FORMULIR KUNJUNGAN RUMAH PK I

A. Identitas Pasien / Keluarga

Nama : ..........................................................................................................
Umur : ..........................................................................................................
Jenis Kelamin : ..........................................................................................................
Alamat : ..........................................................................................................
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No. Telp : ..........................................................................................................
Sarana kesehatan yang digunakan : .............................................................................
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B. Pemeriksaan
Keluhan yang dirasakan : ............................................................................................
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Tanda Vital
TD : Nadi : RR : Suhu :

Status Mental
Bingung Disorientasi Menarik diri
Cemas Depresi Sering marah
Keterangan : ................................................................................................................
......................................................................................................................................
......................................................................................................................................
Sistem Integumen
Warna kulit : ..........................................................................................................
Akral : ..........................................................................................................
CRT : ..........................................................................................................
Diaphoresis
Jaundice
Luka
Mukosa mulut : ..........................................................................................................
Lain – lain : ..........................................................................................................
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Sistem Kardiovaskuler
Aritmia Distensi Vena Jugularis
Nyeri dada Edema Perifer

Lain – lain : ..........................................................................................................

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Sistem Pernafasan
Wheezing Batuk
Ronchi Sputum
Lain – lain : ..........................................................................................................
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Sistem Pencernaan
Intake makanan: ..........................................................................................................
Intake cairan : ..........................................................................................................
Sonde Flatus Diare
Mual/Muntah Distensi Konstipasi
Hematemesis Nyeri perut
Frekuensi BAB : ..........................................................................................................
Bising usuh : ..........................................................................................................
Lain – lain : ..........................................................................................................
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Sistem Perkemihan
Disuria Inkontontinensia Konsistensi
Hematuria Retensi
Frekuensi : ..........................................................................................................
Jumlah : ..........................................................................................................
Lain – lain : ..........................................................................................................
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Sistem Persyarafan
Nyeri Kepala Reflek pupil Tremor
Lain – lain : ..........................................................................................................
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Sistem Muskuloskeletal
Paralisis Tonus otot Hemiparesis
Rentang gerak/ROM : .................................................................................................
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Kekuatan otot : ..........................................................................................................
Keseimbangan : ..........................................................................................................
Keterangan : ................................................................................................................
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Nyeri Spesifik
Lokasi : ..........................................................................................................
Tipe : ..........................................................................................................
Intensitas : ..........................................................................................................
Durasi : ..........................................................................................................
Skala : ..........................................................................................................
Keterangan : ................................................................................................................
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Riwayat Pengobatan
Alergi
Jenis obat yang dikonsumsi : .....................................................................................
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Efek Samping : ..........................................................................................................

C. Kegiatan sehari – hari

Makan/Minum : ..........................................................................................................
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Istirahat : ..........................................................................................................
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 BAB/BAK : ..........................................................................................................
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Kebersihan diri : ..........................................................................................................
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D. Perilaku tidak sehat

Merokok , ket : ...........................................................................
Minum kopi , ket : ...........................................................................
Mengkonsumsi garam , ket : ...........................................................................
Minum alcohol/NAPZA , ket : ..........................................................................
Perilaku seks bebas , ket : ..........................................................................

E. Spiritual
Taat beribadah : ..........................................................................................................
Kepercayaan yang berlawanan dengan kesehatan : ...................................................
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F. Psikologi
Keadaan emosi pada saat ini :
Marah Ketakutan Putus asa
Keterangan : ................................................................................................................
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G. Factor resiko masalah kesehatan

Lantai rumah licin : .....................................................................................................
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Pola rentang gerak : .....................................................................................................
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Penataan perabot rumah : ............................................................................................
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Hubungan tidak harmonis : .........................................................................................

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Lain – lain : ..........................................................................................................
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H. Tingkat kemandirian dalam kehidupan sehari – hari (dengan memberikan tanda

“√”pada kolom yang sesuai)
No Jenis Kegiatan Sehari – hari Mandiri Dengan
bantuan
1 Makan dan minum
2 Berpindah dari kursi ke tempat tidur dan
sebaliknya
3 Kebersihan diri : cuci muka, menyisir,
mencukur, dan aktivitas kamar mandi
4 Berjalan di jalan yang datar
5 Naik turun tangga
6 Berpakaian, termasuk mengenakan
 sepatu
7 Mengontrol buang air besar
8 Mengontrol buang air kecil
9 Olahraga / latihan fisik
10 Pemanfaatan waktu luang / rekreasi

Pasuruan, ……………..………

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