Form Pengkajian Kep Maternitas

FORMAT PENGKAJIAN ANTENATAL
UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :
Ruang/kelas : Kamar No :
Pengkajian tanggal : Jam :
IDENTITAS
1. Nama pasien : ................................. Nama Suami : .....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ...................
4. Agama : ................................. Agama : ........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Pernikahan ..................................................
STATUS KESEHATAN SAAT INI

1. Alasan kunjungan ke rumah sakit : ....................................................................
.............................................................................................................................................
...
2. Keluhan utama saat ini : ....................................................................................

.............................................................................................................................................
..
3. Riwayat Kehamilan saat ini
4. Diagnosa medik : ...............................................................................................
RIWAYAT KEPERAWATAN
1. RIWAYAT OBSTETRI :
a. Riwayat menstruasi :
Menarche : umur.................... Siklus : teratur ( ) tidak ( )
Banyaknya : ............................ Lamanya : ...........................
Keluhan : ...........................
HPHT : ............................
TP :
b. Riwayat kehamilan, persalinan, nifas :
Anak ke Kehamilan Persalinan Komplikasi nifas Anak

Umur Pe Las
N Penolo Infe Perdara
Tahun kehamil Penyulit Jenis ny era Jenis BB pj
o ng ksi han
an ulit si
Genogram
2. RIWAYAT KELUARGA BERENCANA :

Melaksanakan KB : ( ) ya ( ) tidak
Bila ya jenis kontrasepsi apa yang digunakan : ......................................................
Sejak kapan menggunakan kontrasepsi : ................................................................
Masalah yang terjadi : ............................................................................................
3. RIWAYAT KESEHATAN :
Penyakit yang pernah dialami ibu : ........................................................................
Pengobatan yang didapat : ......................................................................................
Riwayat penyakit keluarga
( ) Penyakit Diabetes Mellitus
( ) Penyakit jantung
( ) Penyakit hipertensi
( ) Penyakit lainnya : sebutkan ......................................................................
4. RIWAYAT LINGKUNGAN :
- Kebersihan :
..................................................................................................................
- Bahaya :
......................................................................................................................
- Lainnya sebutkan :
......................................................................................................
5. ASPEK PSIKOSOSIAL :
a. Persepsi ibu tentang keluhan/ penyakit : ................................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?............
Bila ya bagaimana ..................................................................................................
c. Harapan yang ibu inginkan : ..................................................................................
d. Ibu tinggal dengan siapa : .......................................................................................
e. Siapakah orang yang terpenting bagi ibu................................................................
f. Sikap anggota keluarga terhadap keadaan saat ini .................................................
g. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
6. KEBUTUHAN DASAR KHUSUS :

a. Pola Nutrisi
Frekwensi makan : .............................. x sehari
Nafsu makan : ( ) baik, ( ) tidak nafsu, alasan ..........................................
Jenis makanan rumah : .................................................................................
Makanan yang tidak disukai/ alergi/ pantangan : .............................................
b. Pola eliminasi :
BAK
- Frekwensi : ....................kali
- Warna : ........................
- Keluhan saat BAK : .......................................................................
BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
- Konsistensi : ......................
- Keluhan : ..................................................................................
c. Pola personal hygiene
Mandi
- Frekwensi : ...................................x /hari
- Sabun : ( ) ya, ( ) tidak
Oral hygiene
- Frekwensi : ...................................x /hari
- Waktu : ( ) ya, ( ) tidak
Cuci rambut
- Frekwensi : ...................................x /hari
- Shampo : ( ) ya, ( ) tidak
d. Pola istirahat dan tidur
Lama tidur : ............................jam/hari
Kebiasaan sebelum tidur : ................................................................................
Keluhan : ..........................................................................................................
e. Pola aktifitas dan latihan

Kegiatan dalam pekerjaan : ..............................................................................
Waktu bekerja : ( ) Pagi, ( ) Sore, ( ) Malam
Olah raga : ( ) ya, ( ) tidak
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Kegiatan waktu luang : .....................................................................................
Keluhan dalam beraktifitas : ............................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan

