Nomor Urut : / /
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6. ANAMNESIS SISTEM:
Sistem Keterangan
(tdk dikeluhkan, dalam batas normal)
Kepala dan Leher
Kardiovaskuler
Respirasi
Gastrointestinalis
Urogenital
Muskuloskletal
Nervorum
B. P E M E R I K S AAN
1. PEMERIKSAAN FISIK
1.1. TANDA - TANDA VITAL:
a) Tekanan darah : ______________________
b) Denyut Nadi : ______________________
c) Pernapasan : ______________________
d) Temperatur : ______________________
e) Tinggi Badan : ______________________
f) Berat Badan : ______________________
1.2. INSPEKSI (STATIS & DINAMIS) (Posture, bengkak, gait, tropic change,
dll):
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c Gerak Isometrik Melawan Tahanan:
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1.9. PEMERIKSAAN
a. Nyeri
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b. MMT
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c. LGS
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d. Antropometri
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e. Test Khusus sesuai kelainan/penyakit/gangguan
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f. Dll.
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2.0 DIAGNOSIS FISIOTERAPI
a. Impairment
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b. Functional Limitations
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c. Disability
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C. PROGRAM/RENCANA FISIOTERAPI
1. Tujuan
a. Jangka Pendek
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b. Jangka Panjang
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2. TINDAKAN FISIOTERAPI:
a. Teknologi Fisioterapi:
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b. E d u k a s i:
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3. R E N C A N A E V A L U A S I:
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F. PELAKSANAAN FISIOTERAPI:
1. Hari: Tgl:
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G. E V A L U A S I:
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H. HASIL EVALUASI TERAKHIR:
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PEMBIMBING
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NIP/NIK.
K. CATATAN TAMBAHAN:
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L. Underlying Process
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