A. IDENTITAS PASIEN
Nama :
Umur :
Berat badan :
Panjang badan :
Jenis kelamin :
Tempat/tanggal lahir :
D. PEMERIKSAAN FISIK
Tanda-tanda vital
Denyut nadi : ________________________ kali/menit
Respirasi : ________________________ kali/menit
Suhu badan : ________________________ °C
Antropometri
Berat badan : ________________________ kg
Panjang badan : ________________________ cm
Lingkar dada : ________________________ cm
1. Pemeriksaan Kepala
Lingkaran Sub Occipto Bregnatica = ______________ cm
Lingkaran Fronto Occipitalis = ______________ cm
Lingkaran Mento Occipitalis = ______________ cm
Kelainan kepala : Caput succedanum
Hidrocephalus
Anencephalus
Cephal hematom
Microcephalus
Tidak ada kelainan
Lainnya : __________________________________________________
2. Pemeriksaan Mata
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3. Pemeriksaan Telinga
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4. Pemeriksaan Hidung
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5. Pemeriksaan Mulut
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6. Pemeriksaan Leher
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7. Pemeriksaan Dada
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8. Pemeriksaan Abdomen
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9. Pemeriksaan Genitalia
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10. Pemeriksaan Anus
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11. Pemeriksaan Kulit
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12. Pemeriksaan Ekstremitas Atas
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13. Pemeriksaan Ekstremitas Bawah
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