Merokok :
..............................................................................................
Minuman keras :
..............................................................................................
Ketergantungan obat :
..............................................................................................
7. PEMERIKSAAN FISIK
Keadaan umum : ......................................Kesadaran : .........................
Tekanan darah : ......................................Nadi : .............x/menit
Respirasi : ......................................Suhu : ...............C
Berat badan : ......................kg Tinggi badan : ................cm
Kepala, mata kuping, hidung dan tenggorokan :

Kepala : Bentuk ..........................................................
Keluhan :........................................................
Mata :
Kelopak mata : .....................................................................................................
Gerakan mata : ....................................................................................................
Konjungtiva : .....................................................................................................
Sklera : ....................................................................................................
Pupil : .....................................................................................................
Akomodasi : .....................................................................................................
Lainnya sebutkan : .................................................................................................
Hidung :
Reaksi alergi : .....................................................................................................
Sinus : ....................................................................................................
Mulut dan Tenggorokan :
Gigi geligi : .....................................................................................................
Kesulitan menelan : ................................................................................................
Dada dan Axilla

Mammae : membesar ( ) ya ( ) tidak
Areolla mammae : ..................................................................................................
Papila mammae : ....................................................................................................
Colostrum : .....................................................................................................
Pernafasan
Jalan nafas : .....................................................................................................
Suara nafas . : ....................................................................................................
Menggunakan otot-otot bantu pernafasan : ............................................................
Sirkulasi jantung
Kecepatan denyut apical : ...............................x/menit
Irama : ...............................................................................................
Kelainan bunyi jantung : ........................................................................................
Sakit dada : ...............................................................................................
Timbul .: ...............................................................................................
Lainnya sebutkan : ..............................................................................................
Abdomen
Tinggi fundus uterus: cm Kontraksi: ya/ tidak
Leopold I :
Leopold II :
Leopold III:
Leopold IV:
Pigmentasi :
Linea nigra :
Striae :
Fungsi pencernaan :
Masalah khusus :
Genitourinary
Perineum : ...............................................................................................
Vesika Urinasria : ...............................................................................................
Hemorrhoid: derajat...............lokasi..........................
Berapa lama........................................nyeri : ya/ tidak
Vagina : varises: ya/ tidak
Kebersihan :
Keputihan :
Jenis/warna :
Ekstrimitas (integumen/muskuloskeletal)
Turgor kulit : ................................................
Warna kulit : .................................................................................................
Kontraktur pada persendian ekstrimitas : .........................................................
Kesulitan dalam pergerakan : .........................................................................
Lainnya sebutkan : ...........................................................................................
8. Kesiapan dalam kehamilan dan persalinan:
a. Senam hamil
b. Rencana tempat melahirkan
c. Perlengkapan kebutuhan bayi dan ibu
d. Kesiapan mental ibu dan keluarga
e. Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses
persalinan
9. Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
4) Terapi yang didapat:
........................................................................................................................................
........................................................................................................................................
.............................................................................................
10. Data Tambahan

................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
............................................................................................
Surabaya, ........................................
Pemeriksa
(..................................................)
FORMAT PENGKAJIAN INTRANATAL

IDENTITAS
1. Nama pasien : ................................. Nama Suami : .....................
2. Umur : ....................... th Umur : ....................... th
3. Suku/ bangsa : ................................. Suku/ bangsa : ...................
4. Agama : ................................. Agama : ........................
5. Pendidikan : .................................. Pendidikan : ...........................
6. Pekerjaan : .................................. Pekerjaan : ...........................
7. Alamat : .................................. Alamat : ...........................
8. Status Pernikahan ..................................................

