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    Formulir Bantu Haji New

    Uploaded by

    Sri Gani Rahayu

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    FORMULIR BANTU

    PEMERIKSAAN KESEHATAN DI UPTD PUSKESMAS GUMURUH

    NAMA JEMAAH HAJI : …………………………………………………………………………...........


    JENIS KELAMIN : …………………………………………………………………………………….
    TTL : ……………………………………………………………………………………. PAS
    ALAMAT : ……………………………………………………………………………………. PHOTO
    NOMOR PORSI : …………………………………………………………………………………….
    A. FAKTOR RESIKO JEMAAH HAJI
     MEROKOK : YA TDK
     KURANG AKTIFITAS FISIK : YA TDK
     MENGGUNAKAN ALAT BANTU : YA TDK
    (MIS : KACAMATA, TONGKAT, HEARING AID, DLL)
     …………………………………………… : YA TDK

    B. RIWAYAT KESEHATAN 5. KEPALA


    1. RIWAYAT KESEHATAN SEKARANG * INSPEKSI (TERMASUK BENTUK, SIMETRISASI) :
     ……………………………………………………………………….. ………………………………………………………………………..
     ……………………………………………………………………….. ………………………………………………………………………..
     ……………………………………………………………………….. * PEMERIKSAAN SYARAF KRANIAL :
    2. RIWAYAT KESEHATAN DAHULU ………………………………………………………………………..
     ……………………………………………………………………….. ………………………………………………………………………..
     ……………………………………………………………………….. ………………………………………………………………………..
     ……………………………………………………………………….. * MATA : ………………………………………………………….
    3. RIWAYAT PENYAKIT KELLUARGA ………………………………………………………………………..
     ……………………………………………………………………….. * TELINGA : ……………………………………………………….
     ……………………………………………………………………….. ………………………………………………………………………..
     ……………………………………………………………………….. * HIDUNG : ……………………………………………………….
    ……………………………………………………………………….
    C. PEMERIKSAAN FISIK * TENGGOROKAN DAN MULUT : …………………….
    1. KESADARAN : ……………………………………………….. ………………………………………………………………………
    2. TANDA VITAL
     TD = ……………………………………………………………… 6. LEHER
     NADI = FREKUENSI ……………….…………..X/MNT * INSPEKSI : …………………………………………………….
    VOLUME : KECIL/CUKUP/BESAR ……………………………………………………………………..
    RITME : REGULER/IREGULER * PALPASI : ……………………………………………………..
     NAFAS = FREKUENSI ………………………...X/MNT ………………………………………………………………………
    VOLUME : DANGKAL/CUKUP/DALAM 7. KELENJAR DAN PEMBULUH GETAH BENING :
     SUHU TUBUH : …………………………..®C * INSPEKSI : …………………………………………………….
    3. POSTUR ………………………………………………………………………
     BENTUK : PROPORSIONAL/TIDAK PROPORSIONAL * PALPASI : ……………………………………………………..
     IMT : ………………………………… ……………………………………………………………………..
    TB : ………………………… CM 8. DADA
    BB : ……………………….. KG * UMUM DAN PARU
     RASIO LPP - INSPEKSI : ………………………………………………..
    LINGKAR PINGGANG : ………………………. CM ………………………………………………………………….
    LINGKAR PANGGUL : ……………………….. CM - PALPASI : ………………………………………………….
    4. KULIT ………………………………………………………………….
     INSPEKSI : ………………………………………………….. - PERKUSI : …………………………………………………
    ……………………………………………………………………. ………………………………………………………………….
     PALPASI : ………………………………………………….. - AUSKULTASI : …………………………………………..
    …………………………………………………………………… ………………………………………………………………….
     JANTUNG D. PEMERIKSAAN PENUNJANG
    - INSPEKSI : ……………………………………………. * DARAH
    …………………………………………………………….. - HB : ……………………………
    - PALPASI : …………………………………………….. – LED : …………………………...
    …………………………………………………………….. – LEUKOSIT : ……………………………
    - PERKUSI : …………………………………………….. – HIT JENIS LEUKOSIT : ………../………/……….
    …………………………………………………………….. – GOL DARAH : A/B/O/AB RH + / -
    - AUSKULTASI : ……………………………………… - KOLESTEROL LDL : …………………………….
    …………………………………………………………….. – GULA SEWAKTU : …………………………….
    9. PERUT (SEMUA ORGAN DALAM PERUT) - PEMERIKSAAN DARAH LAIN ATAS INDIKASI :
    * INSPEKSI : …………………………………………………... …………………………………………………………………….
    …………………………………………………………………….. …………………………………………………………………….
     PALPASI : …………………………………………………… * URINE
    …………………………………………………………………… - MAKROSKOPIS : ……………………………………………
     PERKUSI : ………………………………………………….. ……………………………………………………………………….
    …………………………………………………………………… - MIKROSKOPIS : .…………………………………………..
     AUSKULTASI : ……………………………………………. ………………..……………………………………………………
    …………………………………………………………………… ………………………………………………………………………
    10. EKSTREMITAS - GLUKOSA URINE : ……………………..................
    * INSPEKSI : ………………………………………………….. – PROTEIN URINE : ………………………………………..
    ……………………………………………………………………. ………………………………………………………………………
     PALPASI : …………………………………………………… - TEST KEHAMILAN : POSITIF / NEGATIF
    …………………………………………………………………… (TGL/BLN/THN : …………./…………./………….)
     KEKUATAN OTOT : ……………………………………. – PEMERIKSAAN URINE LAIN ATAS INDIKASI :
    ………………………………………………………………….. ……………………………………………………………………
     REFLEKS : …………………………………………………… ……………………………………………………………………
    …………………………………………………………………… * EKG : (TULISAN PENILAIAN DAN LAMPIRAN)
    11. REKTUM DAN UROGENITAL ……………………………………………………………………..
    * TRAKTUS URINARIUS ……………………………………………………………………..
    - INSPEKSI : …………………………………………………. ……………………………………………………………………..
    …………………………………………………………………… * PENCITRAAN RADIOLOGI / USG
    -PALPASI : …………………………………………………… ……………………………………………………………………
    ……………………………………………………………………. …………………………………………………………………..
     GENITALIA .....………………………………………………………………
    -INSPEKSI : ………………………………………………. E. DIAGNOSA
    ………………………………………………………………... 1. ………………………………….... KODE ……………………
    -PALPASI : ……………………………………………….. 2. ……………………………………. KODE …………………...
    ………………………………………………………………… 3. ……………………………………. KODE …………………….
     REKTUM 4. ……………………………………. KODE …………………….
    -INSPEKSI : ………………………………………………. F. KESIMPULAN
    ……………………………………………………………….. 1. KATEGORI : MANDIRI / OBSERVASI /
    -PALPASI : ……………………………………………….. PENGAWASAN / TUNDA
    ……………………………………………………………….. 2. SARAN / ANJURAN :
    D. PEMERIKSAAN JIWA - ……………………………………………………………………
    1. KELUHAN SOMATIK TANPA KELAINAN ORGANIK - ……………………………………………………………………
    ………………………………………………………………… - ……………………………………………………………………
    ………………………………………………………………… - ……………………………………………………………………
    2. KELUHAN PSIKOSOMATIK
    ……………………………………………………………….. BANDUNG, ………………………………..
    ……………………………………………………………….. DOKTER PEMERIKSA
    3. KELUHAN MENTAL EMOSIONAL
    ………………………………………………………………..
    ……………………………………………………………….. dr. ……………………………………………..
    ……………………………………………………………….. NIP. …………………………………………..

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