FORMULIR BANTU PEMERIKSAAN KESEHATAN

haji i (PERTAMA)
NAMA JEMAAH HAJI
JENIS KELAMIN
TEMPAT/TGL LAHIR
ALAMAT
PEKERJAAN
NO.REGISTER PUSKESMAS
NO.BUKU

: ......................................................................................................
: ..............................................................................................
: ..............................................................................................
: .............................................................................................
: ..............................................................................................
: ..............................................................................................
: ..............................................................................................

A.FAKTOR RESIKO JEMAAH HAJI

1.
2.
3.
4.
5.

..................................................................
..................................................................
..................................................................
..................................................................
..................................................................

6.
7.
8.
9.
10.

................................................................
................................................................
................................................................
................................................................
................................................................

B.RIWAYAT KESEHATAN
1. Riwayat Kesehatan Sekarang
a. ..........................................................
b. ..........................................................
c. ..........................................................

d. ...........................................................
e. ...........................................................
f. ............................................................

2. Riwayat Penyakit Dahulu ( RPD )

a. ..........................................................
b. ..........................................................
c. ..........................................................
d. ..........................................................
C.PEMERIKSAAN FISIK

3. Riwayat Penyakit Keluarga ( RPK )

a. ............................................................
b. ............................................................
c. ............................................................
e. ............................................................

1. Kesadaran :
2. Tanda Vital :
a. Tekanan darah
Sistol
Diastol

: .........................................................................mmhg
: .........................................................................mmhg

b. Nadi
Frekuensi
: .........................................................................kali/menit
Isi
: cukup / kurang
Tegangan
: kuat / cukup / lemah
Ritme
: ........................................................................
c. Napas
Frekuensi
: .........................................................................kali/menit
Ritme
: .........................................................................
d. Suhu
: .........................................................................oC
3. Postur
a. Bentuk / Habitus
: ........................................................................
b. IMT ( Indeks Massa Tubuh ) : ........................................................................
Tinggi Badan (TB) : ........................................................................cm
Berat Badan (BB)
: ........................................................................kg

c. Rasio LPP
: ........................................................................
Lingkar Pinggang
: ........................................................................cm
Lingkar pinggul
: ........................................................................cm
4. Kulit
a. Inspeksi
: .......................................................................................................
b. Palpasi
: ........................................................................................................
5. Kepala
a. Inspeksi (termasuk bentuk,simetrisitas)
: ........................................................
b. Pemeriksaan saraf kranial
: ................................................................................
c. Mata : ....................................................................................................................
d. Telinga: ...................................................................................................................
e. Hidung: ...................................................................................................................
f. Tenggorokan dan mulut
: ................................................................................
6. Leher
a. Inspeksi
: .......................................................................................................
b. Palpasi
: .......................................................................................................
7. Kelenjar dan pembuluh getah bening
a. Inspeksi
: .......................................................................................................
b. Palpasi
: ........................................................................................................
8. Dada
a. Umum
Inspeksi
: ............................................................................................
Palpasi
: ............................................................................................
Perkusi
: ...........................................................................................
Auskultasi
: ............................................................................................
b. Jantung
Inspeksi
: ............................................................................................
Palpasi
: ............................................................................................
Perkusi
: ............................................................................................
Auskultasi
: ............................................................................................
c. Paru
Inspeksi
: ............................................................................................
Palpasi
: ............................................................................................
Perkusi
: ............................................................................................
Auskultasi
: ............................................................................................
9. Perut ( meliputi semua organ dalam )
a. Umum
Inspeksi
: ............................................................................................
Palpasi
: ............................................................................................
Perkusi
: ............................................................................................
Auskultasi
: ............................................................................................
b. Sistem Khusus
Hati ( Liver ) : ............................................................................................
Limpa (spleen): .............................................................................................
10. Ekstremitas
a. Inspeksi (termasuk bentuk,simetrisitas)
: .........................................................
b. Palpasi
: ........................................................................................................
c. Kekuatan otot : ........................................................................................................
........................................................................................................
d. Refleks
: ........................................................................................................
11. Rektum dan Urogenital
a. Umum
Inspeksi
: ............................................................................................
Palpasi (termasuk colok dubur): ..................................................................

b. Sistem Khusus
Sistem Reproduksi
Sistem Kemih

: ................................................................................
: ................................................................................

E.PEMERIKSAAN PENUNJANG
1. Laboratorium
a. Darah
Pokok :
- Hemoglobin (Hb)
: ....................................................................
- Laju Endap Darah (LED) : ....................................................................
- Jumlah leukosit
: ....................................................................
- Hitung jenis leukosit
: ....................................................................
- Golongan darah: A/B/O/AB : RH : (+) / (-)
Lanjut :
- Gula Darah Sewaktu (GDS)
: ........................................................
- Kolesterol (LDL)
: ........................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
b. Urine
Pokok :
- Makroskopis
Penilaian
: ................................................................................
Lampiran hasil : ................................................................................
- Mikroskopis
Penilaian
: ................................................................................
Lampiran hasil : ................................................................................
- Glukosa Urin
Penilaian
: ................................................................................
Lampiran hasil : ................................................................................
- Protein Urin
Penilaian
: ................................................................................
Lampiran hasil : ................................................................................
Lanjut
- Tes Kehamilan : Pos / Neg Tgl : ...........................................................
c. Khusus (sebutkan jenis pemeriksaannya)
: ................................................................................................................................
...
2. Elektro Kardio Grafi (EKG)
a. Lanjut (istirahat)
:
Penilaian ( didampingi hasil pemeriksaan ): ...........................................................
b. Khusus
:
Penilaian ( didampingi hasil pemeriksaan ): ............................................................
3. Radiologi ( lampirkan hasil pembacaan Ro )
a. Lanjut ( Thoraks-AP ):
Penilaian (didampingi hasil pemeriksaan): ..............................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
...................................................................................................................................
b. Khusus
:
Penilaian (didampingi hasil pemeriksaan): .............................................................

..................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
..................................................................................................................................
4. Barthel Indeks (BAI) ( untuk > 60 thn )
a. Skore
: .......................................................................................................
b. Keterangan : .......................................................................................................
..................................................................................................................................
5. Tes Kebugaran ( untuk pendamping jemaah )
a. Metode
: .......................................................................................................
b. Nilai
: .......................................................................................................
F.DIAGNOSA
1. ......................................................................
2. ......................................................................
3. ......................................................................
4. ......................................................................
5. .....................................................................
6. ......................................................................
G.KESIMPULAN

Kode : ....................
Kode : ....................
Kode : ....................
Kode : ....................
Kode : ....................
Kode : ....................

1. Kategori
: Mandiri / Observasi / Pengawasan / Tunda
2. Saran / Anjuran
:
a. ..................................................................................................................................
b. ..................................................................................................................................
c. .................................................................................................................................
d. .................................................................................................................................
e. .................................................................................................................................
f. .................................................................................................................................

4X6

..................................
Dokter pemeriksa