1. Alasan kunjungan ke rumah sakit : ....................................................................
.............................................................................................................................................
2. Keluhan utama saat ini :
.....................................................................................................................................
.............................................................................................
3. Riwayat Persalinan saat ini
4. Diagnosa medik : ...............................................................................................
RIWAYAT KEPERAWATAN

Keluhan : ...........................
HPHT : ............................
TP :
Ana Kehami
Persalinan Komplikasi nifas Anak
k ke lan
U
m
ur
T k
a e Pe Pe Las
N Peno Infe Perdara
h h ny Jenis ny era Jenis BB pj
o long ksi han
u a ulit ulit si
n m
il
a
n
Genogram
Riwayat keluarga berencana :

Riwayat kesehatan :
Riwayat lingkungan :
- Kebersihan :
..................................................................................................................
- Bahaya :
......................................................................................................................
......................................................................................................
Aspek psikososial :
Persepsi ibu tentang keluhan/ penyakit : ................................................................
Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?............
Harapan yang ibu inginkan : ..................................................................................
Ibu tinggal dengan siapa : .......................................................................................
Siapakah orang yang terpenting bagi ibu................................................................
Sikap anggota keluarga terhadap keadaan saat ini .................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
Kebutuhan dasar khusus (Di rumah dan di rs) :

Pola Nutrisi
Pola eliminasi :
BAK
Frekwensi : ....................kali
Warna : ........................
Keluhan saat BAK : .......................................................................
BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
Konsistensi : ......................
Keluhan ........................................................................
Pola personal hygiene
Mandi
Frekwensi : ...................................x /hari
Sabun : ( ) ya, ( ) tidak
Oral hygiene
Frekwensi : ...................................x /hari
Waktu : ( ) ya, ( ) tidak
Cuci rambut
Frekwensi : ...................................x /hari
Shampo : ( ) ya, ( ) tidak
Pola istirahat dan tidur
Keluhan : ..........................................................................................................
Pola aktifitas dan latihan
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Pola kebiasaan yang mempengaruhi kesehatan
Merokok : ..............................................................................................
Minuman keras : ..............................................................................................
..............................................................................................
Pemeriksaan fisik
Respirasi : .....................................Suhu : ...............C
Kepala : Bentuk ..........................................................
Keluhan :........................................................
Mata :
Kelopak mata : .....................................................................................................
Gerakan mata : ....................................................................................................
Konjungtiva : .....................................................................................................
Sklera : ....................................................................................................
Pupil : .....................................................................................................
Akomodasi : .....................................................................................................
Hidung :
Reaksi alergi : .....................................................................................................
Sinus : ....................................................................................................
Gigi geligi : .....................................................................................................
Dada dan Axilla
Areolla mammae : ..................................................................................................
Papila mammae : ....................................................................................................
Colostrum : .....................................................................................................
Pernafasan
Jalan nafas : .....................................................................................................
Suara nafas . : ....................................................................................................
Sirkulasi jantung
Irama : ...............................................................................................
Sakit dada : ...............................................................................................
Timbul .: ...............................................................................................
Abdomen
Leopold I :
Leopold II :
Leopold III:
Leopold IV:
Pigmentasi :
Linea nigra :
Striae :
Fungsi pencernaan :
Masalah khusus :
Genitourinary
Perineum : ...............................................................................................
Hemorrhoid: derajat...............lokasi..........................
Berapa lama........................................nyeri : ya/ tidak
Vagina : varises: ya/ tidak
Kebersihan :
Keputihan :
Jenis/warna :
Turgor kulit : ................................................
Warna kulit : .................................................................................................
Kesiapan dalam kehamilan dan persalinan:

Senam hamil
Rencana tempat melahirkan
Perlengkapan kebutuhan bayi dan ibu
Kesiapan mental ibu dan keluarga
Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses
persalinan
Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
............................................................................................................................................
........................................
Data Tambahan
................................................................................................................................................
..........................................
Surabaya, ........................................
Pemeriksa
(..................................................)
FORMAT PENGKAJIAN POST PARTUM

IDENTITAS
Nama pasien : ................................. Nama Suami : .....................
Umur : ....................... th Umur : ....................... th
Suku/ bangsa : ................................. Suku/ bangsa : ...................
Agama : ................................. Agama : ........................
Pendidikan : .................................. Pendidikan : ...........................
Pekerjaan : .................................. Pekerjaan : ...........................
Alamat : .................................. Alamat : ...........................
Status Pernikahan ..................................................

