PEMERINTAH KABUPATEN KUDUS

DINAS KESEHATAN
BLUD UPT PUSKESMAS DAWE
JL. DAWE GEBOG, CENDONO TELP 0291 420257, KUDUS 59353

FORMULIR PEMERIKSAAN KESEHATAN HAJI

NAMA JEMAAH CALON HAJI : ......................................................................................................

JENIS KELAMIN : ..............................................................................................
TEMPAT/TGL LAHIR : ..............................................................................................
ALAMAT : .............................................................................................
PEKERJAAN : ..............................................................................................
NO.PORSI : ..............................................................................................
NO.BUKU : ..............................................................................................

A.FAKTOR RESIKO JEMAAH HAJI

1. .................................................................. 6. .................................................................
2. .................................................................. 7. .................................................................
3. .................................................................. 8. .................................................................
4. .................................................................. 9. ................................................................
5. .................................................................. 10. ................................................................

B.RIWAYAT KESEHATAN
1. Riwayat Kesehatan Sekarang
a. ..........................................................
b. ..........................................................
c. ..........................................................
d. ...........................................................
e. ...........................................................
f. ............................................................

2. Riwayat Penyakit Dahulu ( RPD ) 3. Riwayat Penyakit Keluarga ( RPK )

a. .......................................................... a. ............................................................
b. .......................................................... b. ............................................................
c. .......................................................... c. ............................................................
d. .......................................................... e. ............................................................
C.PEMERIKSAAN FISIK
1. Kesadaran :
2. Tanda Vital :
a. Tekanan darah
Sistol : .........................................................................mmhg
Diastol : .........................................................................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 ) : ........................................................................
 PEMERINTAH KABUPATEN KUDUS
DINAS KESEHATAN
BLUD UPT PUSKESMAS DAWE
JL. DAWE GEBOG, CENDONO TELP 0291 420257, KUDUS 59353

Tinggi Badan (TB) : ........................................................................cm

Berat Badan (BB) : ........................................................................kg
c. Rasio LPP : ........................................................................
Lingkar Pinggang : ........................................................................cm
Lingkar pinggul: ........................................................................c m
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
 PEMERINTAH KABUPATEN KUDUS
DINAS KESEHATAN
BLUD UPT PUSKESMAS DAWE
JL. DAWE GEBOG, CENDONO TELP 0291 420257, KUDUS 59353

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): .............................................................
..................................................................................................................................
 PEMERINTAH KABUPATEN KUDUS
DINAS KESEHATAN
BLUD UPT PUSKESMAS DAWE
JL. DAWE GEBOG, CENDONO TELP 0291 420257, KUDUS 59353

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

4. Barthel Indeks (BAI) ( untuk > 60 thn )

a. Skore : .......................................................................................................
b. Keterangan : .......................................................................................................
..................................................................................................................................
5. Tes Kebugaran ( untuk pendamping jemaah )
a. Metode : .......................................................................................................
b. Nilai : .......................................................................................................

F.DIAGNOSA

1. ...................................................................... Kode : ....................

2. ...................................................................... Kode : ....................
3. ...................................................................... Kode : ....................
4. ...................................................................... Kode : ....................
5. ..................................................................... Kode : ....................
6. ...................................................................... Kode : ....................
G.KESIMPULAN

1. Kategori : Mandiri / Observasi / Pengawasan / Tunda

2. Saran / Anjuran :
a. ..................................................................................................................................
b. ..................................................................................................................................
c. .................................................................................................................................
d. .................................................................................................................................
e. .................................................................................................................................
f. .................................................................................................................................

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