Home Visite Form Kosong
Home Visite Form Kosong
HALAMAN PERSETUJUAN
Laporan kunjungan rumah
Nama Penderita
Nomor Register
Alamat
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Nomor register
Umur
Jenis kelamin
Pendidikan
Status perkawinan
Alamat
Diagnosa
: (..... tahun)
No
Nama
Jenis
Kelamin
Umur
Pendidikan
Status
Pekerjaan
Keterangan
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
Menika
h/
................. /
Tidak
Sehat /
Sakit / ...............
L/
P / ............
...
..... th
L/
P / ............
...
..... th
L/
P / ............
...
..... th
L/
P / ............
..... th
2
...
L/
P / ............
...
..... th
L/
P / ............
...
..... th
L/
P / ............
...
..... th
L/
P / ............
...
..... th
L/
P / ............
...
..... th
10
L/
P / ............
...
..... th
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Tidak
Sekolah /
SD / SLTP /
SMU / S-1 /
S-2 / S3 / .................
..
Belum
Menika
h / .......
......
Bekerja
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
Menika
h/
Belum
Menika
h / .......
......
................. /
Tidak
Bekerja
Sehat /
Sakit / ...............
.........
.........
..........
..........
..........
..........
..........
Kunjungan
rumah
diterima
dengan
..........
Sewaktu hamil ibu penderita sedang / tidak sedang mengalami kelainan maupun
penyakit fisik.
B. Masa Natal
C. Masa Post-natal
Tumbuh kembang penderita seperti berdiri, berjalan, dan berbicara dalam batas normal
dan tidak ada kelainan / ada kelainan, yaitu ..............................
Saat bayi, balita, dan anak-anak penderita pernah / tidak pernah mengalami kejang,
panas, maupun penyakit serius.
D. Riwayat Pendidikan
Penderita
pernah
mengenyam
pendidikan
4
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...................................................................
E. Riwayat Sakit
Sebelum
tampak
mengalami
gangguan,
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V. FAKTOR HEREDITER
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penderita
termasuk
keluarga
yang............................................................................ .......................................................................
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6
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Untuk biaya pengobatan dan perawatan penderita di RS Jiwa Menur Surabaya, didapat
dari ....................................................................................................................................................
.......
IX. KEADAAN RUMAH DAN LINGKUNGAN
A. Ukuran rumah
B. Status rumah
: Milik ....................................................................................................
C. Bangunan rumah
D. Keterangan rumah
Rumah mempunyai ..... kamar tidur, ..... kamar dibagian ..... rumah dan ..... kamar
dibagian ..... rumah; hanya ..... kamar mandi; ..... dapur; dengan ruang makan di
bagian .................... rumah..
Kamar
penderita
E. Keadaan lingkungan :
Lingkungan ....................................................................................................................
Rumah yang satu dengan yang lain ...............................................................................
Jangan memusuhi dan mengucilkan penderita sepulang dari RS Jiwa Menur Surabaya,
Perhatikan semua kebutuhan penderita termasuk berkomunikasi, makan, minum, dan mandi,
Perhatikan hal-hal yang menimbulkan rasa sedih atau marah penderita, dan sebisa mungkin
hindarkan penderita dari hal-hal tersebut,
Motivasi, latih, dan ajak penderita untuk mampu mengerjakan hal-hal yang berguna
(misalnya bersih-bersih rumah ataupun berbelanja kebutuhan toko pracangan) dengan
perlahan-lahan, dimulai dengan lebih sering memujinya jika penderita melakukan hal
berguna dengan baik,
Ajak penderita berbincang-bincang tentang hal-hal yang bersifat ringan dan menarik bagi
penderita seperti acara TV, sepak bola, dan lain-lain,
Jangan terlalu sering memarahi dan menasehati penderita, karena hal itu akan menjadikan
penderita merasa tertekan dan memperlambat proses rehabilitasinya,
Berikan obat sesuai dengan dosis dan petunjuk dokter, awasi penderita dalam meminumnya,
dan taati jangka waktu pemakaian obat,
Kontrol rutin ke dokter bila obat habis atau tampak efek samping obat yang tidak biasa pada
penderita, ataupun jika tidak tampak perkembangan yang bermakna dalam kejiwaan
penderita.