1. Keluhan utama saat ini : ....................................................................................
.............................................................................................................................................
..
2. Riwayat Kondisi saat ini
3. Diagnosa medik : ...............................................................................................
RIWAYAT KEPERAWATAN
Keluhan : ...........................
HPHT : ............................
TP :
Ana Kehami
k ke lan
U
m
ur
T k
a e Pe Pe Las
N Peno Infe Perdara
h h ny Jenis ny era Jenis BB pj
o long ksi han
u a ulit ulit si
n m
il
a
n
Genogram
Riwayat Persalinan Dan Post Partum Sekarang

Keluhan his
Pengeluaran pervaginan
Kala persalinan
Kala 1
Kala 2
Kala 3
Kala 4
DATA BAYI
Bayi lahir tanggal/ jam..................................
Jenis kelamin................................................
Nilai APGAR..................................................
BB/PB/Lingkar kepala bayi.................gram..................cm................cm
Kelainan Kepala
Suhu...........................c
Anus: berlubang/ tertutup
Perawatan tali pusat.................................
Perawatan mat
RIWAYAT KELUARGA BERENCANA :

RIWAYAT KESEHATAN :
RIWAYAT LINGKUNGAN :
- Kebersihan :
..................................................................................................................
- Bahaya :
......................................................................................................................
......................................................................................................
ASPEK PSIKOSOSIAL :
Persepsi ibu tentang persalinan saat ini: ................................................................
Harapan yang ibu inginkan : ..................................................................................
Ibu tinggal dengan siapa : .......................................................................................
Siapakah orang yang terpenting bagi ibu................................................................
Sikap anggota keluarga terhadap keadaan saat ini .................................................
Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
KEBUTUHAN DASAR KHUSUS (Di rumah dan di rs) :

Pola Nutrisi
Pola eliminasi :
BAK
Frekwensi : ....................kali
Warna : ........................
Keluhan saat BAK : .......................................................................
BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
Konsistensi : ......................
Keluhan ........................................................................
Pola personal hygiene
Mandi
Frekwensi : ...................................x /hari
Sabun : ( ) ya, ( ) tidak
Oral hygiene
Frekwensi : ...................................x /hari
Waktu : ( ) ya, ( ) tidak
Cuci rambut
Frekwensi : ...................................x /hari
Shampo : ( ) ya, ( ) tidak
Pola istirahat dan tidur
Keluhan : ..........................................................................................................
Pola aktifitas dan latihan
Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
Pola kebiasaan yang mempengaruhi kesehatan
Merokok : ..............................................................................................
Minuman keras : ..............................................................................................
..............................................................................................
PEMERIKSAAN FISIK
Respirasi : .....................................Suhu : ...............C
Kepala : Bentuk ..........................................................
Keluhan :........................................................
Mata :
Kelopak mata : .....................................................................................................
Gerakan mata : ....................................................................................................
Konjungtiva : .....................................................................................................
Sklera : ....................................................................................................
Pupil : .....................................................................................................
Akomodasi : .....................................................................................................
Hidung :
Reaksi alergi : .....................................................................................................
Sinus : ....................................................................................................
Gigi geligi : .....................................................................................................
Dada dan Axilla
Areolla mammae : ..................................................................................................
Papila mammae : ....................................................................................................
Colostrum : .....................................................................................................
Pernafasan
Jalan nafas : .....................................................................................................
Suara nafas . : ....................................................................................................
Sirkulasi jantung
Irama : ...............................................................................................
Sakit dada : ...............................................................................................
Timbul .: ...............................................................................................
Abdomen
Bising usus
Perineum dan Genital

Integritas Vagina :
Perineum : ...............................................................................................
Tanda REEDA
R:Rednes : ya/tidak
E:Edema : ya/tidak
E: Echimosis : ya/tidak
D: Discharge : ya/tidak
A: Approximate : baik/tidak
Lokia : jumlah warna/jenis bau
Hemorrhoid : derajat lokasi nyeri
Turgor kulit :
Warna kulit :
Edema :
Kontraktur pada persendian ekstrimitas :
Tanda Homan : +/-
Kesulitan dalam pergerakan :
Lainnya sebutkan :
Kesiapan dalam perawatan bayi:

