FRM/73.

3 Rev 01/RSBM

No RM :........................................
ASESMEN AWAL MEDIS Nama : ........................................
KLNIK INTERNA Tgl Lahir : .......................................
Jenis Kelamin :  Laki Perempuan
DATA AWAL Tgl: Jam
Rujukan:  Ya dari  RS.......................................  Puskesmas................................................
 dr. .......................................  Lainnya.....................................................
Dx Rujukan........................................................................................................
 Tidak  Datang Sendiri  Diantar................................................................

Nama Keluarga yang bisa dihubungi:................................................ NO HP/Telp................................

Alamat :...........................................................................
RIWAYAT ALERGI  Tidak  Ya, Obat:....................................Gejala / reaksi alergi.............................
Makanan :.............................Gejala / reaksi alergi.............................
Lain-lain: ...............................Gejala / reaksi alergi............................
Riwayat Penyakit : Hipertensi  Diabetes  Jantung  Stroke  Gagal Ginjal  Astma  Kejang
 Liver  Cancer  TBC  Glaukoma  STD  Perdarahan
 Lainnya............. .................
Riwayat Operasi :  Tidak  Ya, jenis dan Kapan …………………..
Riwayat Transfusi :  Tidak
 Ya Reaksi transfusi :  Tidak  Ya, reaksi yang timbul……………….
Riwayat Penyakit dalam Keluarga :...................................................................................................

ANAMNESA
1. Keluhan Utama: .......................................................................................................................................
.................................................................................................................................................................
2. Riwayat Penyakit Sekarang: ....................................................................................................................
.................................................................................................................................................................
3. Riwayat Penyakit Dahulu :.......................................................................................................................
.................................................................................................................................................................

Pemeriksaan Fisik
Keadaan umum :  Baik  Sedang  Lemah  Jelek Gizi : Baik Sedang Kurang Buruk
Mata : .................................................................................................................................................
THT :..................................................................................................................................................
Leher : .................................................................................................................................................
Thorax : ............................................................................................................. ....................................
......................................................................................................................................
Pulmo : .................................................................................................................................................
Abdomen : .................................................................................................................................................
Extrimitas : .................................................................................................................................................

Pemeriksaan Lainnya
......................................................................................................................................................................
......................................................................................................................................................................
 LANJUTAN
RENCANA KERJA HASIL PEMERIKSAAN PENUNJANG

DIAGNOSA (ICD-X) : TERAPI / TINDAKAN

DISPOSISI KOMPLIKASI
 Boleh Pulang, Jam Keluar:..................................WITA
Kontrol :  Ya Tanggal..........................
 Tidak

Dirawat : Ruang :  Intensif ....................................

 Ruang lain:...............................
Nama dan Tanda tangan Pasien/ Keluarga Nama dan Tanda tangan DPJP

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