PROTOCOL PENGUMPULAN DATA

PROYEK KATAMATAKU
23-24 APRIL 2018

1. Pasien kusta yang sed

2. Telah memb

IDENTITAS

NO URUT
NAMA ALAMAT RUMAH

1 001 UUN MARYANAH KOMP. SERBAGUNA RT/RW 001/013

2 002 ROMLI LORONG I NO 18 RT 01/13
 3 003 ADE LORONG I SITANALA
4 004 POPON GUNAKARYA RT 01/13 NO 20
5 005 UMSIYAH DEPAN GOR SITANALA
6 006 SATNAH SITANALA
7 007 SUHAETI KOMPLEK SITANALA NO 40
8 008 MASUYAH DEPAN GOR SITANALA
9 009 TUTI KOMPLEK SITANALA NO 40
10 010 MARHUMAH KOMPLEK SITANALA NO 36
11 011 SAMSIYAH KOMPLEK SITANALA NO 40
12 012 MARTA KOMPLEK SITANALA NO 39 RT 01/13
13 013 MARYAM KOMPLEK SITANALA NO 71
14 014 ELI HERAWATI KOMPLEK SITANALA NO 36
15 015 KOMARIAH KOMPLEK SITANALA 30/31
16 016 ABDUL RASYID KOMPLEK SITANALA NO 23 RT 01
17 017 ROSYID KOMPLEK SITANALA NO 71
18 018 MIMIK KOMPLEK SITANALA NO 38
19 020 RASMA KOMPLEK SITANALA RT 01/13
20 021 HASAN KOMPLEK SITANALA NO 28 RT 01/13
21 022 SAFARI KOMPLEK SITANALA
22 023 SUBUR KOMPLEK SITANALA GUNA KARYA NO 37
23 024 ABDURAHMAN KOMPLEK SITANALA RT 01/13
24 025 ABAN KOMPLEK SITANALA NO 115
25 026 JULEHA KOMPLEK SITANALA RT 01/ RW 013
26 027 EMI KOMPLEK SITANALA RT 01/ RW 013
27 028 ZAENAL ABIDIN KOMPLEK SITANALA RT 01/ RW 013 NO 40
28 030 RUBIEM KOMPLEK SITANALA NO 113
29 031 MAEMUNAH KOMPLEK SITANALA RT 01/ RW 13
30 032 TASWI KOMPLEK SITANALA RT 1/ RW 13
31 033 TASIM KOMPLEK SITANALA RT 01/ RW 013 NO 51
32 034 ERNI KOMPLEK SITANALA RT 01/ RW 013 NO 51
33 035 IWAN KOMPLEK SITANALA RT 01/ RW 013
34 037 SURTINI KOMPLEK SITANALA RT 01/ RW 013
35 038 MUSA KOMPLEK SITANALA RT 01/ RW 013
36 039 WATI KOMPLEK SITANALA NO 106
37 040 SAMSUDIN KOMPLEK SITANALA RT 01/ RW 013
38 041 ATA KOMPLEK SITANALA NO 90
39 042 NYAI SUMIATI KOMPLEK SITANALA
40 043 PULUNG KOMPLEK SITANALA RT 01/ RW 013 NO 133
41 044 AAM KOMPLEK SITANALA
42 045 ISKANDAR KOMPLEK SITANALA RT 01/ RW 013
43 046 JONYAH KOMPLEK SITANALA RT 01/ RW 013
44 047 YUNUS PRIHADI KOMPLEK SITANALA RT 01/ RW 013
45 048 TAHIYAR KOMPLEK SITANALA RT 01/ RW 013 NO. 5
46 049 RAHMAT KOMPLEK SITANALA RT 01/ RW 013
47 050 BOY PUNDOKO KOMPLEK SITANALA RT 02/ RW 013
48 051 MARUDIN KOMPLEK SITANALA RT 01/ RW 013
49 052 EPI KOMPLEK SITANALA RT 01/ RW 013 NO 52
50 053 SLAMET PURWADI KOMPLEK SITANALA RT 01/ RW 013 NO 187
51 054 ELI MARULI KOMPLEK SITANALA RT 01/ RW 013
52 055 SUPRIYANTONO HADI KOMPLEK SITANALA RT 01/ RW 013
53 056 NENGSIH KOMPLEK SITANALA RT 01/ RW 013
54 057 KARNI KOMPLEK SITANALA RT 01/ RW 013 NO 87
55 058 ANISAH KOMPLEK SITANALA RT 01/ RW 013 NO 42
56 059 BUNYAMIN KOMPLEK SITANALA RT 01/ RW 013
57 060 MURSITI KOMPLEK SITANALA RT 01/ RW 013
58 061 GEMI KOMPLEK SITANALA RT 01/ RW 013
59 062 YATI KOMPLEK SITANALA RT 04/ RW 013
60 063 CASTIWI KOMPLEK SITANALA RT 04/ RW 013
61 064 ALI KOMPLEK SITANALA RT 01/ RW 013 NO 35
62 065 SAJAN KOMPLEK SITANALA RT 01/ RW 013
63 066 SUHARTO KOMPLEK SITANALA RT 02/ RW 013
64 067 AKLANI KOMPLEK SITANALA RT 01/ RW 013
65 068 FATULLAH KOMPLEK SITANALA RT 01/ RW 013
66 069 NURBISNA KOMPLEK SITANALA RT 01/ RW 013 NO 66
67 070 HADIJAH KOMPLEK SITANALA RT 02/ RW 013
68 071 ALI M RSK SITANALA BANGSAL KUSTA TERPADU
69 072 KOMARUDIN KOMPLEK SITANALA RT 04/ RW 013
70 073 SUDIN SITANALA
71 074 YATI KOMPLEK SITANALA NO 94
72 075 ASHARI KOMPLEK SITANALA NO 94 RT 01/ RW 13
73 076 SACA KOMPLEK SITANALA RT 01/ RW 13
74 077 AGUNG KOMPLEK SITANALA RT 02/ RW 013
75 078 DASUKI KOMPLEK SITANALA RT 01/ RW 13
76 079 YAYAH CAHYATI KOMP SERBAGUNA RT 02/ RW 13
77 080 MARIYATI SITANALA
78 081 JUMINEM KOMPLEK SITANALA RT 01/ RW 13
79 082 CASMADI KOMPLEK SITANALA RT 01/ RW 13
80 083 RONI KOMPLEK SITANALA RT 01/ RW 13
81 084 TITIN KOMPLEK SITANALA RT 01/ RW 13 NO 24
82 085 USMAN KOMPLEK SITANALA RT 01/ RW 13 NO 93
83 086 INDAYATI KOMPLEK SITANALA RT 05/ RW 13
84 087 HARTONO KOMPLEK SITANALA RT 01/ RW 13 NO 163
85 088 UTI KOMPLEK SITANALA RT 01/ RW 13
86 089 ROJALI KOMPLEK SITANALA RT 01/ RW 13
87 090 SAPEI KOMPLEK SITANALA RT 01/ RW 13
88 091 SRIWAHYUNINGSIH KOMPLEK SITANALA RT 01/ RW 13
89 092 YUMIATI KOMPLEK SITANALA RT 01/ RW 13
90 093 SISWANTO KOMPLEK SITANALA RT 01/ RW 13
91 094 RATNAWATI KOMPLEK SITANALA RT 01/ RW 13
92 095 DOMIN KOMPLEK SITANALA RT 01/ RW 13
93 096 KASMIN KOMPLEK SITANALA RT 01/ RW 13
94 097 ESEM KOMPLEK SITANALA RT 01/ RW 13
 95 098 TITIN KOMPLEK SITANALA RT 01/ RW 13
96 099 ISMAIL KOMPLEK SITANALA
97 100 ITAH KOMPLEK SITANALA RT 01/ RW 13
98 101 MARKUS UTONO KOMPLEK SITANALA RT 01/ RW 13 NO 148
99 102 SITI JENAH KOMPLEK SITANALA RT 01/ RW 13
100 103 DEWI KOMPLEK SITANALA RT 01/ RW 13
101 104 SUTINEM KOMPLEK SITANALA RT 05/ RW 13
102 105 ENAH KOMPLEK SITANALA RT 04/ RW 13
103 106 HERI KOMPLEK SITANALA RT 01/ RW 13 NO 50
104 107 MERNI KOMPLEK SITANALA RT 02/ RW 13
105 108 OTONG KOMPLEK SITANALA RT 03/ RW 13
106 109 KACUNG BAMBANGRETNO KOMPLEK SITANALA RT 02/ RW 13
107 110 ARMAIN KOMPLEK SITANALA RT 01/ RW 13
108 111 ROSIAH KOMPLEK SITANALA RT 04/ RW 13 NO 14
109 112 SURAHMAN KOMPLEK SITANALA RT 01/ RW 13
110 113 SUJIMAN KOMPLEK SITANALA RT 01/ RW 13
111 114 TAUFIK KOMPLEK SITANALA RT 01/ RW 13
112 115 MARDIANA KOMPLEK SITANALA RT 01/ RW 13
113 116 MIAN KOMPLEK SITANALA RT 01/ RW 13
114 117 CATA KOMPLEK SITANALA RT 01/ RW 13
115 118 DAKMIN KOMPLEK SITANALA RT 01/ RW 13
116 119 IDEH KOMPLEK SITANALA RT 01/ RW 13
117 120 MUNAWAROH KOMPLEK SITANALA RT 01/ RW 13 LORONG 3
118 121 MARYAM KOMPLEK SITANALA LORONG 9 NO 108
119 122 ANININGSIH KOMPLEK SERBAGUNA RT 01/013
120 123 ASMADI KOMPLEK SERBAGUNA RT 02/013
121 124 HIKMAH KOMPLEK SITANALA RT 01/ RW 013
122 125 MUNAWIR KOMPLEK SERBAGUNA RT 003/RW 013
123 126 HARTINI KOMPLEK SITANALA
124 127 TONI SILALAHI KOMPLEK SERBAGUNA RT 003/ RW 013
125 128 SEHADI KOMPLEK SERBAGUNA RT 01
126 129 AMIR KOMPLEK SERBAGUNA RT 03/13
127 130 WARDI KOMPLEK SITANALA RT 003/013
128 131 AMIN KOMPLEK SERBAGUNA RT 05/RW 13 LORONG 9
129 132 DAENG MATAJANG KOMPLEK SERBAGUNA SITANALA RT 03/ RW 013
130 133 SOMA KOMPLEK SITANALA RT 01/ RW 013
131 134 M. SLAMET SUPRIYADI KOMPLEK SERBAGUNA RT 003/RW 013
132 135 MASTUROH KOMPLEK SERBAGUNA RT 003/RW 013
133 136 SUSANTO KOMPLEK SERBAGUNA RT 003/RW 013
134 137 LUKMAN SUMANTI KOMPLEK SERBAGUNA SITANALA RT 02/RW013
135 138 AGUS BADARUDIN KOMPLEK SERBAGUNA SITANALA RT 03/RW 013
136 139 YAS SITANALA LORONG 10 RT 05/ RW 13
137 140 JOSEPH SIRBOLON KOMPLEK SITANALA LORONG 5 RT 02/RW 013
138 141 ANA SITANALA RT 03/ RW 013
139 142 SITI SALBIAH KOMPLEK SERBAGUNA SITANALA RT 05/ RW 013
140 143 ABDUL SUKUR KOMPLEK SITANALA RT 04/ RW 013
141 144 ANITI KOMPLEK SITANALA RT 05/ RW 013
142 145 NADIN KOMPLEK SITANALA RT 05/ RW 013
143 146 PROSI KUSUMAWATI KOMPLEK SERBAGUNA RT 03/RW013
144 147 RINA KOMPLEK SITANALA RT 05/ RW 013
145 148 ITA MUNJAITA KOMPLEK SERBAGUNA SITANALA RT 03/ RW 013
146 149 SIDUP KOMPLEK SITANALA RT 05/RW 013
147 150 SURYATI KOMPLEK SERBAGUNA SITANALA RT 05/ RW 013 NO 4
148 151 SUTARJO KOMPLEK SERBAGUNA RT 03/ RW 013
149 152 JUARI ISMAIL KOMPLEK SITANALA RT 04/ RW 013
150 153 YATMI KOMPLEK SERBAGUNA RT 03/ RW 013
151 154 MA'AH KOMPLEK SERBAGUNA RT 03/ RW 013
152 155 NASRULLAH KOMPLEK SERBAGUNA SITANALA RT05/RW013
153 156 D. EFFENDI KOMPLEK SERBAGUNA SITANALA RT 04/RW 013
154 157 MUHAMAD KOMPLEK SERBAGUNA RT 03/ RW 013
155 158 MONZILA KOMPLEK SEBAGUNA SITANALA RT 03/RW 013
156 159 BUSIRIH H KOMPLEK SERBAGUNA RT 003/ RW 013
157 160 MIAN KOMPLEK SERBAGUNA RT 02/RW013
158 161 KADIR KOMPLEK SERBAGUNA RT 02/RW 013
159 162 USIN KOMPLEK SITANALA RT 03/RW013
160 163 WINAL KOMPLEK SERBAGUNA RT 03/RW013
161 164 JAMIUN KOMPLEK SERBAGUNA LORONG 7 RT 06/RW 013
162 165 AMAN KOMPLEK SITANALA LORONG 9 RT 03/RW013
163 166 LAPADUAI KOMPLEK SITANALA RT 05/ RW 013
164 167 SULHI PRASISTYAN KOMPLEK SERBAGUNA RT 02/ RW 013
165 168 MAKKA KOMPLEK SERBAGUNA SITANALA RT 04/ RW 013
166 169 SAROH KOMPLEK SERBAGUNA RT 03/ RW 013
167 170 AGUS MITE KOMPLEK SERBAGUNA LORONG 5 RT 02/ RW 013
168 171 UDIN BURHANUDIN KOMPLEK SITANALA RT 04/013
169 172 SAHRIM KOMPLEK SERBAGUNA SITANALA
170 173 YOHADI KOMPLEK SERBAGUNA SITANALA RT 04/013
171 174 UDIN KOSENG KOMPLEK SERBAGUNA SITANALA RT 03/013
172 175 EMAT KOMPLEK SERBAGUNA SITANALA RT 03/013
173 176 SYAMSUDIN KOMPLEK SITANALA LORONG 8 RT 01/013
174 177 NURSEN KOMPLEK SERBAGUNA SITANALA RT 01/013
175 178 WARSINAH KOMPLEK SERBAGUNA SITANALA RT 04/013
176 179 MARTONO KOMPLEK SERBAGUNA LORONG 5 SITANALA RT 06/013
177 180 BUDI KOMPLEK SERBAGUNA SITANALA RT 04/013
178 181 BASOR KOMPLEK SERBAGUNA SITANALA RT 01/013
179 182 SADIN KOMPLEK SITANALA RT 03/013
180 183 ABU BAKAR KOMPLEK SERBAGUNA SITANALA RT 04/013
181 184 DARUN KOMPLEK SERBAGUNA SITANALA
182 185 IDA FARIDA KOMPLEK SITANALA RT 02/013
183 186 NAMAN KOMPLEK SITANALA RT 01/013
184 187 YOSWA SUMINTO KOMPLEK SERBAGUNA SRT 02/013
185 188 WALIM KOMPEK SERBAGUNA SITANALA RT 02/013
186 190 MARIA KOMPLEK SERBAGUNA SITANALA LORONG 5
187 191 ANTONIUS KOMPLEK SITANALA
188 192 CUNSAN KOMPLEK SERBAGUNA RT 02/013
189 193 CECE KOMPLEK SITANALA LORONG 9 RT 03/013
190 194 NURAINI KOMPLEK SITANALA RT 03/013
191 195 KOKOM KOMPLEK SERBAGUNA SITANALA RT 03/013
192 196 ZULAMIN KOMPLEK SERBAGUNA SITANALA RT 04/013
193 197 ABDUL WAHAB KOMPLEK SERBAGUNA RT 03/013
194 198 ANIK KOMPLEK SITANALA RT 02/RW 013
195 199 SITI AISAH KOMPLEK SERBAGUNA RT 03/013
196 200 HERI SETIAWAN KOMPLEK SITANALA RT 05/013
197 201 NINING DAHLIA KOMPLEK SITANALA RT 05/013
198 202 IYANG KOSASIH KOMPLEK SITANALA RT 03/013
199 203 FERI LEWANDATU KOMPLEK SERBAGUNA RT 04/013
200 204 NURLAELA KOMPLEK SERBAGUNA SITANALA RT 04/013
201 205 AMINAH KOMPLEK SERBAGUNA LORONG 7, RT 03/013
202 206 ADE KRISTINA KOMPLEK SERBAGUNA SITANALA RT 03/013
203 207 KHOLIFAH KOMPLEK SERBAGUNA SITANALA RT 03/013
204 208 MININ KOMPLEK SERBAGUNA SITANALA RW 03/013
205 209 PIO KOMPLEK SITANALA RT 03/013
206 210 SUWITO KOMPLEK SERBAGUNA SITANALA RT 03/013
207 211 NUR SAPTADDY KOMPLEK SERBAGUNA SITANALA RT 01/013
208 212 KUSNAMI DEWI KOMPLEK SERBAGUNA SITANALA RT 01/013
209 213 WARHUDI KOMPLEK SERBAGUNA SITANALA RT 03/013
210 214 SUBAGYO KOMPLEK SERBAGUNA SITANALA RT 01/013
211 215 SUGONO KOMPLEK SERBAGUNA SITANALA RT 01/013
212 216 SITI ASIYAH KOMPLEK SERBAGUNA SITANALA RT 02/013
213 217 ACEM KOMPLEK SERBAGUNA SITANALA RT 04/013
214 218 ONYONG KOMPLEK SERBAGUNA SITANALA RT 04/013
215 219 DARSIH KOMPLEK SERBAGUNA SITANALA RT 04/013
216 220 KHADIR KOMPLEK SITANALA RT 01/013
217 221 YOHANES SUPARJI KOMPLEK SITANALA RT 04/013
218 223 SAPRI KOMPLEK SITANALA NO 172, RT 04/013
219 224 ANDRE KOMPLEK SITANALA NO 224 RT 01/013
220 225 MARDIYATI KOMPLEKS SITANALA LORONG II RT 04/013
221 226 SUMAAH KOMPLEK SITANALA RT 03/013
222 227 SING KOMPLEKS SITANALA NO 5 RT 02/013
223 228 WATI KOMPLEK SITANALA RT 05/013
224 229 EEM KOMPLEK SITANALA LORONG 5 RT 02/013
225 230 ABDUL BAKAR KOMPLEK SITANALA RT 04/013
226 231 MASWANTO KOMPLEKS SITANALA RT 02/013
227 232 HAMBALI KOMPLEK SITANALA NO 81 RT 03/013
228 233 MARYATIN KOMPLEK SERBAGUNA LORONG 9 RT 04/013
229 234 DEDE SISMANA KOMPLEKS SITANALA NO 37 LORONG 8, RT 03/013
230 235 GIOK PERMANA KOMPLEK SITANALA NO 19, RT 04/013
231 236 KHOLIL KOMPLEK SITANALA NO 236 RT 02/ RW 013
232 237 DURAHMAN KOMPLEK SERBAGUNA NO 192 RT 04/ RW 013
233 238 OBAY KOMPLEK SERBAGUNA SITANALA RT 01/ RW 013
234 239 NURLELI SITANALA LORONG 8 RT 03/RW013
235 240 LIDYA KOMPLEKS SITANALA NO 52 RT 02/RW013
236 241 BAHARUDIN KOMPLEK SERBAGUNA RT 02/RW013
237 242 ANDU KOMPLEK SERBAGUNA RT 02/RW013
238 243 TAJUDIN KOMPLEK SITANALA RT 001/ RW 013
239 244 AHMAD TOLIBIN KOMPLEKS SITANALA NO 147 RT 01/ RW 013
240 245 ENENG ROHAYAH KOMPLEK SITANALA
241 246 DUDUNG ABDURAHMAN KOMPLEK SERBAGUNA RT 02/ RW 013
242 247 SUEB KOMPLEKS SERBAGUNA RT 02/ RW 013
243 248 DARI KOMPLEKS SITANALA RT 01/ RW 01
244 249 MUCHTAR KOMPLEKS SERBAGUNA NO 27 RT 03/ RW 013
245 250 KOSIM KOMPLEK SERBAGUNA RT 04/ RW 013
246 251 AHMAD SUDARTO KOMPLEK SITANALA RT 01/ RW 013
247 252 SOPIAH KOMPLEKS SITANALA LORONG 6 RT 02/ RW 013
248 253 MARULLOH KOMPLEKS SITANALA NO 35 RT 04/RW 013
249 254 SALIM KOMPLEKS SITANALA RT 05/RW013
250 255 UMANG KOMPLEKS SITANALA LORONG 9 RT 04/ RW 013
251 256 CARITEM KOMPLEKS SERBAGUNA RT 04/ RW 13
252 257 MUH. ABADI KOMPLEKS SITANALA NO 171 RT 02/RW13
253 258 SUBAKAR DKI RT 05/013
254 259 SARTINI KOMPLEK SERBAGUNA LORONG 8 RT 03/RW13
255 260 SUNU KOMPLEK SITANALA NO 5 RT 02/ RW 13
256 261 KOMARUDIN KOMPLEK SERBAGUNA RT 03/RW13
257 262 RUNDA KOMPLEK SITANALA RT 01/RW 13
258 263 ASMANAH KOMPLEK SITANALA NO 88 RT 03/RW 13
259 264 HESTI KOMPLEK BULAK NO 27 RT 05/RW13
260 265 MANSYUR KOMPLEK SITANALA RT 05/RW 13