Senam hamil
Rencana tempat melahirkan
Perlengkapan kebutuhan bayi dan ibu
Kesiapan mental ibu dan keluarga
Pengetahuan tentang tanda- tanda melahirkan, cara menangani nyeri, dan proses
persalinan
Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
............................................................................................................................................
............................................................................................................................................
.....................................................................................
Data Tambahan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
............................................................................................
Surabaya, ........................................
Pemeriksa
FORMAT PENGKAJIAN
GANGGUAN SISTEM REPRODUKSI

IDENTITAS
Nama pasien : ................................. Nama Suami : .....................
Umur : ....................... th Umur :
....................... th
Suku/ bangsa : ................................. Suku/ bangsa : ...................
Agama : ................................. Agama : ........................
Pendidikan : .................................. Pendidikan : ...........................
Pekerjaan : .................................. Pekerjaan : ...........................
Alamat : .................................. Alamat : ...........................
Status Pernikahan ..................................................

A. Alasan kunjungan ke rumah sakit : ....................................................................
.............................................................................................................................................
...
B. Keluhan utama saat ini : ....................................................................................

.............................................................................................................................................
..
C. Riwayat penyakit sekarang ;
................................................................................................................................................
.......................................................................................................................
D. Riwayat penyakit dahulu :
.............................................................................................................................................
.........................................................................................................................
E. Diagnosa medik : ...............................................................................................
RIWAYAT KEPERAWATAN

HPHT : ............................ Keluhan : ...........................
(..................................................)
Ana Kehami
k ke lan
U
m
ur
T k
a e Pe Pe Las
N Peno Infe Perdara
h h ny Jenis ny era Jenis BB Pj
o long ksi han
u a ulit ulit si
n m
il
a
n
Genogram
13. RIWAYAT KELUARGA BERENCANA :

14. RIWAYAT KESEHATAN :

15. RIWAYAT LINGKUNGAN :

- Kebersihan :
..................................................................................................................
- Bahaya :
......................................................................................................................
......................................................................................................
16. ASPEK PSIKOSOSIAL :

a. Persepsi ibu tentang keluhan/ penyakit : ................................................................
b. Apakah keadaan ini menimbulkan perubahan terhadap kehidupan sehari-hari ?............
c. Harapan yang ibu inginkan : ..................................................................................
d. Ibu tinggal dengan siapa : .......................................................................................
e. Siapakah orang yang terpenting bagi ibu................................................................
f. Sikap anggota keluarga terhadap keadaan saat ini .................................................
g. Kesiapan mental untuk menjadi ibu : ( ) ya, ( ) tidak
17. KEBUTUHAN DASAR KHUSUS :

a. Pola Nutrisi
b. Pola eliminasi :
BAK
- Frekwensi : ....................kali
- Warna : ........................
- Keluhan saat BAK : .......................................................................
BAB
- Frekwensi : ....................kali
- Warna : ..........................
- Bau : ..........................
- Konsistensi : ......................
- Keluhan : ..................................................................................
c. Pola personal hygiene
Mandi
- Frekwensi : ...................................x /hari
- Sabun : ( ) ya, ( ) tidak
Oral hygiene
- Frekwensi : ...................................x /hari
- Waktu : ( ) ya, ( ) tidak
Cuci rambut
- Frekwensi : ...................................x /hari
- Shampo : ( ) ya, ( ) tidak
d. Pola istirahat dan tidur
Keluhan : ..........................................................................................................
e. Pola aktifitas dan latihan

Jenisnya : ..........................................................................................................
Frekwensi : .......................................................................................................
f. Pola kebiasaan yang mempengaruhi kesehatan

Merokok :
..............................................................................................
Minuman keras :
..............................................................................................
..............................................................................................
18. PEMERIKSAAN FISIK

