SURAT RUJUKAN PEMERIKSAAN KESEHATAN SURAT RUJUKAN BALIK PEMERIKSAAN KESEHATAN

CALON JEMAAH HAJI KABUPATEN CILACAP CALON JEMAAH HAJI KABUPATEN CILACAP

Kepada Yth Kepada Yth

Ts Dokter Pemeriksa Kesehatan Rujukan Ts Dokter Pemeriksa Kesehatan CJH
Spesialis …....………………….. Puskesmas ……………………..
RSUD Cilacap/RSUD Majenang/RS
Majenang/RS Pertamina Cilacap Kabupaten Cilacap
Kabupaten Cilacap
Dengan ini kami kirimkan Calon Jam
Jama’ah
a’ah Haji :

Dengan ini kami kirimkan Calon Jama

Jama’’ah haji :
Nama : .............................................................................
Bin/binti...............................................................
Umur : ........... th
Jenis Kelamin : Laki-laki / Perempuan
Alamat : .............................................................................
Kabupaten Cilacap
Diagnosa : .............................................................................
.............................................................................
..............................................................................
Untuk di lakukan pemeriksaan dan penatalaksanaan lebih lanjut.
Terapi yang sudah diberikan :
........................................................................................................
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........
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....
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.....
................................................................................................................
Nama : .............................................................................
Bin/binti...............................................................
Umur : ........... th
Jenis Kelamin : Laki-laki / Perempuan
Alamat : .............................................................................
Kabupaten Cilacap
Diagnosa : .............................................................................
.............................................................................
..............................................................................
Untuk di lakukan pemeliharaan lebih lanjut.
Terapi yang sudah diberikan :
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.............................................................................
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Saran terapi selanjutnya :
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Cilacap, ........................
................................
........2018
2018
Pemeriksa Kesehatan CJH Cilacap, ............
....................
.........................
.................2018
2018
Puskesmas...........................
Puskesmas..................................... Pemeriksa Kesehatan Rujukan CJH
RSUD Cilacap/RSUD Majenang/RS Pertamina

dr...............................................
Nip.........
Nip.............................................
.................................... dr.........................................................
Nip......................
Nip.................................
.......................
............
 PEMERIKSAAN KESEHATAN LANJUTAN  Kolesterol ( LDL ) : ..............................................
 Pemeriksaan darah lain atas indikasi :
1. Nama Dokter : ............................................................. ......................................................................................................
2. Jabatan : ............................................................. ......................................................................................................
......................................................................................................
3. Sarana Kesehatan dan Alamat : .............................................................
b. Urine
.............................................................
 Tes Kehamilan : Positif / Negatif
4. Tanggal Pemeriksaan : ............................................................. ( Tgl/Bln/Th: ............/............../.............)
A. RIWAYAT KESEHATAN  Pemeriksaan Urine Lain atas indikasi :
(perubahan/tambahan keterangan kondisi kesehatan berdasarkan anamnesis ...............................................................................................................
terkini.Termasuk hasil pengobatan,perbaikan kebugaran,perburukan penyakit) ...............................................................................................................
............................................................................................................................ 2. EKG : ( tuliskan penilaian dan lampiran hasil cetakannya )
............................................................................................................................ ...................................................................................................................................
............................................................................................................................ ...................................................................................................................................
............................................................................................................................ 3. Pencitraan Radiologi/USG/CT-Scan : ( tuliskan penilaian dan lampiran
B. PEMERIKSAAN FISIK film /cetakannya )
1. Tanda Vital .................................................................................................................................
a. Tekanan Darah .................................................................................................................................
Sistol : .......................... mmHg, Diastol : ........................... mmHg E. DIAGNOSA
b. Nadi 1. ..................................................................Kode...........................................
Frek : ............kali/menit, Vol : kecil/cukup/besar, Ritme : reguler/ireguler 2. ..................................................................Kode...........................................
c. Napas 3. ..................................................................Kode...........................................
Frek : ............kali/menit, Volume : dangkal/cukup/dalam 4. ..................................................................Kode...........................................
d. Suhu : ..............oC F. KESIMPULAN
2. Pemeriksaan Terkini 1. Kategori : ( harap diisi )
(ket.hasil pemeriksaan u/ mengikuti kondisi kesehatan terkini dari proses a. Memenuhi syarat istithaah kesehatan haji
pemeriksaan,pengobatan,perawatan,&atau peningkatan status kesehatan) b. Memenuhi syarat istithaah kesehatan haji dengan pendampingan
........................................................................................................................ c. Tidak memenuhi syarat istithaah kesehatan haji sementara
........................................................................................................................ d. Tidak memenuhi syarat istithaah kesehatan haji
........................................................................................................................ 2. Prognosa : Baik / Buruk / Stabil
........................................................................................................................ 3. Saran / Anjuran :
C. PEMERIKSAAN JIWA ......................................................................................................................
............................................................................................................................ ......................................................................................................................
............................................................................................................................ ......................................................................................................................
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D. PEMERIKSAAN PENUNJANG
1. Laboratorium Cilacap, .................................2018
a. Darah
 Hemaglobin : ............................................ Dokter Pemeriksa
 Laju Endap Darah ( LED ) : : ............................................
 Jumlah Lekosit : ............./................./.............
dr.....................................................
 Hitung Jenis Lekosit : ..............................................
NIP/NRP
 Gula Darah Sewaktu ( GDS ) : ..............................................