PERTANYAAN WAWANCARA

Nama Pasien

Jenis kelamin

Usia

Alamat

1.

Keluhan apa yang sering bapak/ibu alami ?

Jawab : ........................................................................................................................
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2.

Dimana lokasi/ pada bagian tubuh mana yang mengalami keluhan ?

Jawab : ........................................................................................................................
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3.

Sejak kapan keluhan dirasakan ?

Jawab : ........................................................................................................................
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4.

Bagaiman keluhan yang dirasakan (rasa sakit / nyeri) dan seberapa sakit ?
Jawab : ........................................................................................................................
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5.

Apakah keluhan terjadi secara tiba-tiba atau terus menerus ?

Jawab : ........................................................................................................................
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6.

Apa yang membuat keluhan bapak/ibu semakin berat ?

Jawab : ........................................................................................................................
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7.

Bagaimana cara bapak/ibu mengatasi keluhan yang dialami ?

Jawab : ........................................................................................................................
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8.

Apakah ibu/bapak memiliki riwayat penyakit sebelumnya ? Sejak kapan ?

Jawab : ........................................................................................................................
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9.

Apakah bapak/ibu mengkonsumsi obat untuk mengatasi keluhan ?

Jawab : ........................................................................................................................
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10. Bagaimana kegiatan dan kebiasaan bapak/ibu sehari-hari ? ( lifestyle )
Jawab : ........................................................................................................................
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11. Apakah ada anggota keluarga yang lain menglami penyakit yang sama seperti
bapak/ ibu ?
Jawab : ........................................................................................................................
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12. Apakah Bapak/Ibu sering merokok? Bila Iya, sejak kapan?
Jawab...................................................................................................................
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13. Apakah Bapak/Ibu sering mengkonsumsi makanan dengan garam yang tinggi?
Jawab............................................................................................................................
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14. Apakah Bapak/Ibu sering berolah raga?

Jawab............................................................................................................................
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15. Apakah Bapak/Ibu mematuhi anjuran/saran dari dokter?
Jawab............................................................................................................................
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