HASIL PEMERIKSAAN KESEHATAN

I. GENERAL DATA / DATA PRIBADI

Name : ……………………………………………..
Age : ……………………………………………..
Sex : ……………………………………………..
Address : ……………………………………………..

II. PERSONAL MEDICAL INFORMATION

1). a. Allergic to : ……………………………………………..

b. social Habits / Kebiasaan

(i) Smoking ……………… Yes No ( No. Of cigarettes per day __________ )
(ii) Alcoholic Beverages … Yes No
Social Reguler Heavy

c. On medication/ Drugs/ Obat …….. Yes No

For ( i ) Hypertension
( ii ) Epilepsy
( iii ) Diabetes Mellitus
( iv ) Bronchia Astma
( v ) Others

2). IMMUNIZATION / IMMUNISASI

Tetanus Yes No Comment / Komentar

Hepatitis B Yes No _____________________
Rubella in female only Yes No _____________________
Poliomyelitis Yes No _____________________

3). CHRONIC ILLNESS (DISEASES) PENYAKIT KRONIS

“ Are yoy presenttly suffering from of the following conditions ?
Apakah anda menderita penyakit dibawah ini ?
Comment / Komentar
Cerebral Vascular Accident (CVA) Yes No On Treatment ____________________
Heart Disease Yes No On Treatment ____________________
Hypertension Yes No On Treatment ____________________
Bronchial Asthma Yes No On Treatment ____________________
Peptic Ulcer Yes No On Treatment ____________________
Diabetes Mellitus Yes No On Treatment ____________________
Rheumatism Yes No On Treatment ____________________
Kidney Disease Yes No On Treatment ____________________
Epilepsy Yes No On Treatment ____________________
Pulmonary Tuberculosis Yes No On Treatment ____________________
Cataracts Yes No On Treatment ____________________
Ear Discharge/ OMP Yes No On Treatment ____________________
Piles/ Ambeien Yes No On Treatment ____________________
Hernia/ Usus turun Yes No On Treatment ____________________
Recurent Epistaxis/ Mimisan Yes No On Treatment ____________________
Vertigo/ pening Yes No On Treatment ____________________
Chronic Backage Yes No On Treatment ____________________
Any signs Anemia Yes No On Treatment ____________________
4). FEMALE ONLY / WANITA SAJA
Marital Status
Sigle Married
No. of Children ________
Last Menstrual Period ________

II. PHYSICAL MEDICAL EXAMINATION FINDINGS/ PEMERIKSAAN FISIK

( i ) GENERAL APPEREANCE/ KEADAAN UMUM

Baik Sedang Buruk
- Tinggi ________ cm
- Berat Badan ________ kg Tetap Bertambah Berkurang
- Nadi ________ x/menit Kuat Lemah
Teratur Tidak Teratur

- Blood Pressure (mmHg)/ Tekanan Darah

Sistolic ___________ mmHg
Diastolic ___________ mmHg

( ii ) EXAMINATION OF HEAD/ KEPALA

EYES Comment / Komentar
- Pupils ( Equal and reactive to light ) Normal Abnormal __________________
- Cataract Normal Abnormal __________________
- Visual Acuity Normal Abnormal __________________
- Without Glasses / Contact Lens Normal Abnormal __________________
- With Glasses / Contact Lens Normal Abnormal __________________
- Myopia ( Short – Sightedness ) Normal Abnormal __________________
- Conjunctiva Normal Abnormal __________________
- Colour Blindess Normal Abnormal __________________

NOSE / HIDUNG
- Nasal Mucosa Normal Abnormal __________________
- Lain-lain __________________

TEARS / TELINGA
- Ears Drums ( intact / perforated ) Normal Abnormal __________________

( iii ) EXAMINTAION OF THE NECK / LEHER

Comment / Komentar
- Thyroid Gland Normal Abnormal __________________
- Jugular Gland Normal Abnormal __________________

( iv ) EXAMINATION OF THE CHEST/ DADA

CHEST – CAGE ( i ) Shape Normal Abnormal __________________
( ii ) Movement Normal Abnormal __________________
Action Findings Comment / Komentar
Palpation Normal Abnormal __________________
Percussion Normal Abnormal __________________
Auscultation Normal Abnormal __________________

( v ) EXAMINATION OF THE ABDOMEN/ PERUT

Organs Findings Comment / Komentar
Stomach Normal Abnormal __________________
Liver Normal Abnormal __________________
 Spleen Normal Abnormal __________________
Kidneys Normal Abnormal __________________
Hernial Orifices Normal Abnormal __________________

IV. INVESTIGATIONS

Tgl. Pemeriksaan : …………………………. Kode Lab : ……………….

Haematologi Urinalisa Liver Function Test

- Haemoglobin ………… gr % Colour ………… Indirect. Bil ………. mg/dl
- Leucocyt ………… /ul Glucose ………… Direct. Bil …….. mg/dl
- Eritrocyt ………… /ul Protein ………… SGOT ……… U/L
- Trombocyt ………… /ul Blood ………… SGPT ………. U/L
- Hematocrit ………… % Turbidity ………… HbsAg ………..
- BSR ……… mm/jam PH ………… anti HBS ………..

V. KESIMPULAN
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VI. SARAN
…………………………………………………………………………………………………
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Best regads,

( Dr. ……………………………….. )
Balai Pengobatan Andema