KLINIK ABAH NOMOR IZIN : 441 / DPMTSP – KL / 129 / 2017

Jl. Medan ˗ Banda Aceh, Bukit Rata, Kejuruan Muda, Aceh Tamiang
Kode Pos 24477, HP 081360208556, Email: klinikabah@gmail.com

FORMULIR PEMERIKSAAN KESEHATAN KLINIK ABAH

NAMA : .......................................................................................................
JENIS KELAMIN : ..............................................................................................
TEMPAT/TGL LAHIR : ..............................................................................................
ALAMAT : .............................................................................................
PEKERJAAN : ..............................................................................................
NO.REGISTER : ..............................................................................................

A.FAKTOR RESIKO
1. .................................................................. 6. ................................................................
2. .................................................................. 7. ................................................................
3. .................................................................. 8. ................................................................
4. .................................................................. 9. ................................................................
5. .................................................................. 10. ................................................................

B.RIWAYAT KESEHATAN
1. Riwayat Kesehatan Sekarang
a. ..........................................................
b. ..........................................................
c. ..........................................................
d. ...........................................................
e. ...........................................................
f. ............................................................

2. Riwayat Penyakit Dahulu ( RPD ) 3. Riwayat Penyakit Keluarga ( RPK )

a. .......................................................... a. ............................................................
b. .......................................................... b. ............................................................
c. .......................................................... c. ............................................................
d. .......................................................... e. ............................................................
C.PEMERIKSAAN FISIK
1. Kesadaran :
2. Tanda Vital :
a. Tekanan darah
 Sistol : .........................................................................mmhg
 Diastol : .........................................................................mmhg

b. Nadi
 Frekuensi : .........................................................................kali/menit
 Isi : cukup / kurang
 Tegangan : kuat / cukup / lemah
 Ritme : ........................................................................
c. Napas
 Frekuensi : .........................................................................kali/menit
 Ritme : .........................................................................
 KLINIK ABAH NOMOR IZIN : 441 / DPMTSP – KL / 129 / 2017
Jl. Medan ˗ Banda Aceh, Bukit Rata, Kejuruan Muda, Aceh Tamiang
Kode Pos 24477, HP 081360208556, Email: klinikabah@gmail.com

d. Suhu : .........................................................................oC
3. Postur
a. Bentuk / Habitus : ........................................................................
b. IMT ( Indeks Massa Tubuh ) : ........................................................................
 Tinggi Badan (TB) : ........................................................................cm
 Berat Badan (BB) : ........................................................................kg
c. Rasio LPP : ........................................................................
 Lingkar Pinggang : ........................................................................cm
 Lingkar pinggul : ........................................................................cm
4. Kulit
a. Inspeksi : .......................................................................................................
b. Palpasi : ........................................................................................................
5. Kepala
a. Inspeksi (termasuk bentuk,simetrisitas) : ........................................................
b. Pemeriksaan saraf kranial : ................................................................................
c. Mata : ....................................................................................................................
d. Telinga: ...................................................................................................................
e. Hidung: ...................................................................................................................
f. Tenggorokan dan mulut : ................................................................................
6. Leher
a. Inspeksi : .......................................................................................................
b. Palpasi : .......................................................................................................
7. Kelenjar dan pembuluh getah bening
a. Inspeksi : .......................................................................................................
b. Palpasi : ........................................................................................................
8. Dada
a. Umum
 Inspeksi : ............................................................................................
 Palpasi : ............................................................................................
 Perkusi : ...........................................................................................
 Auskultasi : ............................................................................................
b. Jantung
 Inspeksi : ............................................................................................
 Palpasi : ............................................................................................
 Perkusi : ............................................................................................
 Auskultasi : ............................................................................................
 KLINIK ABAH NOMOR IZIN : 441 / DPMTSP – KL / 129 / 2017
Jl. Medan ˗ Banda Aceh, Bukit Rata, Kejuruan Muda, Aceh Tamiang
Kode Pos 24477, HP 081360208556, Email: klinikabah@gmail.com

c. Paru
 Inspeksi : ............................................................................................
 Palpasi : ............................................................................................
 Perkusi : ............................................................................................
 Auskultasi : ............................................................................................

