No. RM : ..........................................

RS ARSANI ASESMEN AWAL PASIEN Nama : ..........................................

RAWAT JALAN Tgl Lahir : ...................................L / P

(tempelkan label identitas pasien)

Tanggal:………………… Jam : …………… Asuransi/Umum/BPJS

Pendidikan :  SD  SLTP  SLTA  Sarjana Muda/S1/S2  Tidak Sekolah

Status Perkawinan :  Belum Kawin  Kawin  Janda  Duda
Pekerjaan :  PNS  Swasta  Tidak berkerja
Agama :  Islam  Khatolik  Protestan  Budha  Hindu  Khonghucu
 kepercayaan  Lain-lain,...........................................

ASSESMEN MEDIS (Diisi oleh Dokter)

I. ANAMNESA
1. Keluhan Utama (mulai, lama, pencetus) :........................................................................................................................
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2. Riwayat penyakit sekarang :............................................................................................................................................
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3. Riwayat penyakit dahulu ( termasuk riwayat operasi) : ...................................................................................................
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4. Riwayat alergi : a. Obat :  Tidak  Ya Sebutkan : ........................................................................
b. Makanan :  Tidak  Ya Sebutkan : ........................................................................
c. Lain – lain : .............................................................................................................

II. PEMERIKSAAN UMUM / FISIK

III. DIAGNOSIS
IV. PLANING DAN TERAPI/ TINDAKAN

V. EDUKASI

Dokter, Pasien/Keluaarga Pasien/Penanggung Jawab,

(................................................) (.........................................................)
Tanda tangan dan nama jelas Tanda tangan dan nama jelas