I. DATA SUBJEKTIF
1.1 Identitas
Nama ibu : ……………………… Nama Suami : …………………..
Umur : ……………………… Umur : …………………..
Agama : ……………………… Agama : …………………..
Pendidikan : ……………………… Pendidikan : …………………..
Pekerjaan : ……………………… Pekerjaan : …………………..
Alamat : ……………………… No. telp : …………………..
No. telp : ………………………
A. Data Subjektif
1. Alasan datang/dirawat
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2. Keluhan utama
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3. Riwayat menstruasi
Menarche : ................................. Siklus : ........................................
Lama : ................................. Teratur : ........................................
Sifat darah : ................................. Keluhan : ........................................
4. Riwayat perkawinan
Status perkawinan : ..................... Menikah ke : ..................................
Lama : ..................... Usia menikah pertama kali : ..........
8. Riwayat kesehatan
a. Penyakit yang pernah/sedang diderita (menular, menurun dan menahun)
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b. Penyakit yang pernah/sedang diderita keluarga (menular, menurun dan menahun)
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c. Riwayat keturunan kembar
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d. Riwayat operasi
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e. Riwayat alergi obat
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b. Eliminasi
BAB
Frekuensi : ........ x/hari ........... x/hari
Warna : .............................. ...............................
Konsistensi : .............................. ...............................
Keluhan : .............................. ...............................
BAK
Frekuensi : ........ x/hari ........... x/hari
Warna : .............................. ...............................
Konsistensi : .............................. ...............................
Keluhan : .............................. ...............................
c. Istirahat
Tidur siang
Lama : ........ Jam/hari .................. Jam/hari
Keluhan : ................................ ................................
Tidur malam
Lama : ................ Jam/hari ……............ Jam/hari
Keluhan : ................................ ................................
d. Personal Hygiene
Mandi : ...... x/hari ...... x/hari
Ganti pakaian : ...... x/hari ...... x/hari
Gosok gigi : ...... x/hari ...... x/hari
Keramas : ...... x/minggu ...... x/minggu
e. Pola seksualitas
Frekuensi : ...... x/minggu ...... x/minggu
Keluhan : ................................ ................................
B. Data Objektif
1. Pemeriksaan umum
Keadaan umum : .......................................................................
Kesadaran : .......................................................................
Status emosional : .......................................................................
Tanda vital :
Tekanan darah : .............mmHg Nadi : ...........x/menit
Pernafasan : ............x/menit Suhu : ...........x/menit
BB : ............kg TB : ...........cm
2. Pemeriksaan Fisik
Kepala : .................................................................................................................
Wajah : .................................................................................................................
Mata : .................................................................................................................
Hidung : .................................................................................................................
Mulut : .................................................................................................................
Telinga : .................................................................................................................
Leher : .................................................................................................................
Dada : .................................................................................................................
Payudara : .................................................................................................................
Abdomen : .................................................................................................................
Palpasi
Leopold I : .................................................................................................................
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Leopold II : .................................................................................................................
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Leopold III : .................................................................................................................
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Leopold IV : .................................................................................................................
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TFU : ...........cm TBJ :..................................................................
DJJ : ...........x/menit
4. Data penunjang
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B. Masalah
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B. Kolaborasi
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C. Merujuk
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MENGETAHUI,
NIP.