FORMULIR INVESTIGASI

PENDERITA DIARE / KHOLERA

No. Indeks Kasus :.............................. (suspect/positif). Tempat outbreak :......................

Nama Penderita :.......................... bin....................... Umur :............ ( L / P )
Alamat Lengkap :............................. RT...... RW/RK............... Kelurahan................. Kec............
Pekerjaan :..................... Tempat Bekerja :............................
Keterangan lain :.............................................................................................

Gejala Klinis :
□ Berak tak tertahan □ Berak dengan ingus
□ Muntah □ Berak dengan darah
□ Sakit perut hebat □ Ada Panas
□ Dingin □ Tugor baik/jelek
□ Lemah □ Berak 5 kali
□ Shock □ Berak 5 - 10 kali
□ Berak lebih 10 kali

Diagnosa (sementara) :..............................................................................

Oleh :..............................................................................
Tanggal mulai sakit......................... Jam.................. Tanggal Dirawat...................... Jam...............
Tanggal sembuh/mati..................................................... Jam........................

Dirawat di : Puskesmas / BP / RC :...................................... Dokter :.......................

Rumah Sakit :...................................... Dokter :......................

Tidak dirawat dengan alasan :

□ Tempat Jauh □ Tak mengerti, harus kemana
□ Takut membayar □ Ke dukun dan lain-lain
□ Tidak percaya dengan dinas ...............................................
kesehatan

Pengobatan yang diberikan :

Oralit, dosis, □..................... bungkus dengan dosis...........................

Ringer Laktat □..................... kolf dengan dosis...........................
Antibiotika,
Sebutkan :.............................. kapsul
............................... kapsul
............................... kapsul

Specimen / rectal swab diambil □ Ya,................ Hasil................................................

□ Tidak, sebab...........................................................

Diduga ketularan dari (nama, orang dan lain-lain)...................................di........................................

Diduga akan menularkan kepada :...........................................................di.......................................

Sejarah makanan dan minuman 5 hari sebelum sakit :

Hari..................................Tgl.............................makanan/minuman....................di mana......................
Hari..................................Tgl.............................makanan/minuman....................di mana......................
Hari..................................Tgl.............................makanan/minuman....................di mana......................
Hari..................................Tgl.............................makanan/minuman....................di mana......................
Hari..................................Tgl.............................makanan/minuman....................di mana......................

Penderita buang air besar di :

□ Kakus □ Sawah □ Lain-lain
□ Sungai □ Pantai
□ Empang □ Kebun
Keadaan kakus :
□ memenuhi syarat □ tidak memenuhi
kesehatan syarat kesehatan

Sumber air minum dari :

□ Ledeng □ Sumur gali
□ Sungai □ Air hujan
□ Mata air □ Lain-lain

Keadaan Sumur :
□ memenuhi syarat □ tidak memenuhi
kesehatan syarat kesehatan

Air untuk mandi, cuci dll

□ Ledeng □ Sumur gali
□ Sumur Pompa □ Sungai
□ Air Hujan □ Mata air

Catatan :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

Pemegang Program Diare ..............................................

Puskesmas......................... Investigator

(...........................................) (...........................................)

Mengetahui,
Kepala Puskesmas.....................

(...........................................)