Respirasi : ......................................Suhu : ...............C

Kepala : Bentuk ..........................................................
Keluhan :........................................................
Mata :
Kelopak mata : .....................................................................................................
Gerakan mata : ....................................................................................................
Konjungtiva : .....................................................................................................
Sklera : ....................................................................................................
Pupil : .....................................................................................................
Akomodasi : .....................................................................................................
Hidung :
Reaksi alergi : .....................................................................................................
Sinus : ....................................................................................................
Gigi geligi : .....................................................................................................
Dada dan Axilla

Areolla mammae : ..................................................................................................
Papila mammae : ....................................................................................................
Colostrum : .....................................................................................................
Pernafasan
Jalan nafas : .....................................................................................................
Suara nafas . : ....................................................................................................
Sirkulasi jantung
Irama : ...............................................................................................
Sakit dada : ...............................................................................................
Timbul .: ...............................................................................................
Abdomen
Mengecil : ................................................................................................
Linea dan striae : ...............................................................................................
Luka bekas operasi : ...............................................................................................
Kontraksi : ................................................................................................
Lainnya sebutkan : ................................................................................................
Genitourinary
Perineum : ...............................................................................................
Lainnyasebutkan : ...............................................................................................
Turgor kulit : ................................................
Warna kulit : .................................................................................................
d. Data Penunjang
1) Laboratorium : .................................................................................................
2) USG : .................................................................................................
3) Rontgen : .................................................................................................
....................................................................................................................................
....................................................................................................................................
.....................................................................................................
e. Data Tambahan
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
..........................................................................
Surabaya, ........................................
Pemeriksa
(..................................................)

Form Pengkajian Kep Maternitas

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Form Pengkajian Kep Maternitas

Diunggah oleh

Hak Cipta:

Format Tersedia

FORMAT PENGKAJIAN ANTENATAL

UNIT KEPERAWATAN MATERNITAS

STATUS KESEHATAN SAAT INI

2. Keluhan utama saat ini : ....................................................................................

4. Diagnosa medik : ...............................................................................................

Anak ke Kehamilan Persalinan Komplikasi nifas Anak

2. RIWAYAT KELUARGA BERENCANA :

6. KEBUTUHAN DASAR KHUSUS :

e. Pola aktifitas dan latihan

f. Pola kebiasaan yang mempengaruhi kesehatan

Kepala, mata kuping, hidung dan tenggorokan :

Dada dan Axilla

10. Data Tambahan

FORMAT PENGKAJIAN INTRANATAL

UNIT KEPERAWATAN MATERNITAS

Tanggal masuk : Jam masuk :

STATUS KESEHATAN SAAT INI

2. Keluhan utama saat ini :

3. Riwayat Persalinan saat ini

4. Diagnosa medik : ...............................................................................................

11. RIWAYAT OBSTETRI :

Riwayat keluarga berencana :

Kebutuhan dasar khusus (Di rumah dan di rs) :

Kesiapan dalam kehamilan dan persalinan:

FORMAT PENGKAJIAN POST PARTUM

UNIT KEPERAWATAN MATERNITAS

STATUS KESEHATAN SAAT INI

3. Diagnosa medik : ...............................................................................................

Riwayat Persalinan Dan Post Partum Sekarang

RIWAYAT KELUARGA BERENCANA :

KEBUTUHAN DASAR KHUSUS (Di rumah dan di rs) :

Perineum dan Genital

Kesiapan dalam perawatan bayi:

Tanggal masuk : Jam masuk :

STATUS KESEHATAN SAAT INI

B. Keluhan utama saat ini : ....................................................................................

12. RIWAYAT OBSTETRI :

13. RIWAYAT KELUARGA BERENCANA :

14. RIWAYAT KESEHATAN :

15. RIWAYAT LINGKUNGAN :

16. ASPEK PSIKOSOSIAL :

17. KEBUTUHAN DASAR KHUSUS :

e. Pola aktifitas dan latihan

f. Pola kebiasaan yang mempengaruhi kesehatan

18. PEMERIKSAAN FISIK

Kepala, mata kuping, hidung dan tenggorokan :

Dada dan Axilla

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