PEMERINTAH KOTA SURABAYA

DINAS KESEHATAN KOTA

PKM. JEMURSARI KEC.WONOCOLO
JL Jemursari Selatan IV no 5 TELP. 8414743

SURAT KETERANGAN PEMERIKSAAN KESEHATAN

CALON JEMAAH HAJI

Yang bertanda tangan di bawah ini:

Nama : .................................................................................................
Jabatan : .................................................................................................
Alamat : .................................................................................................

Menerangkan bahwa:

Nama Calon Haji : .................................................................................................

Bin/Binti : .................................................................................................
Tempat/Tgl. Lahir : .................................................................................................
Jenis Kelamin : .................................................................................................
Pekerjaan : .................................................................................................
Alamat : .................................................................................................

Telah diperiksa kesehatannya, dengan kesimpulan:

a. Memenuhi syarat kesehatan dengan baik (mandiri)
b. Memenuhi syarat Kesehatan dengan perhatian (observasi)
c. Memenuhi syarat Kesehatan dengan pengawasan
Surat keterangan pemeriksaan kesehatan pertama ini dipergunakan sebagai persyaratan untuk
mengikuti perjalanan ibadah haji tahun 2010/1431 H.

Pas Foto CJH Surabaya,

Dokter Pemeriksa

__________________________

*Coret yang tidak perlu

 FORMULIR REKAM MEDIS
PENILAIAN KESEHATAN HAJI INDONESIA

Nama Lengkap :
Binti/Binti :
Tempat & Tanggal Lahir : Foto

Alamat :
Pekerjaan :
No. Porsi :
Dokter :
Sarana :
Tanggal Periksa :
A. Faktor Resiko Calon Haji (diisi setelah pemeriksaan Kesehatan)
1. ..............................................................................................................................................
2. .............................................................................................................................................
3. .............................................................................................................................................
B. Riwayat Kesehatan
1. Riwayat Penyakit Sekarang (RPS)
..............................................................................................................................................
..............................................................................................................................................
2. Riwayat Penyakit Dahulu (RPD)
..............................................................................................................................................
..............................................................................................................................................
3. Riwayat Penyakit Keluarga (RPK)
..............................................................................................................................................
..............................................................................................................................................
C. Pemeriksaan Fisik
1. Tanda Vital
a. Tekanan Darah :
b. Nadi :
c. Napas :
d. Suhu :
2. Postur
a. Bentuk : Proporsional / Tidak
b. BB :
c. TB :
d. Lingkar Pinggang :
e. Lingkar Pinggul : / mmHg
3. Kulit X / menit Regular/Irregular
a. Inspeksi : .................................................................................................................
.................................................................................................................
X / menit Dangkal/Cukup/Dalam
4. Kepala o
a. Inspeksi C
: .................................................................................................................
.................................................................................................................
b. Pemeriksaan : .................................................................................................................
Syaraf Kranial .................................................................................................................
c. Mata : .................................................................................................................
Kg
.................................................................................................................
IMT = .
d. Telinga : .................................................................................................................
cm
.................................................................................................................
e. Hidung : .................................................................................................................
cm
Ratio LPP =
.................................................................................................................
f. Tenggorokan cm
: .................................................................................................................
 dan Mulut .................................................................................................................
g. Leher : .................................................................................................................
.................................................................................................................
h. Kelenjar Getah : .................................................................................................................
Bening .................................................................................................................
i. Dada :
1. Umum : .................................................................................................................
2. Jantung : .................................................................................................................
.................................................................................................................
3. Paru : .................................................................................................................
.................................................................................................................
j. Ekstrimitas : .................................................................................................................
.................................................................................................................
k. Rektum & : .................................................................................................................
Urogenital .................................................................................................................

D. Pemeriksaan Jiwa
1. Keluhan somatik tanpa kelainan organik
a. Tidak
b. Ada
2. Keluhan psikosomatik
a. Tidak
b. Ada
3. Keluhan mental emosional
a. Tidak
b. Ada

E. Pemeriksaan Penunjang
1. Laboratorium :
a. Darah
1. Pokok :........................................... 2. Lanjut :
Hb :........................................... GDS : ......................................
LED :........................................... LDL : ......................................
Leukosit :........................................... Lain-lain : ......................................
Diff :...........................................
Gol. Darah :...........................................
b. Urine :
1. Pokok : .......................................... 2. Tes Kehamilan : Positif Negatif
2. EKG : .................................................................................................................
.................................................................................................................
3. Radiologist : .................................................................................................................
.................................................................................................................
4. Barthel Indeks : .................................................................................................................
.................................................................................................................
5. Tes Kebugaran : .................................................................................................................
.................................................................................................................
F. Diagnosa
1. ............................................................... Kode ............................................................................
2. ............................................................... Kode ............................................................................
3. ............................................................... Kode ............................................................................

G. Kesimpulan
1. Kategori :
Mandiri Observasi Pengawasan Tunda
2. Saran : .................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
Surabaya, ...................................................

Dokter Pemeriksa,

__________________________