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Form Resume Medical Formulir Tes F
Penjaringan Check Up Kesehatan C
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FORMULIR BANTU PEMERIKSAAN KESEHAT

haji i (PERTAMA)
NAMA JEMAAH HAJI : .......................................................................................
JENIS KELAMIN : ........................................................................................
TEMPAT/TGLLAHIR : ........................................................................................
ALAMAT : ......................... .......................... ............................ .........
PEKERJAAN : ......................... .......................... ............................ .........
NO.REGISTER PUSKESMAS : ........................................................................................
NO.BUKU : ........................................................................................

A.FAKTOR RESIKO JEMAAH HAJI

1. .................................................................. 6. .......................................................
2. .................................................................. 7. .......................................................
3. .................................................................. 8. .......................................................
4. .................................................................. 9. .......................................................
5. .................................................................. 10. .......................................................

B.RIWAYAT KESEHATAN

1. Riwayat Kese ata! Se"a#a!$

a. .......................................................... d. ..................................................
b. .......................................................... e. ...................................................
c. .......................................................... f. ...................................................

%. Riwayat Pe!ya"it &a '(' ) RP& * +. Riwayat Pe!ya"it Ke('a#$a ) RPK

a. .......................................................... a. ...................................................
b. .......................................................... b. ...................................................
c. .......................................................... c. ...................................................
d. .......................................................... e. ...................................................
,.PEMERIKSAAN FISIK

1. Kesa-a#a!
%. Ta!-a ita(
a. Tekanan darah
• Sistol
mm
• !iastol
mm

b. "adi
• #rek$ensi .............................................................................................. kal
• &si :c$k$'%k$ran
• Te an an : k$at % c$k$' % lemah
• (itme : ........................................................................
c. "a'as
#rek$ensi .............................................................................................. kal
•

• (itme : .........................................................................
d. S$h$ ......................................................................................... o)
+. P0st'#
a. *ent$k % +abit$s : ... . . ... . . . ... . . . ... . . . ... . . . ... . . . ... . . . ... .
b. &,T - &ndeks ,assa T$b$h : ..................................................................
• Tin i *adan -T* : ..................................................................
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form pemeriksaan kesehatan haji

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Uploaded by Nurinayah Taibien

form pemeriksaan kesehatan haji Full description

Form Resume Medical Formulir Tes F
Penjaringan Check Up Kesehatan C
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c. (asio / : ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• /in kar in an : ..................................................................
• /in kar 'in $l : ..................................................................
.
K'(it
a. &ns'eksi : ...........................................................................................
b. al'asi : ...........................................................................................
2. Ke3a(a
a. &ns'eksi -termas$k bent$k simetrisitas : ...........................................
b. emeriksaan saraf kranial : ...................................................................
c. ,ata : .......................................................................................................
d. Telin a: .......................................................................................................
e. +id$n : .......................................................................................................
f. Ten orokan dan m$l$t : ...................................................................
4. Le e#
a. &ns'eksi : ...........................................................................................
b. al'asi : ...........................................................................................
5. Ke(e!6a# - a! 3e78'(' $eta 8e!i!$
a. &ns'eksi : ...........................................................................................
b. al'asi : ...........................................................................................
9. &a-a
a. m$m
• &ns'eksi : ...............................................................................
• al'asi : ...............................................................................
• erk$si : ...............................................................................
• $sk$ltasi : ...............................................................................
b. ant$n
• &ns'eksi : ...............................................................................
• al'asi : ...............................................................................
• erk$si : ...............................................................................
• $sk$ltasi : ...............................................................................
c. ar$
• &ns'eksi : ...............................................................................
• al'asi : ...............................................................................
• erk$si : ...............................................................................
• $sk$ltasi : ...............................................................................
:. Pe#'t ) 7e(i3'ti se7'a 0#$a! ----------- a(a7 *
a. m$m
• &ns'eksi : ...............................................................................
• al'asi : ...............................................................................
• erk$si : ...............................................................................
• $sk$ltasi : ...............................................................................
b. Sistem h$s$s
• +ati - /i er : ...............................................................................
• /im'a -s'leen : ................................................................................
1;.E"st#e7itas
a. &ns'eksi -termas$k bent$k simetrisitas : ............................................
b. al'asi : ...........................................................................................
c. ek$atan otot : ...........................................................................................
...........................................................................................
d. (efleks : ...........................................................................................
11. Re"t'7 --- a! U#0$e!ita(
a. m$m
• &ns'eksi : ...............................................................................
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form pemeriksaan kesehatan haji

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form pemeriksaan kesehatan haji Full description

Form Resume Medical Formulir Tes F
Penjaringan Check Up Kesehatan C
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b. Sistem h$s$s
• Sistem (e'rod$ksi : ...................................................................
• Sistem emih : ...................................................................