Catatan
Jumlah pasien
Yang status yangdan
hilang datang
tidak=menyelesaikan
265 pasien penelitian=5 status
( 029,019,036,189,222)
 KRITERIA INKLUSI
1. Pasien kusta yang sedang/pernah menjalani pengobatan monoterapi/MDT di Rumah Sakit Sitanala berdasarkan pengaku
2. Telah memberikan persetujuan ikut penelitian yang terdokumentasikan sebelum dilakukan prosedur penelitian
3. Bersedia mengikuti prosedur penelitian

KRITERIA EKSKLUSI

1. Partisipan menderita gangguan jiwa berat atau kesulitan berkomunkasi berdasarkan penilaian tim peneliti

1= ya 1= ya 1= ya 1= ya
0 = tidak 0 = tidak 0 = tidak 0 = tidak

KRITERIA INKLUSI DAN EKSKLUSI

KRITERIA INKLUSI

NO TELEPON 1. Pasien kusta yang KRITERIA EKSKLUSI

sedang/pernah 2. Telah memberikan
menjalani persetujuan ikut
pengobatan penelitian yang 3. Bersedia mengikuti
monoterapi/MDT di terdokumentasikan prosedur penelitian
Rumah Sakit Sitanala sebelum dilakukan
berdasarkan prosedur penelitian
pengakuan pasien

1 1 1 0
085211196179 1 1 1 0
 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
081210864085 1 1 1 0
1 1 1 0
082299599472 1 1 1 0
1 1 1 0
0895610763219 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0

1 1 1 0
1 1 1 0
081287512324 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
0 1 1 0
1 1 1 0
1 1 1 0
083895901926 1 1 1 0
081210003842 1 1 1 0
1 1 1 0
085214096513 0 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
0895633697172 1 1 1 0
1 1 1 0
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0 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
089630099176 1 1 1 0
081286013405 1 1 1 0
081280998190 1 1 1 1
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
087884029090 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
081272712440 1 1 1 0
087773765890 1 1 1 0
1 1 1 0
1 1 1 0
081219660876 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
081289013143 1 1 1 0
089675219071 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
081293460757 1 1 1 0
081905550501 1 1 1 0
083896857423 1 1 1 0
081807198701 1 1 1 1
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
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1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
087782887636 1 1 1 0
1 1 1 0
1 1 1 0
08210229747 1 1 1 0
1 1 1 0
1 1 1 0
082311551454 1 1 1 0
1 1 1 0
1 1 1 0
081221710554 1 1 1 0
1 1 1 0
081289090807/ 083813211065 1 1 1 0
083813211065 1 1 1 0
085312141476 1 1 1 0
085714221126 1 1 1 0
083878382450 1 1 1 0
1 1 1 0
1 1 1 0
082110312726 1 1 1 0
0 1 1 1
081399844209 1 1 1 0
081293500390 1 1 1 0
087808475375 1 1 1 0
1 1 1 0
081291663114 1 1 1 0
1 1 1 0
0 1 1 0
1 1 1 0
0 1 1 0
089604229925 1 1 1 0
1 1 1 0
081210936130 1 1 1 0
1 1 1 0
082211724008 1 1 1 0
081282796080 1 1 1 0
1 1 1 0
1 1 1 0
081270227654 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
 1 1 1 0
1 1 1 0
1 1 1 0
81384085285 0 1 1 0
02155791403 1 1 1 0
081290406768 1 1 1 0
1 1 1 0
085773408572 1 1 1 0
1 1 1 0
085773408572 0 1 1 0
083893157048 1 1 1 0
1 1 1 0
081381625133 0 1 1 0
1 1 1 0
0818906010339 1 1 1 0
085817441671 0 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
0 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
081340335338 1 1 1 0
081287222141 1 1 1 0
0 1 1 0
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1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
085280094504 1 1 1 0
081340335480 1 1 1 0
1 1 1 0
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081380881562 1 1 1 0
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081218223277 0 1 1 0
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081287859164 1 1 1 0
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085285362020 1 1 1 0
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081277431128 1 1 1 0
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0 1 1 0
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085945775806 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
081906010339 1 1 1 0
1 1 1 0
1 1 1 0
085891168928 0 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
0 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
0 1 1 0
1 1 1 0
081210895801 1 1 1 0
0 1 1 0
1 1 1 0
081394703443 1 1 1 0
1 1 1 0
081213936601 1 1 1 0
1 1 1 0
1 1 1 0
081210005549 1 1 1 0
085717444733 1 1 1 0
081319752566 1 1 1 0
082139706020 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
0857777191898 1 1 1 0
081380336019 1 1 1 0
0 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
081286729199 1 1 1 0
1 1 1 0
1 1 1 0
1 1 1 0
081210005547 1 1 1 0
082297654426 1 1 1 0
081291657771 1 1 1 0
1 1 1 0
081315761730 0 1 1 0
081298856143 1 1 1 0
1 1 1 0
1 1 1 0
0 1 1 0
0 1 1 0
1 1 1 0
la berdasarkan pengakuan pasien
kan prosedur penelitian

penilaian tim peneliti

1= ya 1 = hari 1 1 = pria
0 = tidak 0 = hari 2 2 = wanita

AN EKSKLUSI

KRITERIA EKSKLUSI HARI PEREKRUTAN TANGGAL LAHIR USIA JENIS KELAMIN

0 1 23/04/2018 12/12/1952 65 2
0 1 23/04/2018 30/10/1953 64 1
0 1 23/04/2018 55 1
0 1 23/04/2018 6/6/1952 65 2
0 1 23/04/2018 65 6
0 1 23/04/2018 50 2
0 1 23/04/2018 40 2
0 1 23/04/2018 2
0 1 23/04/2018 09/02/1968 50 2
0 1 23/04/2018 10/04/1973 45 2
0 1 23/04/2018 02/05/1975 43 2
0 1 23/04/2018 19/02/1959 59 1
0 1 23/04/2018 19/11/1974 43 2
0 1 23/04/2018 26/04/1979 39 2
0 1 23/04/2018 LUPA 2
0 1 23/04/2018 31/06/1956 61 1
0 1 23/04/2018 01/01/1957 61 1
0 1 23/04/2018 55 2
0 1 23/04/2018 55 1
0 1 23/04/2018 08/08/1960 57 1
0 1 23/04/2018 15/01/1971 47 1
0 1 23/04/2018 10/11/1964 53 1
0 1 23/04/2018 18/05/1950 68 1

0 1 23/04/2018 18/07/1984 33 2
0 1 23/04/2018 1972 46 2
0 1 23/04/2018 1973 45 1
0 1 23/04/2018 50 2
0 1 23/04/2018 1961 57 2
0 1 23/04/2018 02/02/1969 49 2
0 1 23/04/2018 1956 62 1
0 1 23/04/2018 05/05/1979 39 2
0 1 23/04/2018 34 1
0 1 23/04/2018 12/06/1974 43 2
0 1 23/04/2018 1975 43 1
0 1 23/04/2018 1960 58 2
0 1 23/04/2018 1977 41 1
0 1 23/04/2018 1956 62 1
0 1 23/04/2018 05/05/1963 55 2
0 1 23/04/2018 1969 49 1
0 1 23/04/2018 08/08/1968 49 2
0 1 23/04/2018 1974 44 1
0 1 23/04/2018 1969 49 2
0 1 23/04/2018 08/09/1954 63 1
0 1 23/04/2018 1952 66 1
0 1 23/04/2018 16/09/1983 34 1
0 1 23/04/2018 04/01/1956 62 1
0 1 23/04/2018 1971 47 1
0 1 23/04/2018 27/03/1972 46 2
0 1 23/04/2018 15/06/1975 42 1
0 1 23/04/2018 13/03/1967 51 1
0 1 23/04/2018 27/02/1953 65 1
0 1 23/04/2018 1969 49 2
0 1 23/04/2018 14/03/1980 38 2
0 1 23/04/2018 04/07/1965 52 2
1 1 23/04/2018 10/06/1956 61 1
0 1 23/04/2018 1963 55 2
0 1 23/04/2018 1973 45 2
0 1 23/04/2018 1976 42 2
0 1 23/04/2018 12/08/1973 44 2
0 1 23/04/2018 21/01/1977 41 1
0 1 23/04/2018 1978 40 1
0 1 23/04/2018 16/09/1954 63 1
0 1 23/04/2018 1978 40 1
0 1 23/04/2018 1982 36 1
0 1 23/04/2018 05/05/1983 35 2
0 1 23/04/2018 1954 64 2
0 1 23/04/2018 1955 63 1
0 1 23/04/2018 03/06/1949 68 1
0 1 23/04/2018 1950 68 1
0 1 23/04/2018 08/02/1978 40 2
0 1 23/04/2018 16/09/1976 42 1
0 1 23/04/2018 1940 78 1
0 1 23/04/2018 08/08/1974 43 1
0 1 23/04/2018 05/05/1965 53 1
0 1 23/04/2018 15/02/1973 45 2
0 1 23/04/2018 1956 62 2
0 1 23/04/2018 10/10/1959 58 2
0 1 23/04/2018 1939 79 1
0 1 23/04/2018 02/06/1969 48 1
0 1 23/04/2018 14/07/1966 51 2
0 1 23/04/2018 29/05/1948 70 1
0 1 23/04/2018 01/03/1967 51 2
0 1 23/04/2018 24/06/1966 51 1
0 1 23/04/2018 2
0 1 23/04/2018 1961 57 1
0 1 23/04/2018 01/09/1977 40 1
0 1 23/04/2018 14/12/1965 52 2
0 1 23/04/2018 24/08/1973 44 2
1 1 23/04/2018 1966 52 1
0 1 23/04/2018 1977 41 2
0 1 23/04/2018 1959 59 1
0 1 23/04/2018 1962 56 1
0 1 23/04/2018 2
0 1 23/04/2018 13/12/1972 45 2
0 1 23/04/2018 1959 59 1
0 1 23/04/2018 20/05/1966 52 1
0 1 23/04/2018 01/01/1959 59 1
0 1 23/04/2018 1968 50 2
0 1 23/04/2018 1974 44 2
0 1 23/04/2018 2
0 1 23/04/2018 04/09/1972 45 2
0 1 23/04/2018 1
0 1 23/04/2018 1976 42 2
0 1 23/04/2018 1973 45 1
0 1 23/04/2018 06/06/1972 45 1
0 1 23/04/2018 30/04/1979 39 1
0 1 23/04/2018 1964 54 2
0 1 23/04/2018 10/06/1976 41 1
0 1 23/04/2018 05/05/1974 44 1
0 1 23/04/2018 1971 47 1
0 1 23/04/2018 15/03/1978 40 2
0 1 23/04/2018 1974 44 1
0 1 23/04/2018 01/07/1984 33 1
0 1 23/04/2018 05/07/1961 56 1
0 1 23/04/2018 1988 30 2
0 1 23/04/2018 1978 40 2
0 1 23/04/2018 05/04/1957 61 2
1 2 24/04/2018 05/12/1971 46 2
0 2 24/04/2018 12/03/1963 55 1
0 2 24/04/2018 27/08/1975 42 2
0 2 24/04/2018 17/06/1959 58 1
0 2 24/04/2018 tidak tau - 2
0 2 24/04/2018 30/01/1981 37 1
0 2 24/04/2018 01/01/1962 56 1
0 2 24/04/2018 19/06/1954 63 1
0 2 24/04/2018 19/02/1967 51 1
0 2 24/04/2018 01/02/1958 60 1
0 2 24/04/2018 11/07/1945 72 2
0 2 24/04/2018 10/02/1966 52 1
0 2 24/04/2018 11/11/1969 48 1
0 2 24/04/2018 tidak tau 2
0 2 24/04/2018 01/06/1962 55 1
0 2 24/04/2018 05/03/1963 55 1
0 2 24/04/2018 15/02/1963 55 1
0 2 24/04/2018 1972 46 1
0 2 24/04/2018 15/07/1944 73 1
0 2 24/04/2018 07/02/1975 43 2
0 2 24/04/2018 01/01/1953 65 2
0 2 24/04/2018 05/01/1951 67 1
0 2 24/04/2018 37 2
0 2 24/04/2018 18/03/1979 39 1
0 2 24/04/2018 18/06/1986 31 2
0 2 24/04/2018 29/07/1974 43 2
0 2 24/04/2018 9/11/1952 65 2
0 2 24/04/2018 19/10/1950 67 1
0 2 24/04/2018 04/04/1961 57 2
0 2 24/04/2018 01/11/1964 53 1
0 2 24/04/2018 06/03/1948 70 1
0 2 24/04/2018 2
0 2 24/04/2018 00/12/1949 68 2
0 2 24/04/2018 23/11/1968 49 1
0 2 24/04/2018 05/02/1959 59 1
0 2 24/04/2018 18/10/1960 57 1
0 2 24/04/2018 22/06/1965 53 2
0 2 24/04/2018 12/08/1960 57 1
0 2 24/04/2018 00/00/1963 55 1
0 2 24/04/2018 00/08/1954 63 1
0 2 24/04/2018 00/11/1954 63 1
0 2 24/04/2018 03/05/1957 61 2
0 2 24/04/2018 60 1
0 2 24/04/2018 00/00/1942 76 1
0 2 24/04/2018 03/06/1947 70 1
0 2 24/04/2018 19/06/1968 49 1
0 2 24/04/2018 05/09/1959 58 1
0 2 24/04/2018 2
0 2 24/04/2018 02/07/1949 68 1
0 2 24/04/2018 18/11/1968 49 1
0 2 24/04/2018 1962 56 1
0 2 24/04/2018 1962 56 1
0 2 24/04/2018 08/08/1952 65 1
0 2 24/04/2018 12/12/1978 39 1
0 2 24/04/2018 1960 58 1
0 2 24/04/2018 1950 68 1
0 2 24/04/2018 02/02/1952 66 2
0 2 24/04/2018 1965 53 1
0 2 24/04/2018 1
0 2 24/04/2018 10/02/1973 45 1
0 2 24/04/2018 1
0 2 24/04/2018 24/10/1957 60 1
0 2 24/04/2018 01/10/1957 60 1
0 2 24/04/2018 12/07/1978 39 2
0 2 24/04/2018 1958 60 1
0 2 24/04/2018 23/10/1952 65 1
0 2 24/04/2018 1959 59 1
0 2 24/04/2018 2
0 2 24/04/2018 13/07/1936 81 1
0 2 24/04/2018 1
0 2 24/04/2018 03/04/1973 45 1
0 2 24/04/2018 23/08/1970 47 2
0 2 24/04/2018 20/11/1964 53 2
0 2 24/04/2018 1
0 2 24/04/2018 23/12/1943 74 1
0 2 24/04/2018 60 2
0 2 24/04/2018 03/04/1975 43 2
0 2 24/04/2018 1968 50 1
0 2 24/04/2018 23/07/1973 44 2
0 2 24/04/2018 30/05/1965 53 1
0 2 24/04/2018 27/10/1973 44 1
0 2 24/04/2018 1959 59 2
0 2 24/04/2018 47 2
0 2 24/04/2018 19/01/1979 39 2
0 2 24/04/2018 20/10/1969 48 2
0 2 24/04/2018 09/03/1965 53 1
0 2 24/04/2018 10/10/1961 56 1
0 2 24/04/2018 18/12/1982 35 1
0 2 24/04/2018 03/02/1972 43 1
0 2 24/04/2018 04/04/1985 33 2
0 2 24/04/2018 1980 38 1
0 2 24/04/2018 1964 54 1
0 2 24/04/2018 1966 52 1
0 2 24/04/2018 15/04/1974 44 2
0 2 24/04/2018 71 2
0 2 24/04/2018 25/12/1946 71 1
0 2 24/04/2018 03/06/1964 54 2
0 2 24/04/2018 1950 1
0 2 24/04/2018 01/01/1944 74 1
0 2 24/04/2018 1
0 2 24/04/2018 18/04/1959 59 1
0 2 24/04/2018 08/10/1966 2
0 2 24/04/2018 11/11/1953 2
0 2 24/04/2018 1972 1
0 2 24/04/2018 1965 2
0 2 24/04/2018 31/05/1972 2
0 2 24/04/2018 08/01/1966 1
0 2 24/04/2018 1939 1
0 2 24/04/2018 05/10/1976 1
0 2 24/04/2018 09/1949 2
0 2 24/04/2018 05/10/1959 1
0 2 24/04/2018 14/01/1968 1
0 2 24/04/2018 1
0 2 24/04/2018 24/06/1946 1
0 2 24/04/2018 05/01/1991 1
0 2 24/04/2018 15/04/1968 2
0 2 24/04/2018 15/09/1952 2
0 2 24/04/2018 06/08/1954 1
0 2 24/04/2018 10/12/1962 1
0 2 24/04/2018 12/01/1970 1
0 2 24/04/2018 03/05/1971 1
0 2 24/04/2018 08/04/1975 2
0 2 24/04/2018 31/12/1958 1
0 2 24/04/2018 05/11/1957 1
0 2 24/04/2018 25/07/1945 2
0 2 24/04/2018
0 2 24/04/2018 17/08/1962 1
0 2 24/04/2018 17/10/1980 1
0 2 24/04/2018 2
0 2 24/04/2018 1
0 2 24/04/2018 02/12/1958 1
0 2 24/04/2018 70 1
0 2 24/04/2018 1966 52 2
0 2 24/04/2018 18/08/1967 1
0 2 24/04/2018 1949 69 1
0 2 24/04/2018 17/07/1965 2
0 2 24/04/2018 26/06/1963 1
0 2 24/04/2018 31/12/1960 1
0 2 24/04/2018 1960 58 1
0 2 24/04/2018 24/12/1963 2
0 2 24/04/2018 09/10/1972 2
0 2 24/04/2018 1957 61 1
 PEKERJAAN UTAMA PENGHASILAN RT

1 - Pelajar 1 - <1.5 juta 1 - Tidak Sekolah

2 - Buruh bangunan 2 - 1.5 - 3.5 juta
3 - Buruh Pabrik 3 - > 3.5 juta
4 - Supir Ojek 4 - Tidak mau menjawab

5 - Tukang Masak

6 - IRT
7 - Guru/Pendidik
8 - Pegawai Kantor
9 - Mekanik
10 - Tidak Bekerja
1 = pria 11 - Tidak Berlaku (pasien anak)
2 = wanita 99 - Lainnya

