PENGKAJIAN INDIVIDU

Nama Panti : ..........................................................................................

Alamat Panti : ..........................................................................................
Tgl Masuk : ..........................................................................................
No. Register : ..........................................................................................

I. Identitas
A. Nama : ..............................................................................
B. Jenis kelamin : ..............................................................................
C. Umur : ..............................................................................
D. Agama : ..............................................................................
E. Status perkawinan : ..............................................................................
F. Pendidikan : ..............................................................................
G. Pekerjaan : ..............................................................................
H. Alamat rumah : ..............................................................................

II. Alasan kunjungan ke panti :

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III. Riwayat kesehatan :

1. Masalah kesehatan yang pernah dialami:
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2. Masalah kesehatan yang dirasakan saat ini:
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3. Masalah kesehatan keluarga/ keturunan:
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IV. Keadaan Biologis

1. Pola makan: .................................................................................................................
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2. Pola minum: .................................................................................................................
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3. Pola tidur: ..................................................................................................................
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4. Pola eliminasi (BAB/ BAK):
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5. Rekreasi: ..................................................................................................................
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V. Keadaan Psikologis
1. Keadaan emosi : ..................................................................................................................
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VI. Sosial
1. Dukungan keluarga : ..................................................................................................................
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2. Hubungan antar keluarga :
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3. Hubungan dengan orang lain :
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VII. Spiritual/ Kultural

1. Pelaksanaan ibadah: ..................................................................................................................
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2. keyakinan tentang kesehatan :
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VIII. Pemeriksaan fisik

A. Tanda Vital
1. Keadaan umum: ...........................................................................................................
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 2. Kesadaran:
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3. Suhu:
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4. Nadi :
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5. Tekanan darah: ..........................................................................................................
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6. Pernafasan:.
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7. Tinggi Badan: ............................................................................................................
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8. Berat Badan: ............................................................................................................
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B. Pemeriksaan khusus
1. Kepala
a. Rambut:
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b. Mata:
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c. Hidung:
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d. Mulut :
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e. Telinga:
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2. Leher::
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 3. Dada/ thorax.
a. Dada:
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b. Paru-paru : .....................................................................................................
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c. Jantung :
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4. Abdomen:
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5. Muskuloskeletal:
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6. Lain-lain:
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IX. Lingkungan
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X. Informasi penunjang
1. Diagnosa medik:
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2. Laboratorium:
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3. Terapi medik :
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Tangerang, .....................................
Nama Mahasiswa

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