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YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN


PRORAM STUDI S1 KESEHATAN MASYARAKAT
Jalan Beliang No. 110 Palangka Raya Telp. (0536) 3227707
Email: stikesekaharap110@yahoo.com

Tanggal Pengkajian :

Pukul pengkajian :

A. Identitas Pasien
Nama : .....................................................................................
Umur : .....................................................................................
Jenis Kelamin : .....................................................................................
Suku/Bangsa : .....................................................................................
Agama : .....................................................................................
Pekerjaan : .....................................................................................
Pendidikan Terakhir : .....................................................................................
Alamat : .....................................................................................
Gol Darah : .....................................................................................
Jumlah Anggota
Keluarga (Dalam Rumah) : .....................................................................................

B. Riwayat Kesehatan
1. Riwayat Penyakit Sekarang
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2. Riwayat Penyakit Sebelumnya
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3. Keluhan yang Dirasakan Saat Ini


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4. Riwayat Kesehata Keluarga


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