LAPORAN PEMERIKSAAN FISIK (KESEHATAN)

(Form SP.08)
AJK Jasindo – PA & ND RAHASIA
(COB 745)

Kepada Dokter yang memeriksa diminta mencocokkan keadaan calon tertanggung dengan kartu identitasnya (KTP, SIM) dan
mengisi jawaban dengan jelas :
1. IDENTITAS Tanda Tangan Calon
- Nomor KTP / SIM : ................................................................................
- Nama : .................................................................................
- Jenis Kelamin : ................................................................................
- Tempat/tgl. Lahir : ................................................................................
- Alamat : ................................................................................
2. UKURAN BADAN
a. Tinggi badan dengan/tanpa sepatu : ......................cm d. Lingkar Perut : ...................cm
b. Berat badan dengan/tanpa sepatu : .......................kg e. Lingkar Dada (tarik napas) : ...................cm
c. Lingkar Leher : ......................cm f. Keluar Napas : ...................cm
3. KEADAAN UMUM
a. Apakah Saudara Kenal pada calon ? .........................................................................................

Jika kenal, pribadi atau pasien ? .........................................................................................

b. Apakah calon kelihatan kurang sehat atau lebih tua dari umur ..........................................................................................
yang disebutkan ?

c. Adakah tanda-tanda luar yang memberikan kesan bahwa ..........................................................................................

calon menderita suatu penyakit atau ada ketergantungan
pada obat, minuman keras, atau semacamnya?
4. TELINGA, HIDUNG, TENGGOROKAN, DAN MATA
a. Bagaimana keadaan :
1. Mata 2. Telinga 3. Hidung 1. ........................................ 2. .................................
4. Lidah 5. Gigi 6. Tenggorokan 3. . ...................................... 4. .................................
4. ........................................ 6. .................................
b. Adakah kelainan-kelainan pada leher, misalnya gejala
Basedor atau struma? .........................................................................................
5. KERANGKA OTOT DAN URAT SYARAF
a. Bagaimana keadaan kerangka, otot, dan gizinya? ..........................................................................................
b. Adakan persangkaan penyakit pada otak, spinal dan ..........................................................................................
urat syaraf? ..........................................................................................
c. Bagaimanakah reflek-reflek lutut, A-chili, perut, ..........................................................................................
cremaster Babinski? ..........................................................................................
d. Adakah tanda-tanda kelainan neurologik misalnya ..........................................................................................
Tremor, paralyse, dll? ..........................................................................................
6. RONGGA DADA DAN PARU-PARU
a. Adakah kelainan pada bentuk rongga dada? ..........................................................................................
b. Adakah pernapasan symetris dan teratur? ..........................................................................................
c. Adakah kelainan pada perkusi dan auskultasi? ..........................................................................................
d. Apakah calon Asthmatis? ..........................................................................................

7. SIRKULASI DARAH
a. Tekanan darah : - Systolik ................................... ................................... ...............................
- Diastolik ................................... ................................... ...............................
Pengukuran diulangi sesudah 5 menit, jika tekanan
darah lebih dari 140/90
b. Nadi

Istirahat Tekuk lutut 10 x 5 menit kemudian

Rata-rata per menit
Extra systole
 c. Adakah tanda-tanda peripheral vascular desease? ................................... ................................... ...............................
8. JANTUNG
a. Dimanakah ictus cordis dada diraba? ................................... ................................... ...............................
b. Tentukan batas-batas jantung! ................................... ................................... ...............................
c. Adakah tanda-tanda pembesaran jantung? ................................... ................................... ...............................
d. Adakah tanda-tanda dari dekompensasi kordis? ................................... ................................... ...............................
e. Adakah murmur atau bunyi-bunyi jantung yang tidak
normal? Kalau ada, isi pertanyaan no. 9! ................................... ................................... ...............................
9. TEMPAT DIDENGARNYA .............. ................................... ................................... ...............................
Waktu ................................... ...................... Intensity ................................... Quality ........................ ...............................
- Systolik : ................................ - Lemah : ................................. – Grade 1-2 : ..............................................
- Diastolik : ................................ – Sedang :............................... – Grade 2-4 : .............................................
- Prosystolik : ............................... – Kuat :................................. - Grade 5-6 : .............................................
Transimissi ke ................................... ................................... .............................................................
Apakah diagnosa saudara ? ................................... ................................... ...............................
10. PERUT DAN ALAT-ALAT RONGGA TUBUH
a. Bagaimanakah keadaan dinding perut dan isi perut,
misal, sakit ditekan ? ................................... ................................... ...............................
b. Apakah hepar dan lien sehat?
Apakah nyeri tekan/lepas/pembesaran? ................................... ................................... ...............................
c. Apakah ada bekas-bekas operasi? Sebabnya? ................................... ................................... ...............................
d. Adakah Hernia? Jelaskan! ................................... ................................... ...............................
11. ALAT-ALAT KELAMIN (URGENITALIS)
a. Bagaimana keadaan ginjal ? ................................... ................................... ...............................
b. Adakah tanda-tanda sypilis gonorhoe? ................................... ................................... ...............................
c. Adakah tanda-tanda strictura atau kencing batu? ................................... ................................... ...............................
d. Adakah pembesaran prostat, kelenjar-kelenjar lain? ................................... ................................... ...............................
e. Hasil pemeriksaan kemih (harus dikeluarkan pada
waktu pemeriksaan) ................................... ................................... ...............................
Berat Jenis : ................................... ............. Zat gula :... ............... ................................... ...............................
Warna : ................................... ............. Albumin/Protein : ..... ................................... ................................
Reaksi : ................................... ............. Kristal : ..................... ................................... ...............................
12. KHUSUS WANITA
a. Apakah calon pernah/sedang menderita kelainan- ................................... ................................... ...............................
kelainan pada peranakan/payudara? ................................... ................................... ...............................
b. Adakah kelainan-kelainan dalam kehamilan dan ................................... ................................... ...............................
menstruasi? ................................... ................................... ...............................
c. Adakah calon saat ini hamil? ................................... ................................... ...............................
Kalau ya, bulan ke berapa? ................................... ................................... ...............................
d. Kapan terakhir kali bersalin? ................................... ................................... ...............................

13. KESIMPULAN
a. Berdasarkan pemeriksaan saudara, apakah anda ................................... ................................... ...............................
menganjurkan suatu pemeriksaan tambahan atau ................................... ................................... ...............................
laporan tambahan ? ................................... ................................... ...............................
................................... ................................... ...............................
b. Bagaimana pendapat saudara tentang kemungkinan ................................... ................................... ...............................
hidup calon berdasarkan kesehatan sekarang ? (Baik, ................................... ................................... ...............................
sedang, buruk). ................................... ................................... ...............................

Pandangan Dokter Penasehat : ................................... ................................... ...............................

................................... ................................... ...............................
................................... ................................... ...............................

Tanda tangan Dokter Pemeriksa

Dokter Penasehat Nama : ..................... ...............................

Alamat : .................... ...............................
.................... ...............................
NB : Hasil Pemeriksaan ini dikirimkan kepada Dr. Penasehat dalam sampul tertutup.