RSUD Dr.

MOEWARDI – FAKULTAS KEDOKTERAN UNS

Jl. Kolonel Sutarto No. 132. SOLO. Telp 0271 634634

KARTU STATUS
I. UMUM
a. IDENTIFIKASI

Tanggal : ……………………………………………………………………………………………………………………
Nama : ……………………………………………………………………………………………………………………
Jenis Kelamin : ………………………………………… Umur : ……………………………………………………
Kepercayaan : ……………………………………..… Kebangsaan : ……………………………………………………
Status : ……………………………………………………………………………………………………………………
Alamat : ……………………………………………………………………………………………………………………

b. STATUS MEDIS
 Alergi : ………………………………………………………………………………
 Kelainan Herediter/Congenital : ………………………………………………………………………………
 Kelainan Lain : ………………………………………………………………………………
 Kelainan Dalam Perawatan : ………………………………………………………………………………
c. STATUS RONGGA MULUT
 Extra Oral : 1. Maxilla : ………………………………………………………………………………
2. Mandibula : ………………………………………………………………………………
3. Bibir : ………………………………………………………………………………
 Intra Oral : Lingua : ……………………… Palatum : …………………………
Left Bucal : ……………………… Right Bucal : …………………………
Upper Gingiva : ……………………… Lower Gingiva : …………………………
 Oral Higiene : Debris Index : ……………………………..
Calculus Index : ……………………………..
OHIS : ……………………………..

d. DENTAL FORMULA
 Permanent teeth

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

 Decidul teeth

i ii iii iv v vi vii viii ix X

xx xix xviii xvii xvi xv xiv xiii xii Xi

II. SUBJECTIVE
a. Chief Complain : ……………………………………………………………………………………………
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b. Present Illness : ……………………………………………………………………………………………
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c. Disease History : ……………………………………………………………………………………………
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III. OBJECTIVE
a. Gigi : ………………………………………………………………………………………………………
Sondation : ………………………………………………………………………………………………………
Percussion : ………………………………………………………………………………………………………
Palpation : ………………………………………………………………………………………………………
Chlor etil : ………………………………………………………………………………………………………
b. Jaringan Lunak : ……………………………………………………………………………………………………….
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c. Other inspection
Rongent Foto : ………………………………………………………………………………………………………..
Laboratorium : ………………………………………………………………………………………………………..

IV. DIAGNOSE
Diskripsi :
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D/ :
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V. THERAPY : ………………………………………………………………………………………………………..
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Mengetahui,
Dosen Pembimbing Dokter Muda/ CoAss

( ) ( )
NIP.