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KARTU STATUS DAN RENCANA PERAWATAN

RUMAH SAKIT GIGI DAN MULUT-PENDIDIKAN


FAKULTAS KEDOKTERAN GIGI
UNIVERSITAS AIRLANGGA
Tanggal :
Nama Pasien
Usia
Alamat Rumah
Alamat Kantor

: ........................................................
: ..................tahun
: ........................................................
: ........................................................

Kelamin
Pekerjaan
Telepon
Telepon

: L P
: .............................................
: .............................................
: .............................................

I. Anamnesis
1.1. Keluhan / keinginan
:
..........................................................................................................................................................
..........................................................................................................................................................
1.2. Riwayat gigi geligi
:
..........................................................................................................................................................
..........................................................................................................................................................
II. Intra Oral

Keterangan:

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