KLINIK DOKTER KELUARGA

FAKULTAS KEDOKTERAN
UNIV. MUHAMMADIYAH PALEMBANG

KARTU BEROBAT
CATATAN MEDIS USIA LANJUT
No. ..... / ..... / ..... / 20...
Nama Pasien
TTL
Umur

: ....................................................................................................................... (L/P)
: .....................................................................................................................................
: ................................ Tahun

Nama Kepala Keluarga : ...........................................................................................................................

Alamat
: ...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
Kunjungan I

: Umum Gigi KIA/KB

Tindakan Lab

INFORMASI PERSONAL
Status perkawinan :
Lajang
Menikah
Cerai Mati
Cerai Hidup
Pisah
Pendidikan :
Buta huruf
Tidak Tamat SD
Tidak Tamat SMP
Tidak Tamat SMA
Perguruan Tinggi
Pekerjaan:
Tidak Bekerja
Pelajar/Mahasiswa
Buruh
Agama :
Islam
Katolik
Prostestan
Hindu

Tamat SD
Tamat SMP
Tamat SMA

Pegawai Swasta
Pegawai BUMN
Polri/ABRI

Pegawai Negeri
Pensiunan
Lainnya ..................................................

 Budha
Lainnya ..................................................................
Suku bangsa :
Melayu
Sunda
Batak
Jawa
Minang
Lainnya ................................................................
CATATAN KHUSUS
Riwayat penyakit dahulu :
Di rawat di RS, Alasan : .................................................................................................................
Tanggal rawat : .....................................................................................................
Di operasi,

Alasan : .................................................................................................................
Tanggal operasi : ..................................................................................................

Riwayat penyakit keluarga :

1. Penyakit keturunan :
DM
Jantung
Hipertensi
Astma

Lainnya ...................................................................................................................................................
..............
2. Penyakit tersering :
.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
Faktor risiko (alergi ) :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Masalah sosial yang berat dalam keluarga :
......................................................................................................................................................................
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PEMERIKSAAN FISIK PERTAMA
BB
TB
TD

: ................................. kg
: ................................. cm
: ................................. mmHg

No.

Tanggal

SOAP

Diagnosis
(ICD)

Terapi

Pemeriksa
(TTD)

No.

Tanggal

SOAP

Diagnosis
(ICD)

Terapi

Pemeriksa
(TTD)