DEMOGRAFI

PEKERJAAN UTAMA
JENIS KELAMIN PENGHASILAN/BLN

KODE KETERANGAN
2 6 4
1 99 PENDORONG MAKANAN KE BANGSAL KUSTA 1
1 10 1
2 6 1
6 1 1
2 6 1
2 6 1
2 6 4
2 99 GURU 4
2 6 1
2 6 1
1 10 1
2 6 1
2 6 1
2 99 PEDAGANG 2
1 99 TUKANG SAPU 1
1 99 CLEANING SERVICE 1
2 6 1
1 10 1
1 99 TUKANG SAPU 2
1 99 PEMULUNG 1
1 99 PETUGAS KEBERSIHAN 3
1 10 4
1
2 6 4
2 6 1
1 99 PETUGAS KEBERSIHAN 1
2 99 PEDAGANG 1
2 6 1
2 99 PEDAGANG 1
1 99 CLEANING SERVICE 1
2 6 1
1 2 4
2 10 1
1 2 4
2 10 1
1 2 1
1 99 cleaning service 4
2 6 4
1 10 1
2 99 cleaning service 2
1 99 cleaning service 1
2 6 4
1 10 1
1 2 1
1 99 cleaning service 1
1 99 cleaning service 1
1 99 cleaning service 1
2 6 4
1 99 PEMULUNG 2
1 99 WIRASWASTA 1
1 99 CLEANING SERVICE 1
2 6 2
2 6 1
2 6 1
1 99 SERABUTAN 1
2 6 1
2 6 1
2 6 2
2 99 TUKANG SAPU 1
1 99 CLEANING SERVICE 1
1 2 1
1 10 1
1 10 2
1 99 PETUGAS KEBERSIHAN 2
2 6 4
2 6 4
1 10 1
1 99 WIRASWASTA 1
1 10 2
2 99 TUKANG SAPU 1
1 2 1
1 10 2
1 99 SUPIR 4
1 10 3
2 99 TUKANG SAPU JALAN 1
2 99 TUKANG SAPU JALAN 1
2 6 1
1 99 PETANI 4
1 99 TUKANG CUKUR RAMBUT 1
2 6 4
1 10 4
2 6 1
1 99 PEDAGANG 2
2 99 TIM KEBERSIHAN PEMDA 4
1 10 1
1 2 1
2 6 4
2 6 1
1 10 1
2 6 1
1 99 PETANI 4
1 10 4
2 6 4
2 6 1
1 99 TUKANG SAMPAH 1
1 2 4
1 99 PEMBANTU 1
2 99 PEDAGANG 1
2 99 CLEANING SERVICE 1
2 6 1
2 99 CLEANING SERVICE 1
1 99 TUKANG PARKIR 1
2 6 2
1 99 CLEANING SERVICE 1
1 99 SUPIR ANGKOT 2
1 99 TUKANG KEBERSIHAN JALANAN 1
2 99 TUKANG SAPU 1
1 99 CLEANING SERVICE 2
1 99 CLEANING SERVICE 1
1 10 4
2 99 WIRASWASTA 1
1 99 CLEANING SERVICE 4
1 99 PETANI 1
1 99 KARYAWAN SWASTA 2
2 6 1
2 6 2
2 6 4
2 6 1
1 99 WIRASWASTA 1
2 99 PEDAGANG 1
1 99 PENJAHIT 2
2 99 MENYAPU JALAN 1
1 99 ANTAR JEMPUT SEKOLAH 1
1 10 1
1 4 1
1 2 4
1 10 1
2 10 2
1 3 2
1 99 MENYAPU JALAN 4
2 10 1
1 99 TUKANG BECAK 4
1 2 1
1 99 PEDAGANG 4
1 10 4
1 10 1
2 6 1
2 6 1
1 99 WIRASWASTA 2
2 99 PENYAPU JALAN 3
1 99 BURUH SAPU JALANAN 2
2 6 4
2 6 4
2 6 1
1 10 4
2 6 1
1 10 1
1 10 2
2 99 SAPU JALANAN 1
2 6 1
1 2 4
1 4 1
1 99 PENJAHIT KONVEKSI 1
2 6 3
1 99 KEBERSIHAN 2
1 99 DINAS KEBERSIHAN 1
1 99 SUPIR ANGKOT 1
1 10 4
2 6 1
1 99 TUKANG BECAK 4
1 99 PENGEMIS 1
1 99 NARIK BECAK 1
1 4 1
1 99 BURUH MEBEL 4
2 6 4
1 10 1
1 99 PEMULUNG 1
1 10 1
1 99 PENJAGA SEKOLAH 1
1 10 1
1 99 CLEANING SERVICE 1
1 10 1
1 2 4
2 6 1
1 10 1
1 10 4
1 99 SERABUTAN 4
1 99 PEMBANTU RUMAH 1
1 2 1
1 99 TUKANG BECAK 4
2 6 1
1 10 1
1 4 1
1 10 4
2 6 1
1 2 1
1 99 PENJAHIT 1
1 6 1
2 6 1
2 6 1
1 10 1
1 10 4
2 6 4
2 6 1
1 2 4
2 6 1
1 10 2
1 4 1
2 6 1
2 6 4
2 6 2
2 99 PENJAHIT 2
1 99 DINAS LINGKUNGAN HIDUP 1
1 99 2
1 99 CLEANING SERVICE 1
1 99 CLEANING SERVICE 1
2 6 1
1 99 TUKANG BECAK 2
1 99 KARYAWAN 1
1 99 TUKANG BECAK 4
2 6 1
2 10 1
1 10 1
2 6 2
1 99 PEDAGANG 1
1 10 4
1 99 TUKANG PARKIR 1
1 10 1
2 6 1
2 10 4
1 99 SERABUTAN 1
2 6 2
2 6 4
1 10 4
1 10 1
1 99 SUPIR ANGKOT 1
2 10 1
1 10 2
1 99 TUKANG SAPU 1
1 99 CLEANING SERVICE 1
1 10 1
1 8 1
2 6 4
2 6 1
1 10 2
1 99 TUKANG SAPU 2
1 99 TUKANG PARKIR 1
1 8 2
2 6 1
1 10 4
1 99 1
2 6 1
2
1 99 DINAS KEBERSIHAN 1
1 99 TUKANG SAPU 1
2 99 PEDAGANG 1
1 99 4
1 8 4
1 10 2
2 6 2
1 99 WIRASWASTA 4
1 99 TUKANG SAPU 1
2 6 2
1 10 1
1 10 4
1 99 PEMULUNG 4
2 6 1
2 6 4
1 10 1
 PENDIDIKAN STATUS PERNIKAHAN SUKU JUMLAH TINGGAL
SERUMAH
1 - Tidak Sekolah 1 - Belum Menikah 1 - Jawa 1 - Tinggal sendiri
2 - Lulus SD 2 - Menikah 2 - Sunda 2 - 1 orang
3 - Lulus SMP 3 - Cerai (mati/hidup) 3 - Bali 3 - 2 orang
4 - Lulus SMA 4 - Tidak mau menjawab 4 - Betawi 4 - > 2 orang
5 - Sarjana/Magister/
Doktor 5 - Tidak berlaku 5 - Aceh 5 - Tidak mau menjawab

6 - Madura
7 - Lampung
8 - Lainnya

MOGRAFI

JUMLAH ORANG TINGGAL

TINGKAT PENDIDIKAN STATUS PERNIKAHAN SUKU (DARI AYAH) SERUMAH

1 2 4 4
2 2 4 3
1 2 2 4
2 2 2 4
1 2 2 4
1 2 2 4
2 2 1 4
1 2 2 1
3 2 4 3
1 2 4 4
2 2 2 4
2 2 2 4
1 2 2 4
3 3 2 4
1 2 1 4
1 2 1 1
1 2 4 4
1 3 2 4
1 2 1 4
2 2 4 4
3 2 4 4
4 2 4 4
2 2 2 3
2 2 1 4
1 2 1 4
2 2 6 3
1 2 1 4
2 2 2 4
1 2 1 4
1 2 2 3
2 2 8 3
1 3 2 1
4 2 4 4
2 2 2 4
1 3 2 4
2 2 2 3
1 3 2 2
2 2 2 4
1 2 2 4
2 2 2 2
3 2 2 4
1 3 4 3
4 2 2 4
1 3 2 1
4 2 2 4
2 2 8 (MENADO) 4
2 2 4 3
4 2 2 3
2 2 1 4
4 2 8 (BATAK) 3
4 2 1 4
1 2 2 4
2 2 2 4
1 3 2 4
3 2 4 1
2 2 2 4
1 2 1 4
1 3 4 4
1 3 1 4
2 2 2 4
2 2 1 4
4 2 1 3
1 1 1 1
1 2 1 4
2 2 4 4
1 2 4 3
1 1 6 1
3 2 1 4
1 2 2 4
1 2 2 4
2 2 2 4
2 3 2 4
1 2 2 4
3 2 4 3
1 3 4 4
1 2 4 3
1 2 1 4
1 2 2 3
3 1 1 1
1 2 2 4
2 2 1 1
1 2 4 2
2 2 1 4
1 2 2 4
1 2 4 3
2 2 1 4
4 2 1 4
3 2 2 4
1 2 6 4
1 2 8 (PALEMBANG) 4
1 2 1 3
1 3 4 3
1 2 2 4
2 2 1 4
1 2 2 3
1 2 2 4
2 3 1 1
1 2 1 4
2 3 2 3
2 2 1 4
2 2 2 4
4 4 2 1
1 2 2 4
2 2 2 3
4 2 1 4
2 2 1 4
1 2 2 4
4 2 2 1
1 4 2 4
2 2 4 4
4 2 2 4
2 2 2 3
2 3 2 1
1 2 2 3
1 2 2 3
1 2 2 3
1 2 1 4
3 2 2 4
2 2 8 4
4 2 1 4
1 3 6 1
1 2 1 4
1 2 2 3
1 1 2 4
2 2 4 2
4 2 2 3
1 2 4 4
1 2 8 4
2 2 2 3
4 2 1 4
1 2 4 3
2 2 2 4
1 2 4 4
1 2 8 3
1 2 1 4
1 2 8 3
1 2 8 4
1 2 4 4
2 2 1 4
2 2 1 4
1 2 4 4
2 2 4 4
2 2 2 4
2 2 1 3
1 2 4 3
1 2 2 4
1 2 1 4
4 2 1 4
1 2 2 4
1 2 4 4
3 2 4 4
3 2 4 4
1 2 8 3
1 2 4 3
1 2 6 4
1 2 2 3
2 3 4 4
2 2 2 4
1 2 4 4
1 2 1 4
1 2 4 3
1 2 8 4
4 2 4 2
1 2 8 2
1 2 4 4
3 2 8 4
3 2 4 4
2 2 2 4
3 1 4 4
1 2 2 4
1 2 2 4
2 2 8 4
2 2 2 4
1 2 4 3
1 3 1 3
1 2 4 4
1 2 2 4
2 2 8 (KALIMANTAN) 4
1 2 4 4
2 2 2 1
1 2 2 4
1 2 4 3
3 2 1 3
2 1 2 4
1 2 1 4
1 2 8 (FLORES) 4
1 2 8 (CINA) 4
1 2 4 4
1 2 4 3
1 3 4 3
1 2 2 2
3 2 8 (PALEMBANG) 4
1 2 2 1
2 2 2 4
2 2 2 4
2 2 2 4
2 2 2 4
4 2 8 (MANADO) 3
2 2 4 3
1 3 2 4
1 2 2 4
2 2 1 3
3 2 4 4
2 2 1 4
4 2 1 4
1 2 1 4
2 2 2 4
2 2 2 3
4 2 1 4
2 2 1 2
3 2 4 4
1 2 8 (AMBON) 3
1 2 8 (AMBON) 3
2 2 2 4
1 2 8 (PADANG) 3
2 4 1 4
2 2 2 4
2 2 4 4
2 2 1 4
2 3 1 3
1 2 2 4
2 3 4 4
1 2 2 4
2 2 2 4
1 2 2 3
2 4 2 4
1 3 1 4
4 2 2 4
3 2 4 4
1 1 1 4
2 2 1 3
1 2 2 4
4 2 8 4
2 2 8 4
1 2 8 4
1 3 8 2
2 2 2 4
4 2 1 4
2 2 2 4
3 2 4 4
1 2 4 4
1 3 4 2
1 2 5 4
4 2 1 4
3 2 4 4
4 2 2 4
2 2 2 4
2 2 4 4
1 2 1 4
2 2 8 (SUMATRA) 4
1 3 1 2
1 2 1 4
2 3 1 2
2 2 2 4
2 2 1 4
1 2 1 3
1 2 4 4
1 2 8 (BUGIS) 4
1 2 4 4
1 2 8 (BUGIS) 4
 JUMLAH TINGGAL JUMLAH PENDERITA
SERUMAH KUSTA SERUMAH
nggal sendiri 1 - Tidak ada
2 - 1 orang
3 - 2 orang
4 - > 2 orang
2. Saat ini,
mau menjawab 5 - Tidak mau menjawab apakah 4. Seberapa
1. Secara menurut Anda sakit atau tidak
umum, penglihatan nyaman yang
Anda jika 3. Berapa pernah Anda
menurut menggunakan banyak rasakan di
Anda, kedua mata waktu Anda dalam dan
kesehatan (dengan merasa sekitar mata
Anda secara kacamata atau Anda (misal
lena kontak, jika khawatir rasa nyeri
keseluruhan anda dengan seperti
adalah memakainya) penglihatan terbakar, gatal
adalah Anda? atau nyeri?)
sempurna, baik, Apakah
cukup, bruuk menurut anda
atau sangat rasa itu?
buruk?

MLAH ORANG TINGGAL JUMLAH PENDERITA No 1 No 2 No 3 No 4

SERUMAH KUSTA SERUMAH

4 1 5 5 3 1
3 1 4 1 1 1
4 3 3 4 3 2
4 3 5 5 2 2
4 3 4 2 1 3
4 3 4 1 1 1
4 3 4 4 2 2
1 1 5 4 4 1
3 2 3 3 3 2
4 3 4 5 4 3
4 3 4 4 4 2
4 1 4 1 2 3
4 3 5 5 4 4
4 2 4 4 2 2
4 2 4 5 2 2
1 5 3 4 2 3
4 3 5 3 2 2
4 2 3 3 1 1
4 2 3 4 3 3
4 1 5 3 3 1
4 1 4 4 1 1
4 2 3 3 1 1
3 1 5 5 4 1
4 3
4 1 2 2 1 2
3 1 5 5 5 2
4 3 4 1 2 2
4 1 4 4 3 3
4 3 4 1 2 2
3 3 4 4 2 2
3 3 4 4 4 3
1 2 4 4 2 3
4 2 3 5 2 2
4 3 3 3 1 1
4 1 2 3 2 2
3 3 4 3 1 1
2 2 5 4 3 3
4 2 3 5 4 3
4 4 4 4 4 1
2 2 4 4 2 1
4 3 3 4 1 1
3 2 4 1 2 1
4 2 3 3 2 2
1 2 5 6 5 1
4 3 4 5 4 3
4 2 3 3 2 2
3 3 5 5 3 1
3 3 3 4 2 2
4 2 4 1 1 2
3 2 4 4 3 3
4 3 4 5 5 1
4 4 3 4 1 1
4 3 3 4 4 3
4 2 5 5 4 1
1 2 4 4 4 1
4 3 4 4 1 1
4 3 5 4 4 4
4 2 4 3 2 2
4 2 4 6 3 1
4 3 5 5 4 3
4 2 4 4 3 3
3 3 4 3 1 1
1 2 2 5 4 2
4 3 3 2 3 3
4 3 4 3 3 2
3 3 4 4 2 2
1 2 5 4 2 2
4 3 4 1 1 2
4 2 4 4 2 2
4 2 5 6 5 1
4 2 3 4 2 1
4 2 3 5 4 2
4 2 5 5 4 1
3 3 5 4 2 3
4 2 5 6 5 5
3 3 3 5 5 1
4 3 4 4 1 1
3 3 4 3 2 1
1 2 4 1 2 1
4 3 3 4 2 2
1 2 5 6 5 3
2 2 4 5 2 2
4 3 4 4 3 3
4 3 4 4 3 2
3 2 3 4 1 1
4 4 4 4 3 3
4 3 4 1 2 3
4 3 3 4 2 2
4 2 3 4 3 2
4 3 4 4 2 2
3 2 4 3 2 2
3 3 4 5 2 3
4 3 4 4 3 3
4 2 4 4 2 2
3 2 5 5 2 2
4 2 3 3 3 2
1 2 4 3 2 2
4 3 4 4 3 3
3 2 3 3 3 2
4 2 3 3 2 3
4 3 4 1 1 2
1 2 4 4 2 2
4 3 4 2 3 2
3 3 4 4 2 2
4 2 4 4 3 3
4 2 3 3 2 2
4 2 4 4 2 2
1 2 5 5 2 2
4 3 5 3 4 2
4 3 5 5 4 3
4 3 5 5 5 3
3 2 5 2 1 1
1 2 4 4 2 1
3 3 5 2 1 1
3 3 4 3 2 3
3 3 3 5 1 1
4 3 3 4 3 2
4 2 2 6 5 4
4 3 4 4 3 2
4 3 3 5 2 1
1 2 3 3 3 4
4 3 4 5 4 3
3 2 3 3 1 1
4 4 4 4 3 3
2 4 2 4 4 5
3 2 4 3 3 3
4 3 3 4 3 1
4 3 4 5 3 4
3 3 5 5 2 4
4 3 4 4 4 3
3 3 4 4 2 2
4 2 3 4 4 3
4 3 4 4 2 2
3 3 4 4 3 3
4 2 1 5 1 1
3 3 4 5 4 3
4 3 5 5 5 4
4 2 3 4 2 1
4 2 3 4 2 1
4 3 4 4 3 2
4 3 5 5 4 4
4 3 3 4 3 3
4 3 4 4 2 1
3 3 3 3 1 2
3 3 5 5 4 3
4 3 4 4 2 1
4 3 4 4 3 3
4 3 3 4 4 1
4 3 4 5 4 2
4 2 4 4 2 2
4 3 4 4 2 1
4 3 4 4 3 1
3 2 4 4 4 3
3 3 5 5 4 1
4 3 3 5 4 3
3 2 5 4 3 4
4 2 3 4 2 2
4 3 5 5 5 3
4 3 4 5 4 1
4 3 4 4 3 3
3 2 4 5 3 3
4 2 3 5 4 1
2 1 4 4 3 2
2 2 4 2 1 1
4 2 4 4 2 3
4 4 4 4 4 3
4 2 4 4 3 3
4 2 4 5 4 2
4 2 4 4 4 2
4 3 4 4 3 1
4 3 1 1 1 2
4 2 3 1 1 1
4 3 4 5 4 1
3 3 4 5 4 2
3 2 4 4 4 1
4 2 5 5 1 2
4 2 4 5 3 2
4 2 4 4 3 3
4 2 4 4 3 3
1 2 5 4 3 2
4 3 4 4 3 2
3 3 4 4 3 3
3 2 3 5 3 2
4 2 3 4 2 1
4 3 4 4 2 1
4 3 4 4 2 3
4 2 4 4 3 4
4 3 5 4 3 1
3 3 5 5 4 3
3 2 3 4 3 1
2 2 5 3 2 2
4 3 3 4 2 1
1 2 4 5 3 2
4 2 4 4 5 3
4 3 1 1 1 1
4 3 4 5 3 2
4 3 4 6 5 3
3 3 4 5 3 2
3 2 4 3 4 4
4 2 3 4 3 1
4 3 2 4 1 1
3 2 4 4 3 3
4 3 3 4 3 2
4 2 2 5 3 1
4 3 3 5 3 2
4 3 1 5 3 1
4 3 3 5 1 2
3 3 4 4 3 2
4 3 3 4 3 1
2 2 3 5 4 1
4 3 3 5 3 2
3 3 4 4 2 3
3 3 5 2 1 1
4 3 1 1 1 2
3 2 3 5 3 2
4 2 1 1 1 2
4 3 4 5 4 2
4 3 4 4 3 3
4 2 5 2 1 1
3 2 3 4 2 1
4 3 2 4 1 1
4 2 4 4 3 3
4 3 3 5 2 2
4 2 5 5 3 1
3 2 4 4 3 3
4 2 3 5 1 1
4 2 4 4 3 1
4 2 4 3 1 1
4 3 4 4 2 2
4 3 4 4 3 1
3 2 2 3 1 1
4 2 3 3 1 1
4 3 2 3 2 2
4 3 3 5 3 2
4 2 4 3 3 3
2 2 5 4 3 2
4 2 4 4 2 1
4 3 2 5 5 1
4 3 2 2 2 1
4 2 2 5 2 2
4 3 4 4 2 1
2 2 4 4 4 3
4 3 5 6 4 4
4 2
4 3 3 4 3 2
4 3 3 4 3 3
4 2 2 2 1 1
4 4 2 3 2 1
4 3 4 4 1 1
4 2 4 4 3 3
2 2 3 5 4 3
4 3 3 3 3 2
2 2 4 2 1 1
4 2 4 4 3 3
4 2 4 4 2 1
3 2 5 2 3 2
4 3 4 5 2 2
4 2 4 4 3 2
4 3 4 4 3 3
4 2 3 5 1 2
 6. Seberapa besar 10. Karena
kesulitan yang 7. Karena 9. Karena
penglihatan
anda alami saat
penglihatan 8. Seberapa penglihatan anda, 11. Karena
5. Seberapa melakukan
penglihatan
pekerjaan atau anda, besar anda, seberapa seberapa
besar anda, sebeapa
hobi yang seberapa kesulitan besar kesulitan besar
kesulitan mengharuskan besar
yang anda alami kesulitan yang anda kesulitan
besar yang Anda alami
yang Anda anda untuk saat berjalan
melihat baik dari kesulitan alami yang anda saat melihat
alami saat menuruni
jarak dekat, yang anda membaca undakan, alami saat bagaimana
membaca seperti memasak, orang-orang
alami saat rambu- tangga atau memperhatik
tulisan biasa menjahit, bereaksi
memperbaiki mencari rambu di trotoar dalam an benda
di surat terhadap hal-
cahaya redup yang jatuh di hal yang anda
benda-benda sesuatu di jalan atau
kabar? disekitar rumah atau malam samping saat
atau rak yang nama toko? hari? katakan?
mengguanakan penuk sesak? anda
alat-alat tangan? berjalan?

