STATUS PEMERIKSAAN MATA

I. Identitas :

Nama .....................................................................................
NIK :....................................................................................
No. Rekam Medis :....................................................................................
Jenis kelamin :....................................................................................
Agama :....................................................................................
Tempat tanggal lahir :....................................................................................
Usia :....................................................................................
Alamat :.....................................................................................
......................................................................................

II. Riwayat Penyakit Sekarang

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

III. Riwayat Penyakit

Dahulu :.................................................................................................................................
..................................................................................................................................

IV. Pemeriksaan Fisik

A. Generalisata
Berat Badan : .. Pernafasan : ..
Tekanan Darah : .. Suhu : .
Nadi : ..
 Kepala : .....
Leher : .....
Jantung : .....
Paru-paru : .....

B. Mata

OD Pemeriksaan Mata OS


Visus


Tekanan Bola Mata (Digital)


Konjungtiva


Kornea


Iris


Lensa


Funduskopi



C. Laboratorium :
Gula Darah Sewaktu :

V. Diagnosis
Diagnosis utama
........................................................................
Diagnosis sekunder
:.......................................................................
Komorbiditas :.........................................................
..............

VI. Follow Up Post Operasi


OD Pemeriksaan Mata OS


Visus


Tekanan Bola Mata (Digital)


Konjungtiva


Kornea


Iris


Lensa


Funduskopi