9. Perut ( meliputi semua organ dalam )

a. Umum
 Inspeksi : ............................................................................................
 Palpasi : ............................................................................................
 Perkusi : ............................................................................................
 Auskultasi : ............................................................................................
b. Sistem Khusus
 Hati ( Liver ) : ............................................................................................
 Limpa (spleen): .............................................................................................
10. Ekstremitas
a. Inspeksi (termasuk bentuk,simetrisitas) : .........................................................
b. Palpasi : ........................................................................................................
c. Kekuatan otot : ........................................................................................................
........................................................................................................
d. Refleks : ........................................................................................................
11. Rektum dan Urogenital
a. Umum
 Inspeksi : ............................................................................................
 Palpasi (termasuk colok dubur): ..................................................................
b. Sistem Khusus
 Sistem Reproduksi : ................................................................................
 Sistem Kemih : ................................................................................

E.PEMERIKSAAN PENUNJANG
1. Laboratorium
a. Darah
 Pokok :
- Hemoglobin (Hb) : ....................................................................
- Laju Endap Darah (LED) : ....................................................................
 KLINIK ABAH NOMOR IZIN : 441 / DPMTSP – KL / 129 / 2017
Jl. Medan ˗ Banda Aceh, Bukit Rata, Kejuruan Muda, Aceh Tamiang
Kode Pos 24477, HP 081360208556, Email: klinikabah@gmail.com

- Jumlah leukosit : ....................................................................

- Hitung jenis leukosit : ....................................................................
- Golongan darah: A/B/O/AB : RH : (+) / (-)
 Lanjut :
- Gula Darah Sewaktu (GDS) : ........................................................
- Kolesterol (LDL) : ........................................................
..................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..........................................................
b. Urine
 Pokok :
- Makroskopis
Penilaian : ................................................................................
Lampiran hasil : ................................................................................
- Mikroskopis
Penilaian : ................................................................................
Lampiran hasil : ................................................................................
- Glukosa Urin
Penilaian : ................................................................................
Lampiran hasil : ................................................................................
- Protein Urin
Penilaian : ................................................................................
Lampiran hasil : ................................................................................
 Lanjut
- Tes Kehamilan : Pos / Neg Tgl : ...........................................................
c. Khusus (sebutkan jenis pemeriksaannya) :
...................................................................................................................................
2. Elektro Kardio Grafi (EKG)
a. Lanjut (istirahat) :
Penilaian ( didampingi hasil pemeriksaan ): ...........................................................
b. Khusus :
Penilaian ( didampingi hasil pemeriksaan ): ............................................................
3. Radiologi ( lampirkan hasil pembacaan Ro )
 KLINIK ABAH NOMOR IZIN : 441 / DPMTSP – KL / 129 / 2017
Jl. Medan ˗ Banda Aceh, Bukit Rata, Kejuruan Muda, Aceh Tamiang
Kode Pos 24477, HP 081360208556, Email: klinikabah@gmail.com

a. Lanjut ( Thoraks-AP ):
Penilaian (didampingi hasil pemeriksaan): ..............................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
...................................................................................................................................
b. Khusus :
Penilaian (didampingi hasil pemeriksaan): .............................................................
..................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
..............................................

4. Barthel Indeks (BAI) ( untuk > 60 thn )

a. Skore : .......................................................................................................
b. Keterangan : .......................................................................................................
..................................................................................................................................
5. Tes Kebugaran
a. Metode : .......................................................................................................
b. Nilai : .......................................................................................................

F.DIAGNOSA

1. ...................................................................... Kode : ....................

2. ...................................................................... Kode : ....................
3. ...................................................................... Kode : ....................
4. ...................................................................... Kode : ....................
5. ..................................................................... Kode : ....................
6. ...................................................................... Kode : ....................
G.KESIMPULAN

Saran / Anjuran :

a. ..................................................................................................................................
b. ..................................................................................................................................
c. .................................................................................................................................
 KLINIK ABAH NOMOR IZIN : 441 / DPMTSP – KL / 129 / 2017
Jl. Medan ˗ Banda Aceh, Bukit Rata, Kejuruan Muda, Aceh Tamiang
Kode Pos 24477, HP 081360208556, Email: klinikabah@gmail.com

d. .................................................................................................................................
e. .................................................................................................................................
f. .................................................................................................................................

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Dokter pemeriksa