No 5 No 6 No 7 No 8 No 9 No 10 No 11

3 2 2 1 1 2 2
2 1 1 1 1 1 1
2 3 3 2 3 3 2
1 1 1 1 2 1 1
5 1 1 1 1 1 1
1 1 1 1 1 1 1
3 3 2 1 2 2 2
3 3 2 2 3 3 3
2 3 1 3 1 1 1
3 2 2 2 4 4 3
2 3 2 2 2 2 2
3 1 1 1 4 1 1
3 1 1 1 1 2 2
3 2 2 2 2 1 2
3 2 1 3 2 2 1
3 1 2 2 2 1 2
3 1 1 1 1 1 1
1 1 1 1 1 1 1
3 2 2 2 3 3 2
4 4 4 3 3 1 1
4 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1

1 1 1 1 1 1 1
3 2 1 1 2 1 2
3 1 1 1 1 1 1
2 2 2 2 2 2 2
4 1 1 1 3 2 1
2 1 1 1 1 1 1
2 2 2 2 2 3 3
3 2 1 1 1 1 1
1 1 1 1 1 1 1
1 2 1 1 2 2 1
2 2 1 1 1 1 1
1 1 1 1 1 1 1
3 1 3 1 1 4 1
3 1 1 2 3 4 1
1 1 1 1 1 1 1
2 1 1 1 2 1 1
3 1 1 1 1 1 1
3 2 2 2 2 2 1
2 2 2 2 2 2 2
4 4 4 4 3 3 3
4 4 4 4 4 4 4
1 1 1 1 1 1 1
3 2 1 2 2 1 1
2 2 1 1 1 1 1
2 1 2 1 2 2 2
4 3 3 2 2 2 2
3 1 1 1 1 1 1
1 1 1 1 1 1 1
2 2 1 1 1 1 1
1 1 1 1 1 1 1
3 3 3 3 3 3 2
2 1 1 2 2 1 1
3 2 2 2 2 2 2
0 3 3 2 1 1 1
4 3 2 1 3 3 3
2 2 1 1 2 2 1
3 2 1 1 1 1 1
1 1 1 1 1 1 1
3 3 2 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
3 1 3 2 2 1 1
5 5 1 2 5 1 1
3 1 1 2 1 1 1
3 2 3 1 2 2 2
4 4 4 4 4 4 4
2 1 1 2 1 1 1
2 1 3 1 1 1 1
1 1 1 1 3 3 1
2 2 1 2 1 1 1
4 4 4 4 4 4 4
2 1 1 1 1 1 1
1 1 1 1 1 1 1
3 2 2 1 1 2 2
3 1 1 1 1 1 1
1 1 1 1 1 1 1
4 3 4 4 4 4 4
2 2 1 2 2 1 1
3 3 1 1 2 2 2
4 1 1 1 1 1 1
2 2 1 1 1 1 1
3 3 3 3 3 3 3
3 1 1 1 1 1 1
2 1 1 2 1 1 1
4 2 2 2 1 2 2
3 3 2 2 2 2 2
3 2 2 2 1 2 1
2 2 3 3 2 2 2
4 4 3 2 3 3 3
2 2 1 2 1 1 1
2 3 1 2 5 5 1
3 3 2 3 3 2 2
3 2 2 2 2 2 1
5 5 3 3 3 3 3
4 3 2 2 2 2 2
2 2 2 2 2 1 2
3 1 1 1 1 1 1
2 2 1 1 1 1 1
3 3 2 2 2 2 2
3 1 1 1 2 1 1
2 2 1 1 1 1 2
2 2 2 1 1 1 1
2 2 1 2 2 1 1
2 2 2 2 1 1 2
3 3 3 2 3 2 2
5 5 2 2 2 2 3
4 4 4 4 4 4 4
2 1 1 1 1 1 1
3 1 1 2 2 2 2
1 1 1 1 1 1 1
2 2 1 1 1 1 1
1 1 1 1 1 1 1
0 1 1 1 1 1 1
3 3 3 4 3 3 1
3 3 3 3 3 3 3
4 3 3 3 3 3 3
3 3 1 1 1 1 1
3 2 2 1 3 3 1
2 1 3 1 1 1 1
1 1 1 1 1 1 1
4 4 3 1 1 1 1
3 3 3 3 3 3 3
3 3 3 3 3 3 3
4 3 4 3 4 4 4
5 5 4 4 4 4 3
3 3 3 3 3 3 3
3 2 2 2 2 2 2
5 4 1 2 1 1 1
3 2 3 3 2 3 3
3 3 3 3 3 3 3
5 1 3 1 3 3 2
4 4 4 4 4 4 4
4 4 4 4 4 4 4
3 3 2 2 2 2 2
2 3 1 1 2 2 1
3 3 3 3 3 3 3
2 1 1 3 1 1 2
3 3 3 3 3 3 3
3 3 3 3 3 3 3
1 1 1 1 1 1 1
4 4 1 1 2 2 1
2 1 1 1 1 1 1
4 4 3 3 3 3 2
2 2 2 2 2 2 2
4 3 3 3 3 3
3 3 3 3 3 3 3
3 2 1 1 1 1 1
3 3 3 3 3 3 3
3 3 3 3 3 3 3
5 3 1 1 1 1 1
4 1 1 1 1 1 1
3 2 1 1 2 1 1
4 4 3 1 2 1 2
4 4 3 3 3 2 2
4 3 3 3 3 3 3
2 3 2 2 2 2 2
2 1 1 1 1 1 1
2 3 1 3 4 4 3
3 3 3 3 3 3 3
1 1 1 1 1 1 1
3 2 2 2 2 2 2
3 3 3 3 3 3 3
3 3 3 3 3 3 3
4 3 3 3 3 3 3
4 3 3 3 3 3 3
3 3 3 3 3 3 3
2 1 1 1 1 1 1
1 1 1 1 1 1 1
3 3 3 3 3 3 3
3 3 3 3 3 3 3
3 4 3 3 4 3 3
5 3 1 1 3 3 1
3 3 3 3 3 3 3
4 3 3 3 3 3 3
4 2 3 3 3 3 3
3 4 3 2 2 2 2
3 3 3 3 3 3 3
4 1 1 2 1 1 1
4 3 3 3 3 3 3
3 3 1 1 2 1 1
3 3 3 3 3 3 3
3 2 3 3 2 2 2
5 5 5 5 3 3 3
3 2 1 2 2 1 2
5 2 2 1 3 3 1
3 1 1 1 1 1 1
3 3 3 3 3 4 1
2 2 2 2 2 2 2
3 4 3 1 3 1 1
4 3 3 3 3 3 2
1 1 1 1 1 1 1
3 3 3 3 3 3 3
3 2 2 2 2 2 2
3 3 3 3 3 3 3
2 1 3 1 1 4 1
3 3 3 3 3 3 3
2 1 1 1 1 1 1
2 1 1 1 1 1 1
2 2 2 2 2 2 2
1 2 1 1 1 1 1
3 3 3 3 3 3 3
1 1 2 2 1 1 1
0 3 1 1 3 3 1
5 5 3 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
3 3 3 3 3 3 3
4 2 2 1 1 1 1
5 1 1 1 3 3 1
3 5 5 2 3 1 2
3 3 3 3 3 3 3
1 5 5 1 1 1 1
3 3 3 3 3 3 3
4 3 3 3 2 3 3
1 2 1 1 1 1 1
3 3 1 1 1 1 1
5 1 1 2 1 1 1
3 2 2 2 2 2 3
3 3 3 3 3 3 3
3 1 1 1 2 2 1
4 2 2 2 3 2 2
3 3 2 2 3 3 1
3 3 3 3 3 3 3
2 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 3 3 3
3 3 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
4 1 2 1 3 3 1
4 2 2 2 4 2 2
1 2 2 1 2 2 1
2 2 2 2 2 2 2
1 1 1 1 1 1 1
3 3 1 1 1 1 1
2 1 1 1 1 1 1
2 2 2 2 2 2 2
4 2 3 3 3 3 1
5 3 2 4 4 4 2

4 4 2 2 3 2 2
2 2 1 1 1 1 1
2 2 1 1 1 1 1
3 3 1 1 1 1 1
3 3 1 1 1 1 1
3 3 2 2 3 2 3
4 3 3 2 4 2 3
1 1 1 2 1 1 1
5 1 1 1 1 1 1
4 2 2 2 2 3 2
2 2 2 2 2 2 2
2 3 1 1 1 1 1
2 3 3 3 3 3 3
2 3 3 3 3 3 3
4 3 3 3 3 3 3
5 1 3 3 3 3 3
 PERTANYAAN NOMOR

13. Karena 14. Karena 15b. 15c. JIKA

12. Karena penglihatan penglihatan JIKA ANDA SAAT INI
15a. Jika
penglihatan anda, Anda, 15. Sekarang, BERHENTI MASIH
TIDAK, MENGEMUDI
anda, seberapa seberapa saya ingin MENGEMUDI
TANYAKAN Apakah hal itu
seberapa besar besar bertanya Seberapa
Apakah Anda terutama
besar kesulitan kesulitan tentang karena banyak
belum
kesulitan yang anda yang Anda mengendarai penglihatan kesulitan
pernah
yang anda alami saat alami saat mobil. Anda, terutama yang Anda
mengemudik karena suatu
alami saat mengunjungi pergi Apakah Anda alami saat
an mobil alasan lain atau
memilih dan orang di menonton mengemudi, mengemudi
atau Anda karena
memadanka rumah bioskop, sebaiknya penglihatan di siang hari
sudah
n pakaian mereka, di drama, atau sekali-sekali? Anda dan di tempat
berhenti
anda sendiri? pesta atau di pertandingan alasan lainnya yang Anda
restoran? olahraga? itu? kenali?

INDEKS KUALITAS HIDUP OFTALMOLOGI

No 12 No 13 No 14 No 15 No 15a No 15b No 15c

2 2 2 2 2 2 0
1 1 1 1 0 0 1
2 2 2 1 0 0 3
1 1 1 2 1 0 0
1 1 1 2 1 0 0
1 1 1 2 1 0 0
1 3 2 2 1 0 0
3 2 3 2 1 0 0
1 1 2 1 0 0 1
1 1 2 2 1 0 0
3 3 3 2 2 0 0
1 1 1 2 2 1 0
1 1 1 2 1 0 0
2 2 2 2 0 0 0
1 1 1 2 1 2 0
1 1 1 1 0 0 1
1 1 1 1 0 0 1
1 1 1 2 1 0 0
2 2 2 2 2 0 0
1 1 1 2 2 1 0
1 1 1 1 0 0 1
1 1 1 1 0 0 1
1 1 1 2 2 0 0

1 1 1 2 1 0 0
1 1 1 2 1 0 0
1 1 1 1 0 0 1
2 2 2 2 1 0 0
1 1 1 2 1 0 0
1 1 1 2 1 0 0
1 2 1 2 1 0 0
1 1 1 2 1 0 0
1 1 1 1 0 0 1
1 1 1 2 1 0 0
1 1 1 1 0 0 1
1 1 1 1 0 0 1
1 1 1 1 0 0 2
3 3 3 1 0 0 1
1 1 1 2 1 0 0
1 1 1 1 0 0 1
1 1 1 2 1 0 0
1 1 1 1 0 0 1
1 2 2 1 1 0 0
4 4 4 2 2 0 0
1 3 1 2 1 0 0
1 1 1 2 1 0 0
1 1 2 2 2 1 0
1 1 1 1 0 0 1
1 1 1 2 2 2 0
2 2 2 2 2 3 0
1 1 1 1 0 0 1
1 1 1 1 0 0 1
1 2 1 2 2 3 0
1 1 1 1 0 0 1
2 2 2 1 1 0 0
1 1 1 2 1 0 0
1 2 2 2 1 0 0
1 1 1 2 0 0 0
3 3 3 2 1 0 0
1 1 1 2 1 0 0
1 1 1 1 0 0 1
1 1 1 1 0 0 1
1 1 1 1 0 0 2
1 1 1 2 1 0 0
1 1 1 1 0 0 2
1 1 2 2 1 0 0
1 1 1 2 1 0 0
1 1 1 1 0 0 1
2 2 2 1 0 0 3
4 4 4 2 1 0 0
1 1 1 1 0 0 1
1 1 2 1 0 0 1
1 1 1 2 2 2 0
1 1 1 1 0 0 1
4 4 4 2 1 0 0
1 1 1 1 0 0 1
1 1 1 2 1 0 0
1 1 2 2 1 0 0
1 1 1 1 0 0 1
1 1 1 1 0 0 1
3 3 4 1 1 0 0
1 1 1 2 1 0 0
1 2 2 2 1 0 0
1 1 2 1 0 0 1
1 1 1 2 1 0 0
2 2 3 2 1 0 0
1 1 1 1 0 0 1
1 1 1 2 1 0 0
1 2 2 2 1 0 0
1 1 1 2 1 0 0
1 1 2 2 1 0 0
1 1 3 2 2 1 0
3 3 2 2 1 0 0
1 1 1 2 1 0 0
1 1 1 2 1 0 0
1 1 2 2 1 0 0
1 1 2 2 1 0 0
3 3 3 2 2 3 5
2 1 2 2 1 0 0
2 1 1 2 1 0 0
1 1 1 2 2 2 0
1 1 1 2 1 0 0
2 2 2 2 1 0 0
1 1 1 2 1 0 0
1 1 1 2 1 0 0
1 1 1 1 0 0 1
1 1 1 2 1 0 0
1 1 1 2 1 0 0
3 3 3 2 1 0 0
3 3 3 2 1 0 0
3 4 4 2 2 1 0
1 1 1 1 0 0 1
1 1 2 1 0 0 2
1 1 1 1 0 0 1
1 2 1 1 0 0 1
1 1 1 2 1 0 0
1 1 1 2 1 0 0
1 3 3 1 0 0 1
3 3 5 0 1 0 0
3 3 3 1 0 0 3
1 1 1 2 2 2 0
1 1 1 1 0 0 1
1 1 1 2 1 0 0
1 1 1 1 0 0 1
1 1 1 1 0 0 1
3 3 1 2 2 3 3
2 2 2 1 0 0 2
3 3 4 2 1 1 4
3 4 4 2 1 0 0
3 3 3 1 0 0 3
2 2 2 1 0 0 2
1 1 1 2 1 0 0
2 3 3 2 1 3 0
3 3 3 2 1 2 3
1 1 5 1 0 0 1
4 3 4 2 1 0 0
4 4 4 2 1 0 0
2 2 2 2 1 0 0
1 2 1 2 1 0 0
3 3 3 1 0 0 3
1 1 5 1 0 0 1
3 3 3 2 1 2 5
3 3 3 2 1 0 0
1 1 1 1 2 1 1
1 1 5 2 2 1 0
1 1 1 1 0 0 2
3 3 3 2 1 0 0
2 2 2 1 0 0 2
3 3 3 2 2 3 0
2 2 2 2 0 0 0
1 1 1 2 1 0 0
3 3 3 1 0 0 3
3 2 3 2 1 2 3
1 1 5 1 0 0 1
1 1 5 2 1 0 0
5 1 5 1 0 0 1
1 1 1 1 0 0 1
1 3 3 2 2 1 3
3 3 3 2 1 0 0
3 3 3 2 1 0 0
1 1 2 1 0 0 2
3 3 3 2 1 0 0
3 3 3 2 1 0 0
1 1 1 1 0 0 1
2 2 2 2 1 0 0
3 3 3 2 1 0 0
3 3 3 1 2 2 3
3 3 3 2 2 3 0
3 3 3 2 2 3 0
3 3 3 2 1 0 0
5 1 1 1 0 0 1
1 1 1 1 0 0 1
3 3 3 2 1 0 0
3 3 3 2 1 0 0
2 3 3 1 0 0 3
1 1 5 1 0 0 1
3 3 3 2 1 0 0
3 2 2 2 1 0 0
3 3 3 2 1 0 0
1 2 2 1 0 0 2
3 3 3 2 1 0 0
1 1 1 2 1 0 0
3 3 3 2 1 0 0
1 1 1 1 0 0 1
3 3 3 2 1 0 0
2 2 2 2 1 0 0
5 2 2 2 2 2 5
1 2 2 1 0 0 2
2 2 4 2 1 0 0
1 1 5 1 0 0 1
1 1 2 1 0 0 2
2 2 2 2 1 0 0
1 1 1 1 0 0 1
2 2 2 2 1 0 0
1 1 1 1 0 0 1
3 3 3 2 1 0 0
2 2 1 2 1 0 0
3 3 3 2 1 0 0
5 1 1 1 0 0 1
3 3 3 2 1 0 0
1 1 5 2 1 0 0
1 1 1 2 1 0 0
2 2 2 2 1 0 0
1 1 5 1 0 0 1
3 3 3 2 1 0 0
1 1 5 1 0 0 1
1 1 5 1 0 0 1
5 1 2 1 0 0 1
2 2 2 2 1 0 0
3 3 3 2 1 0 0
3 3 3 2 1 0 0
1 1 1 2 1 0 0
1 1 5 2 1 0 0
5 1 1 2 1 0 0
3 3 3 2 1 0 0
5 1 1 1 0 0 1
3 3 3 2 1 0 0
3 2 3 2 1 0 0
1 1 5 2 2 2 0
1 1 1 1 0 0 1
1 1 5 2 1 0 0
2 2 1 2 1 0 0
3 3 3 2 1 0 0
1 1 5 1 0 0 1
2 2 2 2 1 0 0
1 1 2 2 0 0 0
3 3 3 1 0 0 2
1 1 5 2 1 0 0
2 2 2 2 1 0 0
3 3 3 2 1 0 0
1 1 1 1 0 0 2
1 5 5 1 0 0 1
1 1 1 1 0 0 1
1 1 1 1 0 0 1
1 2 2 1 0 0 2
1 1 1 1 0 0 1
2 2 2 2 1 0 0
1 1 5 1 0 0 1
1 1 1 1 0 0 1
1 1 5 1 0 0 1
2 2 2 1 2 3 3
1 1 1 1 2 1 4
1 5 2 2 2 1 0

1 2 2 1 0 0 2
1 5 5 1 0 0 2
1 1 1 1 0 0 1
1 1 1 1 0 0 1
1 1 1 1 0 0 1
1 2 2 1 0 0 3
2 2 2 1 0 0 3
1 1 5 1 0 0 1
1 1 5 1 0 0 1
2 5 5 2 1 0 0
2 2 2 2 1 0 0
1 1 5 1 0 0 1
3 3 3 2 1 0 0
3 3 2 2 1 0 0
2 2 2 2 1 0 0
1 1 5 1 0 0 1
 19. Seberapa
18. Apakah berpengaruh
16a.Seberapa rasa sakit atau
besar kesulitan Anda tidak nyaman
17. Apakah
16. Seberapa yang Anda terbatasi yang pernah
Anda 20. Saya 21. Saya
besar alami saat dalam hal Anda rasakan di
mengemudi di mencapai berapa dalam dan di sering kali sering sekali
kesulitan lama
keadaan yang kurang dari Anda dapat sekitar mata tetap tinggal merasa
yang Anda sulit, seperti yang Anda Anda (misalnya, di rumah frustasi
alami saat inginkan bekerja
dalam cuaca atau rasa seperti karena karena
mengemudi buruk, pada melakukan terbakar, gatal
karena penglihatan penglihatan
di malam penglihatan kegiatan
jam sibuk, di lain atau nyeri)
jalan bebas dalam saya saya
hari? karena
hambatan atau Anda? mencegah Anda
lalu lintas kota?
penglihatan melakukan apa
Anda? yang Anda ingin
lakukan?

