NOMOR REKAM MEDIS :

REKAM MEDIK POLI GIGI NAMA :

UMUR/ JK :
ALAMAT :
KK :

UMUM BPJS/

ANAMNESA ( dari penderita/oang lain)

KELUHAN UTAMA :

RIWAYAT PENYAKIT SEKARANG :

(penyakit yang pernah atau sedang diderita/gejala sistemik yang disarankan/riwayat
pengobatan/ kebiasaan dn lingkungan keluarga)

RIWAYAT PENYAKIT GIGI LAINNYA :

PEMERIKSAAN FISIK
PEMERIKSAAN FISIK
UMUM
UMUM
Kesadaran……………………………………. Suhu………………………………………..
Kesadaran……………………………………. Suhu………………………………………..
Jantung……………………………………….. Tekanan Darah………………………….
Jantung……………………………………….. Tekanan Darah………………………….
Paru………………………....................... Nadi………………………………………….
Paru………………………....................... Nadi………………………………………….
Tanda Vital……………….................... Pernafasan………………………………..
Tanda Vital……………….................... Pernafasan………………………………..
Gizi……………………………………………..
Gizi……………………………………………..

MUKA/KEPALA
MUKA/KEPALA
Ekstra Oral (kelainan karena keluhan utama diuraikan pada status lokalis)
Ekstra Oral (kelainan karena keluhan utama diuraikan pada status lokalis)
muka……………………………………. Ekspersi………………………………………..
muka……………………………………. Ekspersi………………………………………..
Mata/Pupil…………………………… Skelra…………………………………………..
Mata/Pupil…………………………… Skelra…………………………………………..
Bibir………………………................ Kelenjar limfe………………………………
Bibir………………………................ Kelenjar limfe………………………………
Sendi TM………………................. Lain-lain………………………………………
Sendi TM………………................. Lain-lain………………………………………
INTRA ORAL ( kelainan karena keluhan utama diuraikan pada status lokalis)

Oral Higiene…………………………. Kalkulus………………………………………..

INTRA ORAL ( kelainan karena keluhan utama diuraikan pada status lokalis)
Mukosa Buka……………………….. Lidah…………………………………………..
Oral Higiene…………………………. Kalkulus………………………………………..
Sublingual………………………....... Gusi……………………………………………
Mukosa Buka……………………….. Lidah…………………………………………..
Tonsil………………...................... Palatum………………………………………
Sublingual………………………....... Gusi………………………………

Tonsil………………...................... Palatum………………………………………
STATUS LOKAL (Uraikan kelainan karena keluhan utama dengan rincian secara inpeksi, palpasi,
perkusi, bila perlu disertai gambar)

Ekstra oral :

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Intra Oral :

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...........................................................................................................................................................
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Resume :
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PEMERIKSAAN PENUNJANG DAN INTERPESTASINYA

FOTO RONTGENT

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PEMERIKSAAN LABORATORIUM
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DIAGNOSA DAN DIAGNOSA BANDING

ODONTOGRAM
11 [51] [61] 21
12 [52] [62] 22
13 [53] [63] 23
14 [54] [64] 24
15 [55] [65] 25
16 26
17 27
18 28

48 38
47 37
46 36
45 [85] [75] 35
44 [84] [74] 34
43 [83] [73] 33
42 [82] [72] 32
41 [81] [71] 31

Occlusi : Normal Bite / Cross Bite / Steep Bite

Torus Palatinus : Tidak Ada / Kecil / Sedang / Besar / Multiple

Torus Mandibularis : Tidak ada / sisi kiri / sisi kanan / kedua sisi

Palatum : Dalam / Sedang / Rendah

Diastema : Tidak Ada/ Ada: (dijelaskan dimana dan berapa lebarnya) .......................

Gigi Anomali : Tidak Ada / Ada: (dijelaskan gigi yang mana, dan bentuknya) ..................

Lain-lain : (hal-hal yang tidak tercakup diatas) .............................................................

D : ...... M : ....... F : ......

CIS = DIS =

SKOR OHIS = DI+CI =

SKOR OHIS

BAIK = 0-1,0

SEDANG = 1,1-2,0

BURUK = 2,1-3,0
NO TANGGAL TINDAKAN DAN MEDIKASI PETUGAS