E.P EMERIKSAAN

PENUNJANG 1.

La80#at0#i'7
a. &a#a
• okok :
- +emo lobin -+b : .......................................................
- /a $ nda' !arah -/ ! : .......................................................
- $mlah le$kosit : .......................................................
- +it$n enis le$kosit : .......................................................
- olon an darah: %*% % * : (+ : -; % -------- <
• /an $t :
- $la !arah Se=akt$ - !S : ...........................................
- olesterol -/!/ : ... . . . . . . . . . . . . . . . . . . . .
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
8. U#i!e
okok :•

- ,akrosko'is
enilaian : ...................................................................
/am'iran hasil : ...................................................................
- ,ikrosko'is
enilaian : ...................................................................
/am'iran hasil : ...................................................................
- l$kosa rin
enilaian : ...................................................................
/am'iran hasil : ...................................................................
- rotein rin
enilaian : ...................................................................
/am'iran hasil : ...................................................................
• /an $t
- Tes ehamilan : os % "e T l : ...............................................
<. K 's's )se8't"a! 6e!is 3e7e#i"saa!!ya*
: ...................................................................................................................
...
%. E(e"t#0 Ka#-i0 G#a=i )EKG*
a. /an $t -istirahat :
enilaian - didam'in i hasil 'emeriksaan : ...............................................
b. h$s$s :
enilaian - didam'in i hasil 'emeriksaan : ...............................................
+. Ra-i0(0$i ) (a73i#"a! asi( 3e78a<aa! R0 *
a. /an $t Thoraks< :
enilaian -didam'in i hasil 'emeriksaan : .................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
b. h$s$s :
 3 0 RELATED TITLES
3.0K views

form pemeriksaan kesehatan haji

di puskesmas
Uploaded by Nurinayah Taibien

form pemeriksaan kesehatan haji Full description

Form Resume Medical Formulir Tes F
Penjaringan Check Up Kesehatan C
Save Embed Share Print

.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

. Ba#t e( I!-e"s )BAI* ) '!t'" > 4; t ! *

a. Skore : ...........................................................................................
b. eteran an : ...........................................................................................
.......................................................................................................................
2. Tes Ke8'$a#a! ) '!t'" 3e!-a73i!$ 6e7aa *
a. ,etode : ...........................................................................................
b. "ilai : ...........................................................................................

F.&IAGNOSA

1. ... . . ... . . . . ... . . . ... . . . ... . . . ... . . . ... . . . ... . . ode : ... ... . . . ... .
2. ... . . ... . . . . ... . . . ... . . . ... . . . ... . . . ... . . . ... . . ode : ... ... . . . ... .
3. ... . . ... . . . . ... . . . ... . . . ... . . . ... . . . ... . . . ... . . ode : ... ... . . . ... .
4. ... . . ... . . . . ... . . . ... . . . ... . . . ... . . . ... . . . ... . . ode : ... ... . . . ... .
5. ... . . ... . . . . ... . . . ... . . . ... . . . ... . . . ... . . . ... . . ode : ... ... . . . ... .
6. ... . . ... . . . . ... . . . ... . . . ... . . . ... . . . ... . . . ... . . ode : ... . ... . . . ...
G.KESIMPULAN

1. Kate$0#i Ma!-i#i/O8se#?asi/Pe!$awasa!/T'!-a
%. Sa#a!/A!6'#a!
a. ................................................ ....................................................... ...............
b. ......................................................................................................................
c. ................................................ ....................................................... ...............
d. ......................................................................................................................
e. ................................................ ....................................................... ...............
f. ................................................ ....................................................... ...............

4X6 ..................................
!okter 'emeriksa