No 16 No 16a No 17 No 18 No 19 No 20 No 21

0 0 5 5 5 4 5
1 1 5 5 5 5 5
4 4 3 4 3 2 3
0 0 5 5 5 5 5
0 0 5 5 5 5 5
0 0 5 5 4 5 5
5 5 4 5 3 4 3
0 0 2 2 5 2 5
3 3 4 4 4 2 4
0 0 4 5 4 5 3
4 5 4 4 4 4 4
0 0 5 4 5 5
0 0 4 5 3 5 5
5 5 4 4 4 2 4
0 0 5 4 5 5 4
1 2 4 4 2 4 4
4 3 3 3 3 5 5
0 0 5 5 5 5 5
2 3 2 3 3 3 3
0 0 5 4 5 5 5
1 1 5 5 5 5 5
2 2 5 5 5 5 5
0 0 5 5 5 4 4

0 0 5 5 5 5 5
0 0 3 4 4 4 4
1 1 5 4 5 5 5
0 0 4 4 3 4 4
0 0 5 4 4 5 5
0 0 5 5 5 5 5
0 0 4 4 4 3 4
0 0 4 4 4 5 5
1 1 5 5 5 5 5
0 0 5 5 5 5 5
1 1 4 4 5 5 5
1 1 5 5 4 5 5
3 3 5 4 4 5 2
4 4 2 3 3 4 2
0 0 5 5 5 4 5
2 2 4 4 5 5 5
0 0 5 5 4 5 5
2 2 4 4 4 5 2
0 0 4 4 4 4 4
0 0 1 1 4 2 3
0 0 1 1 1 4 1
0 0 5 5 4 5 5
0 0 4 4 5 5 5
1 2 4 5 4 4 5
0 0 5 5 5 5 5
0 0 3 3 3 2 2
2 3 4 5 5 5 5
1 1 5 5 5 5 5
4 5 4 4 4 4 5
2 2 5 5 5 5 5
0 0 3 3 5 4 4
0 0 5 5 5 5 5
4 4 3 4 4 2 4
0 0 4 4 2 5 5
0 0 1 1 5 2 2
0 0 3 3 3 3 2
2 2 4 5 5 5 5
1 1 5 5 5 5 5
4 4 2 2 3 1 4
0 0 5 5 5 5 5
1 1 4 5 5 5 5
0 0 4 4 4 5 5
0 0 4 2 1 5 5
1 1 5 5 5 5 5
4 4 5 5 5 5 2
0 0 1 1 5 1 2
4 4 4 5 5 5 5
3 3 3 3 4 5 2
0 0 5 5 2 2 5
3 2 4 4 3 5 5
0 0 1 1 2 1 1
2 1 5 5 5 5 1
0 0 5 5 4 5 5
0 0 5 5 4 5 5
1 1 4 5 5 5 5
1 1 4 3 4 4 4
0 0 1 1 2 1 1
0 0 4 3 4 5 5
0 0 3 3 3 2 2
1 1 5 5 5 5 5
0 0 4 5 5 5 5
0 0 2 2 3 2 2
1 1 4 4 4 5 5
0 0 4 4 4 5 3
0 0 4 4 4 4 4
0 0 5 4 4 5 5
0 0 4 4 4 5 4
0 0 3 3 3 4 2
0 0 2 2 2 4 2
0 0 4 5 4 5 5
0 0 4 4 4 5 5
0 0 3 3 4 4 4
0 0 4 4 4 4 4
5 5 3 3 3 2 2
0 0 3 4 4 4 3
0 0 4 4 4 5 5
0 0 5 5 5 5 5
0 0 4 5 4 5 5
0 0 3 4 4 4 4
0 0 5 5 5 5 2
0 0 3 4 4 4 4
1 1 4 5 5 5 5
0 0 4 5 4 5 5
0 0 4 4 4 3 5
0 0 3 3 4 4 3
0 0 3 3 3 4 4
4 4 2 2 2 2 2
1 1 5 5 5 5 5
2 2 4 5 5 5 5
1 1 5 5 5 5 5
1 2 4 4 4 5 5
0 0 5 5 5 5 5
0 0 4 3 4 4 5
4 4 2 2 2 1 2
3 3 4 3 3 3 3
3 3 3 3 4 4 3
0 0 3 4 4 5 5
4 2 2 2 2 1 1
0 0 4 5 5 5 5
1 1 1 5 5 4 5
4 4 5 5 3 5 3
3 3 3 3 3 3 3
2 2 4 4 5 4
3 3 3 3 3 3 3
0 0 1 1 1 1 4
3 3 2 2 3 5 5
2 2 4 4 5 4 4
0 0 5 5 5 5 5
0 0 3 3 4 4 4
3 3 3 3 3 3 3
4 2 5 5 4 5 5
0 0 2 1 2 1 2
4 4 1 1 1 1 1
0 0 4 4 5 4 4
0 0 2 4 5 5 5
3 3 3 3 4 3 4
2 1 1 2 2 5 4
3 3 3 3 3 3 3
0 0 3 3 4 3 3
1 1 1 1 1 1 1
0 0 2 1 1 2 1
4 2 4 4 5 4 5
0 0 3 3 3 3 3
2 2 4 4 4 4 4
0 0 3 2 4 2 3
2 2 4 4 4 4 3
0 0 4 5 5 5 5
3 3 3 3 3 3 3
3 3 4 3 3 3 3
2 1 5 2 5 5 5
0 0 3 3 3 5 5
1 1 5 4 2 3 5
2 2 5 4 5 5 5
4 4 2 2 3 2 2
0 0 2 2 4 3 3
3 3 4 4 4 3 3
2 2 3 3 3 4 4
0 0 2 2 2 3 5
0 0 3 3 4 3 3
2 1 5 5 5 5 5
2 2 3 3 3 5 5
3 3 3 3 3 3 3
3 3 3 3 3 3 3
0 0 2 2 4 2 3
0 0 3 3 4 3 3
3 3 3 3 3 3 3
1 1 5 5 4 5 5
1 1 5 5 5 5 5
0 0 2 2 4 2 3
0 0 3 3 4 3 3
4 4 2 2 3 2 2
3 4 3 3 3 5 5
0 0 3 3 4 4 4
0 0 4 3 4 5 5
3 3 3 3 3 4 4
4 4 3 3 3 2 3
0 0 3 3 3 3 3
0 0 4 5 4 5 5
0 0 3 3 4 3 4
2 2 4 5 5 5 5
0 0 3 3 3 3 3
0 0 3 4 4 5 5
5 5 3 3 3 2 3
4 4 3 3 5 4 4
0 0 2 3 2 2 2
1 1 5 5 5 5 5
3 3 5 4 4 3 5
0 0 4 4 4 4 4
3 2 5 3 4 2 4
0 0 3 3 3 4 4
2 2 4 4 5 5 5
0 0 3 3 3 3 3
0 0 3 3 2 4 4
0 0 3 3 3 2 3
2 3 5 5 5 4 2
3 3 3 3 4 2 3
0 0 5 5 5 5 5
0 0 5 5 4 5 5
0 0 4 4 4 4 4
1 1 5 5 5 5 5
0 0 3 3 3 4 4
2 1 5 5 5 5 5
3 3 5 5 5 5 5
1 3 5 5 3 1 1
0 0 4 4 4 4 4
0 0 4 3 3 4 4
0 0 3 3 4 4 4
0 0 4 5 3 5 5
0 0 5 5 5 5 5
0 0 3 5 3 2 3
0 0 3 4 4 4 4
2 2 5 5 4 5 5
0 0 3 2 4 2 3
0 0 3 3 3 4 4
0 0 5 5 5 5 5
2 2 2 4 5 5 5
0 0 5 5 5 5 5
0 0 3 3 2 2 5
0 0 3 3 3 3 3
4 4 1 2 5 2 2
0 0 3 3 3 4 4
0 0 4 3 5 4 5
2 2 4 4 4 4 4
0 0 5 5 5 5 5
0 0 4 4 4 4 4
0 0 4 3 4 4 4
3 1 3 4 5 5 5
3 3 5 5 5 5 5
1 1 5 5 5 5 5
5 1 2 2 3 5 2
4 4 3 3 2 2 4
1 1 4 5 5 5 5
0 0 2 2 4 4 4
5 1 4 5 5 5 5
2 2 3 4 5 5 5
4 1 4 3 4 5 5
4 4 2 2 2 3 4
3 3 3 3 3 5 5
0 0 1 1 1 1 1

4 4 2 2 3 2 3
5 3 3 3 2 5 5
1 1 5 5 5 5 5
1 1 4 2 5 5 5
1 1 4 5 5 5 5
4 4 3 3 3 2 3
4 4 3 2 2 2 2
3 3 2 3 5 5 5
1 1 5 5 5 5 5
0 0 3 3 3 2 5
0 0 4 4 4 4 4
1 3 5 4 5 5 2
0 0 4 4 4 4 4
0 0 3 3 4 4 4
0 0 3 3 3 4 4
3 5 5 5 5 5 5
 25. Saya
22. Kontrol 23. Karena khawatir
saya penglihatan 24. Saya melakukan
terhadap apa saya, saya membutuhka hal-hal yang
yang saya terlalu n banyak akan
lakukan banyak bantuan dari mempermalu
hanya bergantung orang lain kan diri
sedikit, kepada apa karena sendiri atau
karena yang penglihatan orang lain
penglihatan dikatakan saya karena
saya orang lain penglihatan
saya

UCVA SNELLEN

No 22 No 23 No 24 No 25

KLASIFIKASI
OD OS
OD

5 3 4 4 6/30 2 6/30
5 5 5 5 6/30 2 6/30
3 5 5 3 6/30 2 6/30
5 5 5 5 6/30 2 6/30
5 5 5 5 6/20 2 6/15
5 5 5 5 6/20 2 6/9
3 3 5 5 6/6 0 6/9
3 4 4 4 6/30 2 6/60
4 5 5 5 6/15 1 6/9
3 5 5 5 6/15 1 6/15
3 3 4 4 6/15 1 6/15
5 5 5 5 6/30 2 6/30
5 5 5 5 6/9 1 6/9
3 4 3 3 6/9 1 6/9
4 4 5 4 6/9 1 6/9
3 4 4 4 6/15 1 6/15
4 5 5 3 6/15 1 6/15
5 5 5 5 1/60 4 1/60
2 4 3 4 6/15 1 6/15
5 5 2 5 6/9 1 6/15
5 5 5 5 6/9 1 6/15
5 5 5 5 6/15 1 6/60
4 4 4 4 6/60 2 3/60
6/15 1 6/15
5 5 5 5 6/6 0 6/9
4 5 5 5 6/15 1 6/15
5 5 5 5 6/9 1 6/15
5 5 4 5 6/9 1 6/15
5 5 5 5 6/9 1 6/9
5 5 5 5 6/9 1 6/9
3 4 4 4 6/15 1 6/20
1 5 5 5 6/20 2 6/20
5 5 5 5 6/15 1 6/9
5 5 5 5 6/15 1 6/15
4 4 4 5 6/9 1 6/9
5 5 5 5 6/15 1 6/15
5 5 5 2 6/6 0 6/6
3 5 5 3 6/15 1 6/60
5 5 4 5 6/15 1 6/20
5 5 5 5 6/20 2 6/15
5 5 5 5 6/9 1 6/9
5 5 5 5 6/9 1 6/9
3 3 4 4 6/9 1 6/6
2 1 1 3 1/300 4 1/-
3 2 2 3 6/30 2 1/-
5 5 5 5 6/6 0 6/6
2 5 5 3 3/60 3 6/30
4 5 5 5 6/9 1 6/9
5 5 5 5 6/30 2 6/30
2 2 4 4 6/15 1 6/15
4 5 5 5 6/30 2 6/30
5 5 5 5 6/15 1 6/15
4 5 5 5 6/9 1 6/6
5 5 5 5 6/9 1 6/6
4 4 4 4 6/9 1 1/-
4 5 5 5 6/20 2 6/15
2 4 4 5 6/15 1 6/20
5 5 5 5 6/15 1 6/15
3 1 1 2 ANOFTHALMIA 4 1/60
4 5 5 5 1/- 4 6/30
5 5 5 5 6/15 1 6/15
5 5 5 5 6/6 0 6/6
1/60 4 6/30
5 5 5 5 6/9 1 6/9
5 5 5 5 6/6 0 6/6
5 4 2 2 6/9 1 6/9
4 5 5 5 6/20 2 6/15
5 5 5 5 6/30 2 6/30
5 5 5 5 4/300 4 6/20
1 1 1 4 1/300 4 1/-
5 5 5 5 6/20 2 6/20
5 5 5 5 6/9 1 6/9
4 5 5 5 1/- 4 2/60
3 5 5 5 6/9 1 6/9
1 1 1 1 NLP 4 1/300
5 5 5 5 ANOFTALMIA 4 6/20
5 5 5 5 6/30 2 6/15
5 5 5 5 6/20 2 6/15
5 5 5 5 6/30 2 NLP
4 4 4 4 6/9 1 6/9
1 1 1 1 6/60 2 NLP
3 5 5 5 6/15 1 6/60
4 4 4 4 6/15 1 6/9
5 5 5 5 6/9 1 6/15
3 5 5 5 6/9 1 6/9
2 4 4 2 6/15 1 6/15
5 5 5 5 6/15 1 6/9
5 5 5 5 6/9 1 6/15
4 4 4 4 6/15 1 6/15
5 5 5 5 6/30 2 6/15
4 5 4 5 6/9 1 6/15
5 5 5 5 6/15 1 6/20
2 2 2 2 6/15 1 6/15
3 5 5 5 6/15 1 6/15
4 5 5 5 6/9 1 6/9
4 4 4 4 6/9 1 6/9
4 4 4 4 6/15 1 6/20
2 4 4 2 6/15 1 6/9
4 4 4 4 6/15 1 6/15
4 5 5 1 6/9 1 6/9
5 5 5 5 6/9 1 6/15
4 5 5 5 6/9 1 6/15
4 4 4 4 6/30 2 6/30
5 5 5 2 6/9 1 6/15
4 4 4 2 1/60 4 1/60
4 5 5 5 6/6 0 6/6
4 5 5 5 6/9 1 6/9
4 5 5 5 6/15 1 6/15
3 3 3 4 1/60 4 6/9
4 4 4 4 6/15 1 6/15
2 2 2 2 1/300 4 NLP
5 5 5 5 6/9 1 6/15
5 5 5 5 6/30 2 6/20
5 5 5 5 6/9 1 6/9
3 5 5 5 6/20 (K) 2 6/30
5 5 5 5 6/15 (K) 1 6/15
4 4 4 4 6/15 1 6/15
3 1 1 3 NLP 4 6/20
3 3 3 3 6/30 2 6/30
4 4 4 4 3/60 3 6/9
3 5 5 5 6/9 1 6/20
4 1 1 5 6/20 2 6/20
5 5 5 5 6/15 1 6/15
5 5 5 5 6/9 1 6/20
5 5 3 3 1/300 4 6/15
3 3 3 3 6/15 1 6/9
4 4 4 4 6/9 1 6/9
3 3 3 3 1/60 4 1/300
2 5 5 5
3 5 5 5 6/60 2 2/60
4 4 4 5 6/9 1 6/9
5 5 5 5 6/30 2 6/30
4 4 4 5 6/15 1 6/60
3 3 3 3 6/30 2 6/20
5 5 5 5 6/60 2 6/60
3 2 2 3 4/60 3 4/60
1 1 3 3 6/30 2 LP
4 4 4 4 6/9 1 6/9
4 4 5 5 6/15 1 6/15
4 4 4 4 6/20 2 6/15
5 5 5 5 1/60 4 6/60
3 3 3 3 6/9 1 6/9
3 4 4 4 3/60 3 2/60
1 1 1 1 6/30 2 6/30
1 5 5 2 6/20 2 6/30
4 5 5 5 6/60 2 6/30
3 3 3 3 6/15 1 6/15
4 4 4 4 1/300 4 6/15
2 2 2 3 6/15 1 LP
3 3 3 3 6/15 1 6/15
4 4 5 5 6/30 2 LP
4 4 4 3 6/15 1 6/15
3 3 3 3 6/30 2 6/30
5 5 5 5 6/9 1 6/15
5 5 5 3 1/60 4 6/15
2 5 5 5 6/15 1 6/20
4 5 5 5 6/9 1 6/9
2 2 2 3 6/30 2 6/30
2 2 2 3 LP 4 6/60
3 4 4 3 6/15 1 6/15
4 4 4 5 6/20 2 1/60
1 1 1 1 LP 4 4/60
4 4 4 3 6/15 1 1/300PB
5 5 5 5 6/15 1 6/15
5 5 5 5 6/15 1 6/30
3 3 3 3 3/60 3 6/20
3 3 3 3 6/15 1 6/20
2 2 2 3 1/300 4 1/300
3 2 2 3 6/20 2 6/20
4 3 4 3 2/300 4 6/20
4 5 5 5 6/9 1 6/9
5 5 5 5 6/6 0 6/6
2 2 2 3 6/9 1 6/9
4 3 4 4 6/60 2 6/60
2 2 2 3 6/15 1 1/300
5 4 4 5 6/15 1 3/60
2 2 2 4 6/15 1 6/15
3 3 3 3 6/9 1 6/9
4 4 5 5 6/15 1 6/15
2 2 2 3 2/60 4 6/30
3 4 3 3 6/60 2 3/60
2 5 5 5 6/9 1 6/9
3 2 2 3 2/60 4 1/60
4 5 5 5 6/20 2 6/15
4 4 4 4 6/15 1 6/15
3 3 3 3 6/20 2 1/60
4 3 4 4 1/60 4 1/60
3 4 4 5 6/30 2 6/60
5 2 2 2 LP 4 6/9
5 5 5 5 6/30 2 6/20
3 4 4 4 6/15 1 6/15
4 4 4 4 2/60 4 2/60
1 2 2 5 6/20 2 6/60
3 3 3 3 1/60 4 3/60
5 5 5 5 6/6 0 6/6
4 4 4 3 6/20 2 6/20
2 3 3 2 2/60 4 LP
2 2 2 3 6/9 1 6/15
1 5 5 5 6/9 1 6/9
4 4 4 3 6/9 1 6/9
5 5 5 5 6/9 1 6/9
2 5 5 5 6/9 1 6/9
4 4 4 4 6/15 1 6/15
5 5 5 5 6/9 1 6/6
4 4 4 3 6/15 1 6/15
5 5 5 5 6/60 2 6/30
5 5 5 5 6/9 1 6/9
2 5 5 5 6/9 1 6/15
4 4 4 4 6/9 1 6/9
4 4 4 4 6/60 2 2/60
4 4 4 4 6/20 2 4/60
5 5 5 5 6/9 1 6/9
5 5 5 5 6/20 2 6/20
2 5 5 5 6/15 1 6/15
4 4 4 5 6/15 1 6/15
5 5 5 5 6/15 1 6/15
2 2 2 3 2/60 4 1/60
2 2 2 3 3/60 3 3/60
5 5 5 5 6/9 1 6/15
4 5 5 5 6/20 2 6/20
5 5 5 5 6/60 2 6/60
3 4 4 4 6/20 2 6/30
3 4 4 3 6/9 1 6/15
5 5 5 5 6/9 1 6/9
2 4 4 3 6/15 1 6/15
4 4 4 5 6/60 2 6/15
4 4 4 4 6/15 1 6/20
5 5 5 5 6/15 1 6/15
4 4 4 4 6/30 2 6/15
4 4 4 4 6/15 1 6/15
5 5 5 5 1/60 4 3/60
5 5 5 5 6/20 2 6/20
5 5 5 5 6/9 1 6/6
5 3 3 5 6/60 2 6/30
3 4 4 4 6/15 1 6/9
5 5 5 5 6/20 2 6/20
4 4 4 4 4/60 3 5/60
5 5 5 5 6/30 2 6/30
4 5 5 5 6/9 1 6/6
5 5 5 5 6/6 0 6/6
4 4 4 4 6/30 2 6/30
2 2 2 2 6/30 2 6/15
3 2 2 2 6/30 2 6/30
6/9 1 6/15
3 4 4 4 6/60 2 6/30
5 5 5 5 6/15 1 6/9
5 5 5 5 6/15 1 6/15
5 5 5 5 6/15 1 6/15
5 5 5 5 6/15 1 3/60
4 4 4 4 6/30 2 6/30
3 2 2 3 6/9 1 6/9
5 5 5 5 6/20 2 6/15
5 5 5 5 6/30 2 6/20
2 4 4 4 1/300 4 6/30
4 4 4 4 6/15 1 6/15
5 5 5 5 6/9 1 6/9
4 4 4 4 2/60 4 6/30
2 3 4 3 6/15 1 6/15
3 5 5 5 6/15 1 6/9
5 2 2 5 6/30 2 6/30
 PEMERIKSAAN VISUS, TIO DAN RE

