Tanggal Masuk

I IDENTITAS
Nama Umur JK
Status Kawin :

Agama :
Pekerjaan :
Alamat :
II RIWAYAT KESEHATANN
TD mmHg Nadi : S : P :
Alasan datang ke Puskesmas :

Penyakit yang pernah dialami :

III PERTUMBUHAN DAN PERKEMBANGAN (UNTUK PASIEN BALITA)

PERTUMBUHAN
Lahir kehamilan:…............bl/mgg Di : …............... Ditolong oleh : …............... Anak Ke : …....
BBL : …...…......... Gr TB …...….........cm BB/TB :…..................gr/cm
Kelainan : …...................................................................................................................
Anak Mendapat : ASI Susu Makanan Tambahan
buatan
Imunisasi Dasar Jenis :
Ulang Jenis :
PERKEMBANGAN
Umur membalik badan : bln Duduk : bln berdiri : bl Berjalan : bln
mengoceh: …......... bln Berbicara : ….................bln
IV KEBIASAAN KESEHATAN
Pernafasan melalui : …................................................. Masalah : …...................................................
Makan; frekuensi : x sehari jenis : …............................................................................
masalah : …................….............................................................................................................
Minum; Banyaknya : cc/hr jenis : …................................
Masalah : ...........................
Kesehatan kulit : ….........Warna:…....................... Turgor : …....... Rextor :…...................
kebersihan kulit : …................................................................................Masalah :….......................
Kesehatan gimul : …................................................................................Masalah :….......................
Kebersihan rambut & kuku : …................................................................................Masalah :….......................
Keadaan Indra : …................................................................................Masalah :….......................
 Aktivitas : Cara Berjalan :….........…...................................................................................
Reflex/Gerak
V KESEHATAN REPRODUKSI (PASIEN WANITA/IBU HAMIL)
Menstruasi : Siklus :….................Lamanya :..............................Hr Masalah :…........................
Kehamilan : Menstruasi terakhir :….............................................................................................
Palpasi : TFU.............................................................................Askaltasi : …..................
Presentasi : …................................................................................Masuk pap : …..................
Keadaan Janin : Pergerakan...................................................................Posisi : …..................
Umur Kehamilan : ….................. Minggu Masalah :…........................
Dirujuk : ….................................................................................
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