab Tani Tasu Tbaeng Tbaeng Tbaeng Tbaeng Khpos Tboung Krapeu Tean Kam Thala Borivath Theay Thipakdei Thkov Thlat Thlea Prachum Thlok Thlok Thlok Vien Thma Andaeuk Thma Da Thma Edth Thma Kaev Thma Kor Thma Kreae Thma Pechr Thma Pun Thma Pun Thma Puok Thma Sa Thmea Thmei Thmei Thmei Thmei Thmei Thmor Donpove Thna Thnong Thommoda Ar Ti Pou Tien Ting Chak Tnaot Tnaot Tnaot Tnaot Chong Srang Tnaot Chum Tnaot Chum Toap Mean Toen Toeuk Tla Tong Rong Tong Tralach Tonle Basak Tonle Bet Tonlung Totung Toul Ampil Toul Khpos Toul Sala Trab Trâbêk Trach Tong Traeng Traeng Trayueng Traeuy Kaoh Traeuy Sla Tralach Tram Kak Tram Sasar Tramaeng Tramung Trang Trangel Trapeang Bei Trapeang Chan Trapeang Chong Trapeang Chour Trapeang Chres Trapeang Kong Trapeang Kor Trapeang Kraham Trapeang Kranhung Trapeang krasang Trapeang Krasang Trapeang Phlong Trapeang Plang Trapeang Prasat Trapeang Preah Trapeang Prei Trapeang Pring Trapeang Pring Trapeang Reang Trapeang Ruessei Trapeang Rung Trapeang Sab Trapeang Sala Khang Kaeut Trapeang Sala Khang Lech Trapeang sangkae Trapeang Sdau Trapeang Srae Trapeang Tav Trapeang Thum Trapeang Thum Trapeang Thum Khang Cheung Trapeang Thum Khang Tboung Trapeang Veaeng Tras Trea Trea Trea Trea Treak Treal Trean Treas Trei Nhoar Tuek Chour Tuek Chrov Tuek Hout Tuek Khleang Tuek Kraham Tuek L'ak Tuek L'ak Tuek L'ak Bei Tuek L'ak Muoy Tuek L'ak Pir Tuek Thla Tuek Thla Tuek Thla Tuek Vil Tuek Vil Tuk Meas Khang Kaeut Tuk Meas Khang Lech Tum Ring Tumnob Tumnob Dach Tumnob Rolok Tumnob Thum Tumnob Tuek Tumpoar Meas Tuol Kokir Leu Tuol Kreul Tuol Lvea Tuol Pongro Tuol Preah Khleang Tuol Prech Tuol Sambuor Tuol Sangkae Tuol Sdei Tuol Snuol Tuol Sophi Tuol Svay Prey Muoy Tuol Svay Prey Pir Tuol Ta Aek Tuol Toetueng Tuol Tumpung Muoy Tuol Tumpung Pir Varin Veal Veal Veal Mlu Veal Pon Veal Pung Veal Renh Veal Sbov Veal Vong Veal Vong Veang Chas Veun Sai Vihear Luong Vihear Luong Vihear Suork Vihear Thum Voa Sa Voadthonak Voat Angk Khang Cheung Voat Angk Khang Tboung Voat Kor Voat Phnum Voat Ta Muem Ya Tung Yea Angk Yeak Laom Yeang Yeang Yhmea Yutth Sameakki

Diagnosis Information
Diagnosis	:		Category	:		Location:

Contact Information
Contact Name	:		Contact Number	:		Email	:		Note	:

Document Information
Photo	:		Delete
Photo Labo Imagine Anapath Other

Patient IPD
Date In:                      Date Out:                      Remark:

Surgery Information
Surgery 1	Procedure:	Paraclinic Confirmed:	Date:
	Medicine:
	Protocol:

Follow Up

2020-07-07

Date :       BP : /       Puls : 60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160        T° : 3232.53333.53434.53535.53636.53737.53838.53939.54040.54141.542       RR :       Call Transfer Finished Appointment Important Follow up

Consult

2020-07-08

Date :       BP : /       Puls : 60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160        T° : 3232.53333.53434.53535.53636.53737.53838.53939.54040.54141.542       RR :       Call Transfer Finished Appointment Important Follow up

OP

2020-08-12

Date :       BP : /       Puls : 60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160        T° : 3232.53333.53434.53535.53636.53737.53838.53939.54040.54141.542       RR :       Call Transfer Finished Appointment Important Follow up

Consul

2021-01-08

Date :       BP : /       Puls : 60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160        T° : 3232.53333.53434.53535.53636.53737.53838.53939.54040.54141.542       RR :       Call Transfer Finished Appointment Important Follow up

Consult

2021-01-12

Date :       BP : /       Puls : 60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160        T° : 3232.53333.53434.53535.53636.53737.53838.53939.54040.54141.542       RR :       Call Transfer Finished Appointment Important Follow up

Follow up

2021-01-13

Date :       BP : /       Puls : 60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160        T° : 3232.53333.53434.53535.53636.53737.53838.53939.54040.54141.542       RR :       Call Transfer Finished Appointment Important Follow up

Follow up

2021-01-15

Date :       BP : /       Puls : 60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160        T° : 3232.53333.53434.53535.53636.53737.53838.53939.54040.54141.542       RR :       Call Transfer Finished Appointment Important Follow up

Follow up

2021-01-22

Date :       BP : /       Puls : 60616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160        T° : 3232.53333.53434.53535.53636.53737.53838.53939.54040.54141.542       RR :       Call Transfer Finished Appointment Important Follow up

Follow up