VA SNELLEN UPEEK UREFRAKSI AUTOR

KLASIFIKASI KLASIFIKASI OD
OD OS OD OS
OS KEDUA MATA
S
2 2 6/18 6/18 5/60 6/60 -0.50
2 2 6/12 6/12 6/30 6/30 +0.50
2 2 6/15 6/15 6/20 6/20 +1.50
2 2 6/18 6/18 6/40 6/30 -0.00
1 1 6/15 6/12 6/60 6/12 +1.50
1 1 6/9 6/7.5 6/15 6/15 +2.25
1 0 6/12 6/7.5
2 2 6/18 1/60 1/60 1/60
1 1 6/6 6/5
1 1 6/18 6/18
1 1 6/18 6/12
2 2 6/12 6/18 6/30 4/60 -1.50
1 1 6/9 6/9
1 1 6/7.5 6/6
1 1 6/7.5 6/9
1 1 6/18 6/15 +0.50
1 1 6/9 6/7.5 6/6 6/6 -0.00
4 4 1/60 1/60 1/60 1/60 -6.50
1 1 6/15 6/24 +2.25
1 1 6/7.5 6/12 +0.50
1 1 6/9 6/15 +0.75
2 1 6/12 6/15 6/30 6/30 +1.50
3 2 3/60 6/48 3/60 5/60 -4.50
1 1 6/18 6/12
1 0 6/4.8 6/5
1 1 6/9.5 6/18 -0.25
1 1 6/9 6/15 +1.50
1 1 6/7.5 6/9
1 1 6/7.5 6/9 6/75 6/10
1 1 6/7.5 6/6
2 1 6/19 6/12 6/20 6/20 +1.50
2 2 6/30 6/48 6/20 6/20 -0.50
1 1 6/9 6/6
1 1 6/12 6/9
1 1 6/7.5 6/7.5
1 1 6/12 6/12 -0.75
0 0 6/6 6/6
2 1 6/9 3/60 6/20 4/60 +0.25
2 1 6/24 6/36 6/30 6/30 +3.50
1 1 6/7.5 6/18 6/30 6/10 +0.75
1 1 6/5 6/6
1 1 6/7.5 6/7.5
0 0 6/7.5 6/6 6/6 6/6
4 4 1/60 1/60 1/300 1/300
4 2 6/60 1/60 6/60 1/300
0 0 6/6 6/7.5
2 2 3/60 6/48 3/60 5/60 +4.00
1 1 6/7.5 6/12
2 2 6/30 6/36 6/30 6/30 -1.00
1 1 6/9 6/7.5
2 2 6/7.5 6/6 6/6 6/6 +0.50
1 1 6/7.5 6/6 6/15 6/15
0 0 6/6 6/6
0 0 6/6 6/6
4 1 6/6 1/- 6/6 NLP +0.75
1 1 6/15 6/5 -1.25
2 1 6/24 6/6 5/60 6/20
1 1 6/9.5 6/9.5 6/6 6/6 +0.25
4 4 - 1/60
2 2 1/- 6/15 1/- 6/20 +0.75
1 1 6/6 6/4.8 +1.00
0 0 6/6 6/18
2 2 1/60 6/36 1/60 5/60 -3.75
1 1 6/7.5 6/7.5
0 0 6/6 6/5
1 1 6/12 6/9
1 1 6/30 6/24 6/30 6/20 +2.25
2 2 6/12 6/30 6/40 6/30 +1.75
2 2 3/60 6/15 5/60 6/30
4 4 1/60 1/- 1/300 1/-
2 2 6/24 6/15 6/20 6/30 -1.75
1 1 6/6 6/6
4 4 1/- 6/60 1/- 5/60
1 1 6/9 6/9
4 4 NLP 1/300
2 2 NLP 6/9 NLP 6/6
1 1 3/60 6/15 6/40 6/15 -0.25
1 1 6/24 6/19 6/30 6/20 +2.25
4 2 6/36 NLP 6/40 NLP -0.00
1 1
4 2 1/60 NLP 1/60 NLP +4.25
2 1 6/9.5 3/60 6/40 4/60 -1.25
1 1 6/9 6/7.5 6/6 6/6 -0.50
1 1 6/15 6/12 6/10 6/10 +1.25
1 1 6/9 6/7.5
1 1 6/30 6/20 +3.25
1 1 6/15 6/7.5 6/7.5 6/10 +1.25
1 1 6/9 6/12
1 1 6/12 6/15 6/6 6/6 +0.50
1 1 6/30 6/12 6/40 6/30 +2.75
1 1 6/6 6/7.5
2 1 6/15 6/18 6/15 6/15 +1.50
1 1 6/9 6/12 6/20 6/20 -0.25
1 1 6/9 6/9 6/15 6/15 +1.25
1 1 6/9 6/9
1 1 6/7.5 6/9.5
2 1 6/19 6/30 6/15 6/20 +1.50
1 1 6/12 6/9
1 1 6/15 6/9 -0.50
1 1 6/6 6/7.5
1 1 6/7.5 6/9.5
1 1 6/7.5 6/9
2 2 6/30 6/36 6/40 5/60 +3.50
1 1 6/12 6/9
4 4 1/60 1/60 1/60 1/60 +12.25
0 0 6/6 6/6
1 1 6/7.5 6/7.5
1 1 6/9.5 6/12 +0.25
1 1 1/60 6/9.5 1/60 6/10 +10.25
1 1 6/24 6/12 +1.75
4 4 1/300 NLP
1 1 6/7.5 6/12 +0.50
2 2 6/30 6/18 6/40 6/30 -1.50
1 1 6/7.5 6/15
2 1 6/18 6/19 4/60 5/60 -4.00
1 1 6/12 6/9 +2.00
1 1 6/15 6/15 +1.50
2 2 NLP 6/18 NLP 6/20
2 2 6/48 6/18 6/40 6/40 -2.00
1 1 6/48 6/7.5 4/60 6/15 -2.00
2 1 6/6 6/19 -0.00
2 1 6/24 6/18 6/30 6/20 +2.00
1 1 6/6 6/12
2 1 6/6 6/15 6/6 6/15 -0.25
1 1 1/300 6/12 0.5/60 6/12
1 1 6/9.5 6/12
1 1 6/9 6/7.5
4 4 1/60 1/300

4 2 6/36 3/60 6/60 2/60

1 1 6/6 6/6
2 2 6/20 6/20 6/30 6/30 +3.00
2 1 6/9 3/60 6/15 3/60 +0.75
2 2 6/15 6/15 6/30 6/20 -1.00
2 2 6/60 6/30 5/60 6/60 +4.25
3 3 6/60 3/60 4/60 3/60 -0.25
4 2 6/18 LP 6/40 1/300 +0.5
1 1 6/9.5 6/9.5
1 1 6/18 6/12 6/15 6/15 +2.00
1 1 6/24 6/15 6/20 6/15 +6/50
2 2 1/60 6/36 2/60 6/60 -9.75
1 1 6/6 6/12
4 3 3/60 3/60 3/60 3/60 -6.50
2 2 6/19 6/12
2 2 6/15 6/30 6/20 6/30 +0.75
2 2 3/60 6/20 3/60 5/60 -5.25
1 1 6/12 6/9.5
1 1 1/60 6/12 0.5/60 6/75
4 1 6/24 LP 6/20 LP +0.50
1 1 6/7.5 6/7.5 +0.50
4 2 6/19 LP 6/30 LP -1.75
1 1 6/15 6/24 +3.75
2 2 6/15 6/24 6/15 6/15 +1.25
1 1 6/9 6/9
1 1 1/60 6/9 1/60 6/15
2 1 6/18 6/24 6/20 6/40 +3.00
1 1 6/9 6/7.5
2 2 6/30 6/24 6/30 6/30 -2.50
2 2 LP 6/30 1/300 6/60 +11.75
1 1 6/12 6/12
4 2 6/24 1/60 6/20 1/60 +1.50
3 3 LP 6/60 LP 5/60
4 1 6/12 1/300 6/15 1/300 +0.75
1 1 6/9 6/18
2 1 6/7.5 6/24 6/15 6/20 -0.25
2 2 3/60 6/24 3/60 6/30 +0.75
2 1 6/15 6/15 6/15 6/15 -0.50
4 4 1/60 1/60 1/60 05/60
2 2 6/15 6/18 6/20 6/20 +1.75
2 2 1/60 6/7.5 0.5/60 6/15
1 1 6/6 6/9
0 0 6/5 6/5
1 1 6/6 6/7.5
2 2 3/60 3/60 3/60 3/60 -2.75
4 1 6/75 1/60 +0.50
3 1 6/12 3/60
1 1 6/7.5 6/7.5
1 1 6/12 6/12
1 1 6/7.5 6/9
2 2 6/30 6/24 6/60 6/40 -2.25
3 2 6/60 2/60 -5.00
1 1 6/7.5 6/6
4 4 1/60 1/60 -5.00
1 1 6/15 6/12 6/15 6/10 +1.00
1 1 6/24 6/24 6/20 6/20 +1.25
4 2 6/19 6/15 1/300
4 4 3/60 3/60 1/60 1.5/60
2 2 3/60 6/30 5/60 5/60 -0.25
1 1 LP 6/12
2 2 6/18 6/20 6/30 6/30 +3.00
1 1 6/12 6/12
4 4 6/30 6/30 5/60 4/60 -3.50
2 2 6/12 6/24 6/20 6/40 +4.50
3 3 -3.50
0 0 6/6 6/6
2 2 6/18 6/24 6/15 6/20 +1.75
4 4 1/60 6/60 LP
1 1 6/9.5 6/15
1 1 6/6 6/6
1 1 6/6 6/6
1 1 6/12 6/6
1 1 6/7.5 6/6
1 1 6/12 6/12 6/10 6/10 +1.00
0 0 6/6 6/6
1 1 6/15 6/18 +2.50
2 2 6/30 6/15 6/60 6/60 -2.50
1 1 6/12 6/7.5
1 1 6/7.5 6/12
1 1 6/6 6/6
4 2 6/36 3/60 5/60 3/60 -2.00
3 2 6/7.5 3/60 6/15 5/60 +1.25
1 1 6/9 6/7.5
2 2 6/24 6/24 5/60 4/60
1 1 6/12 6/15
1 1 6/12 6/9
1 1 6/15 6/24 -0.25
4 4 6/48 1/60 0.5/60 0.5/60
3 2 6/18 6/15 6/60 6/60 -6.25
1 1 6/9 6/12
2 2 6/15 6/12 +2.00
2 2 6/60 6/60 +1.25
2 2 6/24 6/30 6/30 6/40 -0.75
1 1 6/7.5 6/9
1 1 6/9 6/7.5
1 1 6/12 6/6 +1.75
1 1 3/60 6/15 -3.00
2 1 6/12 6/15 6/20 6/30 -1.00
1 1 6/20 6/15 6/20 6/15 +1.50
1 1 6/36 6/18 6/40 6/20 -1.75
1 1 6/12 6/12
3 3 3/60 6/15 2/60 4/60
2 2 6/24 6/12 6/20 6/20 +1.75
0 0 6/9 6/5
2 2 6/48 6/30 6/60 6/20
1 1 6/9 6/7.5
2 2 6/15 6/15 6/15 6/15 +1.50
3 3 3/60 6/30 3/60 6/60 +2.75
2 2 6/18 6/30 6/30 5/60 -2.00
0 0 6/6 6/6
0 0 6/6 6/6
2 2 6/30 6/30 6/60 5/60 +3.50
1 1 3/60 6/19 4/60 6/25 +4.50
2 2 6/30 6/30 6/60 6/60 -0.75
1 1 6/7.5 6/9.5
2 2 3/60 6/20 6/60 6/30 -3.25
1 1 6/6 6/6
1 1 6/9 6/12
1 1 6/7.5 6/6 6/6E 6/6E
3 1 6/9 3/60 6/15 3/60 +0.25
2 2 6/30 6/34 6/40 6/40 -2.50
1 1 6/6 6/7.5
1 1 6/24 6/18 6/20 6/7.5 -1.00
2 2 6/30 6/30 6/30 6/20 +1.00
2 2 1/300 6/15 1/300 6/15 +1.75
1 1 6/9 6/15 +0.25
1 1 6/9 6/9
2 2 3/60 6/24 4/60 6/30
1 1 6/15 6/24 6/15 6/20 +1.75
1 1 6/7.5 6/7.5
2 2 6/30 6/24 6/40 6/30 +0.50
AN VISUS, TIO DAN REFRAKSI

AUTOREF SUBJECTIVE VISUS (TRIAL LENSE) BCVA

OD OS OD OS
OD

C A S C A S C A S C A
-4.75 80 +1.00 -3.75 86 0 -3.50 20 0 -2.0 90 6/20
-1.75 83 -0.50 -1.00 89 +0,50 -1.00 90 -0.75 -1.00 90 6/10
-1.50 74 +1.50 -0.75 107 +0.75 -0.75 75 +0.75 -0.75 100 6/10
-3.50 87 +0.25 -3.25 91 0.00 -3.00 90 0.00 -3.00 90 6/7.5
-3.50 88 +4.75 -4.50 163 0.00 -3.00 85 TTK addi TTK TTK 6/20
-1.25 74 +1.50 -1.00 84 +0.75 0 0 +0.75 0 0 6/6

+14.50 -2.00 156 TTK TTK TTK +13.00 -1.50 160 TTK

addisi +1.50 addisi +1.50

addisi +1.50 addisi +1.50
-0.75 83 -1.75 -2.25 41 TTK TTK TTK TTK TTK TTK TTK

-2.50 97 +1.00 -2.50 76 addisi +1.50 Addisi +1.50

-0.25 57 -0.00 -0.25 85 Addisi +2.75 Addisi +2.75
-1.00 59 TDK TDK TDK -6.00 0 0 -6.00 0 0 6/60
-1.50 77 +1.75 -1.50 82
-0.50 100 +1.00 -1.00 77 addisi +2.00 Addisi +2.00
0 0 +1.25 -0.25 88
-2.75 69 +0.50 -2.50 100 +0.50 -1.50 70 0 -1.75 105 6/7.5
-0.75 87 -3.50 -0.75 105 -5.50 0 0 -3.00 0 0 6/30

-1.00 127 +0.25 -1.75 57

-1.50 94 +1.00 -0.50 105

TTK Addisi +2.50

TTKTTK TTK
Addisi +2.50 PDTTK
60/58 TTK TTK

-1.75 102 +0.25 -1.75TTK addisi

93 S +3.00 PD
TTK
63/61TTK addisi -1.50 90 TTK
-1.00 164 TTK TTK TTK TTK TTK TTK TTK TTK TTK TTK

-0.25 55 -0.25 -0.25 22 addisi +3.00 addisi +3.00TDK

-1.25 64 -2.75 -1.50 91 TTK TTK TTK -2.50 0 0 TTK

-1.50 83 +3.00 -1.25 39 +2.50 -0.75 90 +2.50 add +2.75 PD 63 6/7.5
-3.00 78 +0.50 -2.00 96 -2.00 80 110
-1.25
add +2.25 PD 62/60
6/6

add +2.00 PD 62/60

-1.25 150 -1.25 -1.50 116 -1.50 TTK

-0.50 102 -1.00 -0.50 73 -1.50 -1.50
ADD +1.75 PD 63/61 6/6

-0.50 87 +0.50 -0.75 77 ADD +2.25 PD66/64

-0.50 86 +0.50 ADD +2.25 6/6

-0.75 127 +0.75 -0.25 43
-0.75 -4.50 77 TTK TTK TTK TTK
-0.25 34 +1.00 -0.50 107 ADD +2.00 PD 63/61

+0.75 -2.00 163 TTK TTK TTK TTK

-0.50 79 +1.00 -0.25 113

-1.50 85 -4.75 -3.50 75 -5.50 -4.00 -2.00 75 3/60

-0.50 55 +2.25 -1.00 91 +1.50 +1.50 ADD +2.50 PD 63 6/15

-1.75 84 +1.75 -1.00 93 +1.25 -1.25 90 TTK ADD +3.00 PD 64/ 6/15
-0.75 -2.75 86 -0.50 90-2.50
ADD +3.00 PD 62/60

-0.75 107 -1.25 -1.25 65 -1.50 -0.50 105 -1.25 70-1.00

ADD +1.25 PD 61/59
6/6

-2.00 -2.75 72 -2.00 -1.50 75

+0.25 -2.50 146 ADD + 2.00 PD 62/60

-2.25 84 +0.75 -1.50 90 -2.25 90 +0.50 90-1.50
ADD +2.75 PD 61/59
6/6
-2.50 114 +2.00 -0.50 68 +1.50 -1.50 110 +1.50 ADD +2.75 PD 64 6/6
-2.75 87 TTK NLP TTK

-9.25 2
-0.50 127 -2.50 -0.75 56 -1.50 -3.00 ADD +3.00 PD 67 6/7.5
-0.25 -0.25 101 ADD +1.75 PD 56/54
-0.50 83 +1.50 -0.50 69 +0.75 +0.75 ADD +2.25 PD 60 6/6

