FORM PEMERIKSAAN DAN RENCANA TERAPI AKUPRESUR

Nama :................................................... Umur :..............................................

Alamat :.................................................... Jenis Kelamin :..............................................
..................................................... Tanggal Periksa:..............................................
Pekerjaan :.................................................... No. Peserta :..............................................

I. PENGAMATAN
1. Keadaan kejiwaan
...................................................................................................................................................
...................................................................................................................................................
2. Warna wajah dan ekspresi muka (Se)
...................................................................................................................................................
...................................................................................................................................................
3. Bentuk tubuh dan gerak gerik (Xing Tay)
a. Bentuk Tubuh :............................................................................................................
b. Gerak – gerik :............................................................................................................
c. Kulit :............................................................................................................
d. Rambut :............................................................................................................
e. Hidung :............................................................................................................
f. Telinga :............................................................................................................
g. Mata :............................................................................................................
h. Mulut :............................................................................................................
i. Lidah
a) Otot Lidah :............................................................................................................
b) Selaput Lidah :............................................................................................................
II. PENDENGARAN DAN PENGHIBUATAU PENCIUMAN
1. Pendengaran :............................................................................................................
............................................................................................................
2. Penghibu :............................................................................................................
............................................................................................................
III. WAWANCARA
a. Hal-hal Umum
1. Keluhan Utama :.........................................................................................................
.........................................................................................................
2. Keluhan Tambahan :.........................................................................................................
3. Riwayat Penyakit :.........................................................................................................
4. Penyebab Penyakit :.........................................................................................................

b. Hal-Hal Khusus
1. Lingkungan Temapat Kerja :.....................................................................................
......................................................................................
2. Obat dan pengobatan yang :.....................................................................................
pernah didapat ......................................................................................
3. Kebiasaan makan minum :.....................................................................................
(Panas, dingin, pedas, ......................................................................................
manis, dll) ......................................................................................
4. Kehausan :.....................................................................................
5. Keringan :.....................................................................................
 6. Buang Air Kecil :.....................................................................................
7. Buang Air Besar :.....................................................................................
8. Kebiasaan Tidur :.....................................................................................
9. Daerah/Tempat Keluhan :.....................................................................................
10. Khusus Wanita :.....................................................................................
11. Khusus Anak :.....................................................................................
12. Lain - lain :.....................................................................................

IV. PERABAAN
1. Daerah Keluhan :............................................................................................................
2. Titik Khusus :............................................................................................................
3. Nadi :............................................................................................................
V. DIAGNOSA KELUAHAN
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
VI. PERENCANAAN TINDAKAN
1. Alat/bahan yang ..............................................................................................................
digunakan ..............................................................................................................
..............................................................................................................
2. Titik Akupresur ..............................................................................................................
yang dipilih dan ..............................................................................................................
tehnik rangsangan ..............................................................................................................
3. Saran ..............................................................................................................
..............................................................................................................
..............................................................................................................
..............................................................................................................
4. Jenis Terapi ..............................................................................................................
..............................................................................................................

Petugas Akupresur

Sutiyem, S. ST.
NIP. 197203242006042013