-1.50 73 +2.00 -1.00 108 +1.50 +1.00 ADD +2.75 6/15

-0.50 72 +1.00 -0.25 100 +0.50 +0.75 ADD +1.75 PD 61 6/6

-1.00 2 +1.00 -0.50 170 ADD +.200 PD 64/62

-1.00 167 +3.25 -1.25 11 +2.00 +2.50 ADD +2.25 PD 63 6/30

-0.50 61 +1.00 -0.75 67 TTK TTK ADD +2.75 PD 68/ TTK

-0.50 61 +1.50 -0.50 115 TTK TTK ADD +2.50 PD 65/ TTK
-0.50 41 +1.25 -0.75 101 TTK TTK ADD +2.25 PD 59/ TTK
-2.75 83 +1.00 -2.75 92 TTK TTK

-0.50 67 +0.50 -1.25 82

-0.75 109 +4.25 -1.50 79 +2.50 +3.75 80-1.00

ADD +2.50 PD 70/68
6/7.5

-0.50 120 +12.25 -2.50 156 +12.00 +12.50160

-1.50
ADD +3.00 PD 63/61
6/6

-1.25 73 +0.50 -1.00 89

-0.25 169 +0.25 -0.75 26 +10.00 TTK ADD +3.00 PD 60/ 6/6
-0.75 82 +1.50 -0.75 98

-0.50 92 +0.75 -1.50 74

-1.00 98 -1.25 -0.25 5 -0.75 90 -1.25 ADD +1.25 PD 63 6/6

-2.00 105 -2.00 -1.25 81 -3.50 -1.75 6/20

-0.50 82 +2.00 -0.50 103
-0.25 136 +2.00 -0.50 160
+0.75 -2.50 76 +0.50 -1.75 75
-1.25 89 -1.25 -1.00 89 -1.50 -1.00 90 -1.00 -1.00 90 6/6
-1.00 78 -0.00 -0.75 111 -1.75 -1.00 75 +3.00 -1.00 105 6/15
-1.00 165 -1.00 -2.50 180
-0.50 58 +1.50 6/10

-0.25 134 -0.00 -0.25 36

-0.50 -1.25 154

tdk dapat diperiksa e

-1.25 152
-1.50 70 -7.50 -2.25 51 -1.00 75 -7.00 -1.00 50 6/6
-1.00 167 -0.00 -1.75 94
-0.25 120 +2.75 -1.25 19
-5.75 87 -2.50 -1.75 82
+2.25 118 -2.00 120 +3.00 6/15

-0.50 18 +1.50 -0.50 35 ADD +3.00 TTK

-7.00 141 +3.25 -3.25 19 TTK
-3.00 80 -2.75 -1.75 68 -1.00 -1.50 75 -3.00 -1.00 70 6/30

-5.50 -0.50 51 -6.00 -5.50 6/6

-1.00 79 TTK
-1.50 66 -1.50 -3.00 122

-0.25 -0.50 146 ADD +3.00 TTK

-1.25 82 +3.00 -4.00 91 TTK
-1.25 89 +0.50 -1.25 75
-1.25 179 -1.75 ADD +3.00 6/15
-0.25 95 +4.25 -0.75 84
-1.00 60 +1.75 -1.25 86 TTK

+1.00 -0.50 41 +0.75 ADD +2.25 TTK

-2.00 92 +3.75 -1.75 77 +2.25 -1.25 90 +2.00 ADD +2.50 6/6

-2.75 73 +1.25 -3.25 95 -1.50 6/20

-0.75 73 +0.50 -1.50 66 +12.00 +0.75 -1.50 70 1/60

-2.75 104 +1.50 -2.00 69 TTK

-1.25 -4.25 101
-1.00 75 TTK

-1.25 91 -1.00 -0.50 85 ADD +2.50 TTK

-1.25 87 TTK
-1.00 97 -0.00 -1.00 98 ADD +2.50 PD 62/60 TTK

-0.75 18 +2.50 -0.75 11 +1.00 0 0 +1.00 A 0 0 6/7.5

-1.00 -0.25 33 -1.00 ADD +3.00 PD 62/60

-1.00 137 -3.50 -1.0 162 -3.00 0 0 -3.00 0 0 6/60

-0.75 80 +12.00 -1.25 171 +12.00 -1.00 180

-1.25 6 -1.50 -0.75 50 -2.50 -1.00 -1.50 ADD +3.00 PD 65 6/10

-3.75 80

-1.50 106 -7.25 -1.75 114

-2.25 91 +0.25 -1.50 90 TTK TTK TTK TTK ADD TTK TTK
-0.25 53 +1.50 -0.25 110 +1.25 0 0 +1.25 A 0 0 6/6
TTK TTK TTK ADD +3.00
-1.25 94 -0.50 -1.50 92 TTK TTK TTK TTK TTK TTK

-1.00 92 +3.25 -1.00 88 +2.50 -1.00 90 +3.00 A -1.00 90 6/6

-2.25 35 -5.00 -4.00 89 -3.00 -2.00 40 -5.50 P -2.50 90 6/15

-4.00 92 TTK TTK TTK TTK TTK TTK
-0.75 50

-0.50 110 +2.50 -0.50 18 +1.00 0 0 +1.50 A 0 0 6/6

TTK TTK TTK

-0.25 147 +1.00 -0.50 6 +0.50 0 0 +0.50 A 0 0 6/6

-1.75 84 +2.75 -1.50 94

-0.25 38 -2.50 -0.25 112 -2.25 0 0 -2.25 P 0 0 6/6

-0.75 3 -5.75 -0.25 171 -2.25 -0.50 180 -5.55 A 0 0 6/7.5

0.25 59 +0,75 0 0 TTK ADD TTK TTK 6/6

-5.00 -0.50 29 TTK TTK TTK -4.00 0 0

-1.00 120 +0.75 -2.00 77

-4.25 136 -0.25 -1.25 45 TTK TTK TTK TTK TTK TTK

-0.50 90 +1.25 -0.25 84

-3.75 88 -1.25 -2.75 84
-2.25 93 -0.50 -3.75 88 -0.75 -2.00 95 -0.50 -3.00 90 6/6

-1.25 96 +1.25 -0.75 92

-4.00 9 -1.25 -0.50 96
-1.00 72 -2.25 -0.75 164 -1.25 0 0 -1.75 P 0 0 6/6
-0.75 44 +1.00 -1.00 91 TTK TTK TTK TTK TTK TTK
-2.00 91 +0.75 -3.00 88 -1.50 -1.50 90 -2.00 0 90 6/7.5

-2.50 -4.25 91 TTK TTK TTK TTK TTK TTK TTK

-2.75 87 +1.00 -2.00 72 TTK TTK TTK TTK TTK TTK TTK
 +1.25 -0.50 17 +1.50 +1.00 ADD +2.25 PD 62 6/15

-1.75 92 +1.00 -1.50 70 TTK TTK TTK ADD +2. TTK TTK TTK
-0.75 114 +2.25 -1.00 63 +2.00 +2.00 -1.00 75 6/20
-1.75 3 -5.50 -2.25 138 TTK TTK TTK -4.00 TTK TTK TTK

-0.50 84 +3.50 -0.25 91 +2.50 +2.50 ADD +2.50 PD 64 6/6

-0.75 72 +2.75 -1.00 102 +3.00 +2.00 ADD +2.50 6/15
-2.00 79 -1.75 -1.00 4 TTK TTK TTK -1.50 TTK

-0.25 126 -0.25 -2.00 85 -3.00 ADD +2. -2.00 90 6/75

ADD +1.75 PD 59/57

-0.50 39 -5.00 -1.00 126 TTK TTK TTK -5.00 TTK
-1.50 103 -1.00 -1.75 81 -2.00 -1.50 -1.00 85 6/20

-0.25 32 +0.25 -0.25 55 -0.50 TTK ADD +2.25 PD 67/ 6/6

-2.75 85 +0.25 -1.50 94 TTK TTK
-0.50 122 +1.75 -1.25 55 TTK
-0.50 126

+1.75 -2.25 51 TTK TTK

-0.50 87 +2.25 -1.25 101 +1.00 +1.25 ADD +2.25 PD 63 6/6

-2.00 81 -0.00 -0.75 90 TTK TTK

 SENSIBILITAS KORNEA

BCVA TIO

MATA KANAN

OS OD OS Superior Nasal Inferior Temporal

6/10 14 15 60 60 60 60
6/7.5 16 13 55 55 60 55
6/7.5 12 13 60 60 60 60
6/6 13 15 60 60 60 60
TTK 11 14 60 60 60 55
6/6 15 21 60 60 60 60
14 17 60 60 60 60
6/7.5 13 error 60 60 60 60
14 14 60 60 60 60
11 11 60 60 60 60
15 14 60 45 45 60
TTK 12 14 60 60 60 55
14 15 60 60 60 60
14 14 60 60 60 60
16 15 60 60 60 60
14 14 60 60 60 60
14 13 60 60 60 60
6/60 20 22 60 60 60 60
16 14 50 50 50 50
15 19 60 60 60 60
13 12 60 60 60 60
6/6 14 14 60 60 60 60
6/30 13 13 60 60 60 60
10 11 60 55 50 50
16 18 60 60 60 60
13 12 55 60 60 60
13 15 60 60 60 60
16 16 60 60 60 60
TTK 21 18 60 60 60 60
14 14 60 60 60 60
6/15 14 16 60 50 60 60
TTK 16 14 50 55 60 55
11 11 55 60 60 60
18 19
13 15
14 14 60 60 60 60
10 12 60 60 60 60
6/30 15 30 50 60 55 60
6/7.5 16 19 55 60 60 60
6/6 12 14 60 60 60 60
18 16 60 60 60 60
14 15 50 60 60 60
12 12 55 45 60 60
14 12 55 60 60 60
13 ERR 60 60 60 60
12 12 60 60 60 60
6/30 12 11 60 60 55 60
18 17 60 60 60 60
 6/6 14 14 60 60 60 60
19 18 55 50 60 60
16 16 60 60 60 60
13 13 60 60 60 60
20 21 60 60 60 60
16 14 60 60 60 60
14 6 60 60 60 60
13 13 55 60 55 60
TTK 11 9 50 30 45 60
13 12 55 60 60 60
N/P 45 40 40 45
TTK ERR 19 60 60 60 60
14 17 60 60 60 60
15 15 60 60 60 60
6/15 13 16 60 60 60 60
16 17 60 60 60 60
17 17 60 60 60 60
14 13 45 40 50 55
6/15 19 17 50 60 60 60
14 13 55 55 60 60
6/6F 11 12 60 55 55 55
23 16 60 60 60 60
6/6 11 13 60 60 60 60
15 15 60 45 55 60
6/30 12 13 60 60 60 60
17 17 55 55 60 60
60 (PTISIS BULBI) NYERI -
17 PTISIS BULBI
6/6 15 15 60 60 55 60
6/6 13 13 55 45 50 60
TTK 15 55 60 55 60
12 12 60 60 60 60
28 6 60 60 60 60
6/20 13 14 55 60 60 60
16 13 60 60 60 60
6/6 14 13 60 50 60 60
15 13 OS MENOLAK
6/15 14 13 60 60 60 60
6/6 12 15 60 60 60 60
15 16 60 60 60 60
15 14 60 60 60 60
6/15 14 15 60 60 60 60
22 20 60 60 60 60
TTK 11 13 55 60 55 55
TTK 12 13 60 60 60 60
TTK 14 14 60 60 60 60
 14 15 60 60 60 60
15 17 60 60 60 60
13 13 60 60 60 60
9 11 55 60 60 60
19 18 60 60 60 60
14 14 60 60 50 60
14 14 60 60 60 60
17 14 60 60 60 60
6/20 17 16 60 60 60 60
15 15 60 60 60 60
6/15 17 17 60 60 60 60
13 12 60 60 60 60
16 17 60 60 60 60
16 18 60 60 60 60
17 15 60 60 60 60
14 14 35 30 40 45
14 30 40 50 50
14 14 60 60 60 60
6/6 15 12 50 60 60 60
15 17 60 55 60 60
6/15 17 15 60 60 60 60
19 17 60 60 60 60
15 15 60 60 60 60
6/6 12 13 60 50 60 60
6/6 13 12 60 60 60 60
6/15 17 17 60 60 60 60
17 16 55 55 55 55
18 17 60 60 60 60
20 15 60 60 60 60
14 12 60 60 60 60
10 11 60 60 60 60
17 17 60 60 60 60
12 12 60 60 60 60
tdk dapat diperiksa
dk dapatecdiperiksa
ulkus ornea
ecOD+leukoma
pasien
ulkus kesakitan
ornea OS tidak dilakukan
OD+leukoma OS

60 60 60 60
13 16 55 60 60 60
14 13 55 60 60 60
6/20 15 16 60 60 60 60
16 14 60 60 60 60
17 16 60 60 60 60
14 12 40 60 60 60
62/60 15 12 45 50 60 60
15 15 60 60 60 60
TTK 14 14 60 60 60 60
TTK 15 13 60 60 60 60
6/30 14 18 50 55 60 60
12 12 60 55 60 60
6/6 15 16 60 60 60 60
14 11 60 60 60 60
TTK 12 13 60 60 60 60
12 10 45 60 60 60
13 14 60 60 60 60
TTK 13 13 20 30 60 60
18 15 50 45 60 60
16 16 60 60 60 60
LP 7 14 50 60 50 50
15 13 55 55 55 60
TTK 14 13 50 60 60 60
18 19 60 60 60 60
6/6 14 14 60 60 60 60
6/20 15 19 60 60 60 60
13 14 60 60 60 60
TTK 15 14 50 50 60 55
6/15 12 11 55 55 60 60
12 14 60 60 60 60
TTK 11 13 60 60 60 60
16 60 60 60 60
13 13 60 60 60 60
12 12 60 60 60 60
TTK 12 12 45 60 50 60
TTK 14 17 50 50 60 60
TTK 23 21 60 60 60 60
16 15 35 40 50 50
6/10 17 16 60 60 60 60
6/6 17 12 60 60 60 60
14 13 60 60 60 60
12 13 60 60 60 60
13 15 55 60 60 60
6/60 13 13 60 60 60 60
6/15 16 16 60 60 60 60
15 13 55 60 60 60
19 18 60 55 60 60
15 14 60 60 60 60
17 17 60 60 60 60
6/20 11 11 50 50 50 50
17 19 55 40 60 60
13 14 50 50 60 60
14 13 60 55 60 60
18 17 30 60 60 60
6/6 12 12 60 60 60 60
13 14 60 55 60 60
 14 15 55 50 55 60
13 14 60 60 60 60
13 14 50 50 55 60
6/6 15 15 60 60 60 60
18 18 60 60 60 60
6/15 13 13 55 60 60 60
14 13 60 60 60 60
60 60 60 60
16 14 60 60 60 60
6/6 14 12 30 60 60 60
14 60 60 60 60
13 14 60 60 60 60
17 17 60 60 60 60
14 14 60 60 60 60
15 15 60 60 60 60
16 16 60 60 60 60
6/6 14 14 60 60 60 60
13 12 60 60 60 60
15 14 55 55 60 60
6/6 10 11 55 55 60 60
17 16 60 60 60 60
18 15 60 60 60 60
12 10 60 60 60 60
6/20 19 21 55 60 55 60
13 14 60 50 60 60
18 17 60 60 60 60
6/40 14 17 60 60 60 60
14 16 60 60 60 60
15 16 60 60 60 60
23 18 50 60 55 55
17 60 60 60 60
16 14 60 55 60 60
13 11 60 60 60 60
15 14 60 60 60 60
15 18 40 60 60 60
6/7.5 14 14 15 55 55 60
15 14 60 60 60 60
14 14 60 60 60 60
16 16 60 60 60 60
12 15 60 55 60 60
6/6 10 13 55 50 60 60
19 16 55 60 60 60
6/7.5 15 15 60 60 60 60
13 13 55 45 60 60
TTK 13 13 50 60 60 60
TTK 14 16 60 60 60 60
 15 15 50 55 60 60
6/6 14 14 60 60 60 60
11 12 45 60 60 60
TTK 13 10 60 60 60 60
6/15 10 11 45 45 55 60
6/60 16 13 20 55 60 60
17 18 55 60 40 60
12 12 60 60 60 60
6/6 15 14 60 60 60 60
6/75 17 14 60 55 60 60
6/20 17 16 60 60 60 60
13 13 60 60 60 60
6/6 15 17 60 60 60 60
14 13 60 60 60 60
18 18 60 55 60 60
11 10 60 60 60 60
6/40 14 21 60 60 60 60
6/15 13 13 50 50 60 60
14 14 60 60 60 60
15 14 30 60 60 60
12 12 35 35 60 60
12 14 40 60 35 55
12 13 55 60 60 60
13 12 60 60 60 60
15 55 60 55 60
6/6 19 17 60 60 60 60
16 17 60 60 60 60
11 11 40 60 60 60
 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK

SENSIBILITAS KORNEA

MATA KIRI MADAROSIS TRIKIASIS

Superior Nasal Inferior Temporal OD OS OD

60 60 60 60 1 1 0
55 60 60 55 1 1 1
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 55 1 1 1
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 40 40 60 0 0 0
55 60 60 60 0 1 1
60 60 60 60 0 0 1
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 55 55 0 0 1
60 40 60 55 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 1
55 60 60 60 0 0 0
60 60 60 60 1 1 1
60 60 60 60 1 1 0
60 60 60 60 0 0 0
55 60 60 35 1 1 1
60 55 60 60 0 0 0
60 60 60 60 1 1 1

60 60 60 60 0 0 1
60 60 60 60 0 0 0
55 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 0 0
60 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
40 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
 60 60 60 60 1 1 0
45 60 55 55 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
30 50 50 35 0 0 0
45 60 55 60 1 1 0
55 60 60 60 1 1 0
60 60 55 55 1 1 1
60 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 50 55 60 0 0 0
60 60 60 60 0 0 0
55 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 55 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1
60 60 60 60 1 1 1
55 60 60 60 1 1 0
60 (KERATOPATHY) 1 1 0
60 60 55 60 0 0 0
30 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 55 60 1 1 0
OS MENOLAK 0 0 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 0 1
60 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 1 1
60 60 60 60 1 0 0
60 50 55 60 1 1 1
60 60 60 60 1 1 0
60 60 60 60 0 0 1
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 55 55 60 1 1 0
55 50 60 60 1 1 0
55 60 60 55 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 1 1 1
60 60 60 60 0 0 0
30 40 40 40 1 1 0
40 5 10 10 1 1 1
60 60 60 60 0 0 0
60 60 60 60 1 1 0
55 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 1 1
60 60 60 60 1 1 0
55 60 60 60 0 0 0
60 60 60 60 1 1 1
60 60 60 60 0 0 0
60 60 60 60 0 0 0
1 1
0 0 0
60 60 60 60 0 0 0
60 55 60 60 1 1 0
60 60 60 60 0 0 1
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
35 60 60 60 1 1 0
60 60 60 60 1 1 1
60 60 60 60 1 1 0
60 50 60 60 1 1 0
60 60 60 60 1 1 1
60 60 60 60 0 0 1
55 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 1 1
60 60 60 60 1 1 0
60 60 60 60 1 1 1
50 55 60 60 1 1 0
10 50 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 1 1 1
60 60 60 60 0 0 0
60 60 60 60 1 1
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 1 1 1
60 60 60 60 1 1 0
60 60 60 60 1 1 0
55 60 55 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
40 45 45 45 0 0 0
60 55 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
50 45 10 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 1 1 0
55 60 60 60 1 1 1
60 40 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
50 50 50 50 1 1 0
55 60 60 60 0 0 0
60 60 60 60 0 0 0
55 55 60 60 1 1 1
60 60 60 60 1 1 0
55 55 60 60 0 0 0
60 60 60 60 0 0 0
40 60 60 60 1 1 0
60 60 60 60 0 0 0
50 60 55 50 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 1 1 0
55 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
45 60 60 60 0 0 1 (INFERIOR)
55 55 55 55 0 0
60 55 60 60 1 1 0
55 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 1 1 0
60 60 60 55 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 55 60 50 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 1
30 60 60 60 1 1 0
60 60 60 60 0 0 0
50 60 60 60 1 1 1
30 40 20 60 0 0 0
60 60 60 60 0 0 0
55 60 60 60 0 0 0
55 60 60 60 1 1 0
40 60 60 60 0 0 1
45 55 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
50 60 50 60 1 1 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
55 60 60 60 0 0 0
60 60 60 60 0 0 0
55 60 60 60 0 0 0
60 60 60 60 0 0 1
55 60 60 60 0 0 0
60 60 55 60 1 1 0
55 60 60 55 0 0 0
60 60 60 60 0 0 0
55 60 60 60 0 0 0
60 60 60 60 0 0 0
45 60 50 60 0 0 0
60 60 60 60 1 1 0
55 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
55 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
25 60 60 60 0 0 0
60 60 55 60 1 1 1
60 60 60 60 1 1 0
55 60 45 60 1 1 0
60 60 60 60 0 0 0
60 60 60 60 0 0 0
60 60 60 60 1 1 0
60 60 60 60 0 0 0
45 60 55 55 1 1 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK

AD

TRIKIASIS EKTROPION ENTROPION LAGOFTALMOS

OS OD OS OD OS OD OS

0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 1
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1 0 1 1 1
1 0 0 0 0 1 1
1 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0

1 1 1 0 0 1 1
0 0 0 0 0 1 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 0 1 1 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 1 0
0 1 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 1 0 1 0 1 1
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 1 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
1 0 0 0 1 0 0
0 0 0 0 1 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
1 0 0 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1 1 1 1 1
0 1 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 1 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
1 0 0 1 1 0 0
0 0 0 1 1 0 0
1 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
1 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 1 0 1 1
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 (INFERIOR) 0 0 0 0 1 (4MM) 1(4MM)
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 (5MM) 1 (7MM)
0 0 0 0 0 1 (1MM) 0
0 0 0 0 1 0 0
1 0 0 0 0 1 (3.5 MM) 1 (6.5 MM)
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 (2 MM) 0
0 0 0 0 0 0 0
1 0 1 1 (SUP) 1 0 0
1 - - 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 (SUP) 0 0 1 (6 MM)
0 0 1 (INF NASAL) 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 1 (8MM)
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 1 (0.5 MM) 0
0 0 0 0 0 1 (1 MM ) 1 (1 MM)
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 1 1
0 0 0 0 0 0 0
0 1 1 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 1 1 0 0 1 1
1 0 0 0 0 0 0
0 1 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK

ADNEKSA ANTERIOR

OBSTRUKSI LAKRIMAL EPIFORA DAKRIOSISTITIS

OD
OD OS OD OS OD OS

KODE
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 1 1 1 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1

0 0 1 1 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 1 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 0 1 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 1 0 0 0 0
0 0 0 0 0 0 1
0 0 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 1 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 1 1 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 1 1 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
1 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 1 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 1 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
1 1 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 = grade 0 0 = grade 0
1= grade 1 1= grade 1
1 - ADA 2 = grade 2 2 = grade 2 1 - ADA
0 - TIDAK 3 = grade 3 3 = grade 3 0 - TIDAK
ADA
4= grade 4 4= grade 4

MATA

LAIN-LAIN MGD INJEKSI

OD OS
OD OS OD

KET KODE KET

0 0 0 0 0 0
DERMATOKALASIS 1 DERMATOKALASIS 0 0 0
 0 0 0 1 1 1
0 0 0 1 1 0
DERMATOKALASIS 1 DERMATOKALASIS 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOKALASIS 1 DERMATOKALASIS 0 0 1
0 0 0 1 1 1
DERMATOKALASIS 1 DERMATOKALASIS 0 0 1
0 0 0 0 0 0
0 0 0 3 3 0
0 1 BLEFARITIS ANTERIOR 0 0 0
HORDEOLUM SUP 0 0 2 2 0
0 0 0 0 0 0
ORNEAL EXPOSURE (+), LAGOFTALMOS
CORNEAL
07mmEXPOSURE (-), LAGOFTALMOS 6mm 1
NEAL EXPOSURE (+) 5mm, LAGOFTALMOS
CORNEAL1 EXPOSURE
10mm (+) 4mm, LAGOFTALMOS
0 10mm 0 0
0 0 0 0 0 0
CORNEAL EXPOSURE + 2mm, LAGOFCORNEAL
1 1mm ESPOSURE + 2 mm. LAGOF 8mm0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 1 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 1

DERMATOKALASIA 0 0 0 0 0
LAGOFTALMUS + CORNEAL EXPOSURE 0 0 0 0 1
0 0 0 2 2 0
nevus palp sup + inf 0 0 0 0 0
0 0 0 3 3 0
papiloma palpebra superior 0 0 0 0 0
0 1 DERMATOKALASIA 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
CORNEAL EXPOSURE 1 CORNEAL EXPOSURE 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 1
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 1 1 1
0 0 0 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 1
0 0 0 2 2 0
CORNEAL EXPOSURE - 1 CORNEAL EXPOSURE - 0 0 1
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 0 0 0
PTOSIS INVOLUTIONAL 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 CORNEAL EXPOSURE + 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 1
0 0 0 0 0 0
0 0 0 1 1 1
0 0 0 1 1 0
DERMATOKALASIA 1 PTISIS BULBI 0 0 1
0 0 0 1 0 0
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 1 1 0
0 0 0 AGD + AGD + 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
DERMATOKALASIA 1 NEVUS PALP SUPERIOR 0 0 0
0 0 0 1 1 0
 0 0 0 0 0 0
0 0 0 0 0 1
NEVUS PALP SUP 0 0 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
DERMATOKALASIA DERMATOKALASIA
1 + CORNEAL EXPOSURE 01 MM 0 0
0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 1 1 1
0 0 0 0 0 0
0 0 0 1 1 0
DERMATOKALASIA 0 0 0 0 0
0 0 0 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 2 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 1
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1
FOAMY TEAR 1 ANKILOBLEPHARON MEDIA 0 0 0
LAGOFTALMOS 1.5MM 1 HEMIFLACID SPASM 0 0 0
TIC FACIALIS 0 0 0 0
DERMATOCHALASIS 1 DERMATOCHALASIS 0 0 0
0 LAGOFTALMOS
1 7mm, corneal exposure 3mm
0 0 0
0 0 0 0 0 1
0 0 0 0 0 1
0 0 0 0 0 0
lagoftalmos > 3 mm 1 lagoftalmos > 3mm 0 0 1
foam dermatochalasis 0 dermatochalasi foam 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
ptosis 1 ptosis 0 0 0
1 trikiasis superior 0 0 1
dermatocalasia 1 dermatocalasia 0 0 0
0 0 0 2 2 0
0 0 0 3 3 1
dermatochalasis 1 dermatochalasis 0 0 0
0 0 0 3 3 0
dermatochalasis 1 dermatochalasis 0 0 0
dermatochalasis 1 dermatchalasis 0 0 1
 0 0 0 0 0 0
0 0 0 3 3 0
0 0 0 3 3 0
0 1 lagoftalmos 1mm 0 0 0
dermatochalasis 1 dermatochalasis 0 0 1
dermatochalasis 1 dermatochalasis 3 3 0
0 0 0 0 0 1
0 1 dermatochalasis 0 0 0
dermatochalasis 1 dermatochalasis 3 3 0
dermatochalasis 0 0 0 0 0
ptosis, dermatochalasis 1 dermatochalasis 0 0 0
dermatochalasis 1 dermatochalasis 0 0 0
0 0 0 3 3 0
0 0 0 0 0 1
0 0 0 3 3 0
dermatochalasis 1 dermatochalasis 0 0 1
0 0 0 0 0 0
0 0 0 3 3 0
0 0 0 2 2 0
dermatochalasis 1 dermatochalasis 0 0 0
0 0 0 0 0 1
ptosis, sulcus suspek dalam 1 sulkus suspek dalam 0 0 0
dermatochalasis 1 dermatochalasis 0 0 0
dermatochalasis 1 dermatochalasis 2 2 0
0 0 0 2 2 0
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 0
0 0 0 0 0 0
DERMATOCHALASIS 1 DERMATOCHALAASIS 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOCHALASIS 1 DERMATOCHALASIS 0 0 0
0 1 ENTROPION SUP 0 0 0
DERMATOCHALASIS 1 DERMATOCHALASIS 0 0 0
0 0 0 1 1 1
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOCHALASIS 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 0
0 1 DERMATOCHALASIS 0 0 0
BLEFARITIS ANT 1 BLEFARITIS ANT 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 0
 0 0 0 0 0 0
DERMATOCHALASIA 0 0 0 0 0
0 1 DERMATOCHALASIA 0 0 0
0 0 0 0 0 0
0 1 CORENAL EXPOSURE 1 MM 0 0 0
0 0 0 2 2 0
0 0 0 1 1 0
0 0 0 2 2 0
0 0 0 0 0 0
CORNEAL EXPOSURE 1 MM 1 CORNEAL EXPOSURE 1 MM 0 0 1
0 ULKUS
1 TEREPITALISASI DESCEMETOCELE
0+ 0 0
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 0
0 0 0 0 0 0
KORNEA EXPOSURE 1 MM 1 KORNEA EXPOSURE 1 MM 2 2 0
0 0 0 1 1 0
0 0 0 0 0 0
NEAL EXPOSURE 0.2 MM, HEMIFACIAL 1SPASM
CORNEAL
+ EXPOSURE 0.2 MM 0 0 0
0 0 0 0 0 0
0 0 0 3 3 0
0 0 0 0 0 0
0 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 1
0 0 0 0 0 0
0 1 KORNEA EXPOSURE 1 MM 2 2 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
DERMATOCHALASIA DERMATOCHALASIA,
1 CORNEAL EXPOSURE 4.5
0 MM 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 2 2 0
0 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASI 0 0 0
0 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 0
0 0 0 0 0 0
DERMATOCHALASIA 1 DERMATOCHALASIA 0 0 0
0 0 0 0 0 0
0 0 0 2 2 0
 0 1 LAGOFTALMOS 1MM, CE (-) 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
BAGGY EYELIDS, LAGOFTALMOS 1 MM BAGGY
1 EYELIDS, LAGOFTALMOS 1.5MM
0 0 0
0 0 0 0 0 0
DERMATOCHALASIA, LAGOFTALMOSDERMATOCHALASIS,
1MM
1 LAGOFTALMOS 4MM
0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
DERMATOCHALASIS 1 DERMATOCHALASIS 0 0 0
KISTA KANTUS LATERAL, PINGUECULA 1 PINGUECULA 0
0 0 0 4 4 0
0 0 0 2 2 0
DERMATOCHALASIS 1 DERMATOCHALASIS 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
s palpebra superior dan nasal, dermatochalasis
1 dermatochalasis 0 0 0
DERMATOCHALASIS 1 DERMATOCHALASIS 2 1 0
0 0 0 0 0 1
DERMATOKALASIA + XANTHELASMA 1DERMATOKALASIA + XANTHELASMA0 0 1
DERMATOKALASIA 1 DERMATOKALASIA 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 0 0 1
DERMATOKALASIA + PTOSIS 1 DERMATOKALASIA + PTOSIS 0 0 0
0 0 0 0 0 0
DERMATOKALASIA 1 DERMATOKALASIA 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 PTOSIS + 0 0 1
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA

KONJUNGTIVA

INJEKSI KONJUNGTIVITIS PTERIGIUM NODUL

OS OD OS OD OS OD OS

0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
1 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0

0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 1 0 0
0 0 0 0 0 0 0
1 0 0 1 0 0 0
1 0 0 0 1 0 0
0 0 0 0 0 0 0
0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 1 1 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 1 0 0 0
1 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 1 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 1 0 0
0 0 0 1 1 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 00
0 0 0 0 0 0 0
0 0 0 0 1 (GR.II) 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR II)
1 (GR II) DOUBLE HEAD 0 0
0 0 0 1 (GR II) 1 (GR II) 0 0
1 0 0 0 1 (GR I) 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR I) 1 (GR I) 0 0
0 0 0 0 0 0 0
0 0 0 0 1 (GR I) 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR I) 1 (GR I) 0 0
0 0 0 1 (GR I) 1 (GR I-II) 0 0
0 0 0 0 1 (GR II) 0 0
0 0 0 0 1 (GR I) 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR 1) 1 (GR 1) 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR II) 1 (GR I) 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR IV) 0 0 0
1 0 0 1 (GR I) 0 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR III) 1 (GR II) 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR I) 1 (GR I) 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 (GR I) 1 (GR I) 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 1 0 0 0
0 0 0 1 1 0 0
1 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 1 1 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK ADA 0 - TIDAK ADA 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA

LAIN-LAIN INJEKSI EPISKLERITIS

OD OS OD OS OD OS

0 0 0 0 0 0
0 0 0 0 0 0
 0 0 0 0 0 0
0 0 0 0 0 0
pterigium gr III pterigium gr III 0 0 0 0
0 0 0 0 0 0
pterigium gr I pterigium gr I 0 0 0 0
0 pterigium gr III 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
pterigium gr I pterigium gr I 0 0 0 0
0 0 0 0 0 0
pterigium gr I pterigium gr I 0 0 0 0
0 0 0 0 0 0
pterigium gr I pterigium gr I 0 0 0 0
0 0 0 0 0 0
pinguekula 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0
1 1 0 0
0 0 0 0
pterigium II pterigium II 0 0 0 0
konjungtivalisasi di inferior 0 0
pinguecula 0 0 0 0
pterigium gr I pterigium gr II 0 0 0 0
0 0 0 0
pterigium gr II pterigium gr II 1 1 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 pterigium gr III 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
pterigium gr I pterigium gr I 0 0 0 0
0 0 0 0 0 0
0 KONJUNGTIVALISASI 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
NEVUS KONJ 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0
PINGUEKULA PINGUEKULA 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA PINGUEKULA 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
SIKATRIKS DI TEMP POST AVULSI 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
 0 0 0 0 0 0
NEVUS KONJ 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
KONJUNGTIVALISASI KONJUNGTIVALISASI 1 1 0 0
0 MELANOSIS DI TEMP 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUECULA DI NASALPINGUECULA
DAN BILATERAL DI NASAL DAN LATERAL 0 0 0 0
PTERIGIUM GR II 0 0 0 0 0
vasodilatasi
vasodilatasi pemb. darah, pemb.
pterigium gr darah,
II pterigium gr1IV 0
0 0 0 0 0 0
Pterigium GR II pterigium gr II 0 0 0 0
0 0 0 0 0 0
PINGUECULA DI NASAL DAN BILATERAL pterigium gr III 0 0 0 0
pinguecula pinguecula 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
pterigium gr II pterigium gr II 0 0 0 0
Pterigium gr I Pterigium gr I 0 0 0 0
pinguekula lateral 0 0 0 0 0
0 Ptregitium gr III 0 0 0 0
inflamed conjunctival, pterigium grpterigium
III gr III 0 0 0 0
 pterigium gr II 0 0 0 0 0
pinguecula di nasal 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
pinguecula di nasal pinguecula di nasal 0 0 0 0
pinguecula di nasal pinguecula di lateral 0 0 0 0
0 0 0 0 0 0
pterigium gr I pterigium gr I 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
pterigium gr II pterigium gr II 0 0 0 0
pterigium gr I pterigium gr I 0 0 0 0
pinguecula di nasal
pinguicula di nasal dan lateral 0 0 0 0
kornea kips (+), pterigium gr IIpterigium gr III 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
pterigium gr III 0 0 0
0 0 0 0 0 0
pinguecula di nasal pinguicula di nasal 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA NASAL LAT PINGEKUELA NASAL LAT 0 0 0 0
0 0 0 0 0 0
DERMATOCALASIS DERMATOCALASIS 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA NASAL LAT 0 0 0 0 0
0 0 1 1 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA NASAI PINGUEKULA 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA NASAL 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA LAT PINGUEKULA NASAL 1 1 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PTERIGIUM GR I PTERIGIUM GR I 0 0 0 0
 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUECULA 0 0 0 0 0
PTERIGIUM GR II PTERIGIUM GR I 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PTERIGIUM GR I PTERIGIUM GR I 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUECULA 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PTERIGIUM GR II PTERIGIUM GR I 0 0 0 0
PTERIGIUM GR I 0 0 0 0 0
pterigium gr I pterigium gr II 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
PINGUEKULA PINGUEKULA 0 0 0 0
PINGUEKULA PINGUEKULA 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA

SKLERA

SKLERITIS STAFILOMA LAIN-LAIN

OD OS
OD OS OD OS

KODE KETERANGAN KODE

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
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SENSIBILITAS KORNEA, SEGME

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ADA ADA ADA ADA ADA ADA

S KORNEA, SEGMEN ANTERIOR-POSTERIOR, TEAR BREAK UP TIME DAN SCHIRMER

KORNEA

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0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 0 0 1 0
0 0 0 0 0 0 0
0 1 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 1 0 0
0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 1 1 1 0 0
0 0 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 1 1 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 LEKOMA ADHE
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA

HIRMER

LAIN-LAIN IRIS PEARLS IRITIS AQUEOUS FLARE

OD OS OD OS OD OS OD

0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 epiteliopati 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
epitelopati epitelopati 0 0 0 0 0
0 0 0 0 0 0 0
0 epiteliopati 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

epiteliopati 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
KP'5+ di inf, epiteliopati
epiteliopati 0 0 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
NEBULA 0 0 0 0 0 0
0 0 0 0 0 0 0
SIKATRIK SIKATRIK
+ +, COA FLAT 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0
0 0 0 0 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
SIKATRIKS + SIKATRIKS + 0 0 0 0 0
PTISIS 0 0 0
0 0 0 0 0 0 0
0 0 0 0 1 0 1
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELOPATI EPITELOPATI 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
RIW TRAUMA TAJAM KORNEA
0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 TIDAK DAPAT DINILAI
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
SIKATRIKS + NEBULA + 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
imbibisi kornea jahitan di jam 11 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELOPATI EPITELOPATI 0 0 0 0 0
0 0 0 0 0 0 0
0 sikatriks di inferior 0 0 0 0 0
LEUKOMA ADHEREN 1X3mm0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
neovaskularisasi
leukoma
(+0,diulkus
inferior
(+), KP'5
1/2, kuadran KP'5 (+) 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 LEUKOMA SUPERIOR 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
epitelopati 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
tivalisasi kornea, sikatriks perifer 0 di inferior 0 0 0 0 0
 0 0 0 0 0 0 0
makula multifokalmultifokal 0 0 0 0 0
0 0 0 0 0 0 0
makula kornea epiteliopati0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
epiteliopati epiteliopati 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
epiteliopati epiteliopati 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
kornea kips (+) 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI DI INFERIOR 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
NEBULA (+) NEBULA (+) 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI EPITELIOPATI 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI EPITELIOPATI 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI
IRON LINES (+) EPITELIOPATI0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 NEBULA 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
MAKULA + 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
NEBULA 0 0 0 0 0 0
LEKOMA ADHEREN 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI EPITELIOPATI 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI 0 0 1 (NODUL BUSACEA +) 0 0 1
NEBULA NEBULA 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI 0 0 0 0 0 0
0 0 0 0 0 0 0
0 MAKULA 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI EPITELIOPATI 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI EPITELIOPATI 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
EPITELIOPATI EPITELIOPATI 0 0 0 0 0
0 0 0 0 0 0 0
NEBULA + 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA

UVEA

AQUEOUS FLARE AQUEOUS CELLS LAIN-LAIN

OD OS
OS OD OS

KODE KETERANGAN KODE

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 sinekia post j. 2, koeppe + 1
0 0 0 1 iris flocculi j.12 1
0 0 0 busacca
1 nodul inf j.9, koeppe + pupil
1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 1 SINEKIA POST + KOEPPE + 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0
0 0 0 0 0 0
0 1 0 1 SINEKIA POST + KOEPPE + 1
0 0 0
0 0 0 0 0 0
0 0 0 1 IRIS LONJONG KE J 7 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 NODUL FIBRIN + 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 ATROFI IRIS 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 koagulum 0.8 mm 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 sinekia anterior 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 sinekia posterior 1
0 0 0 1 sinekia anterior 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 nodul
1 koepe(+), sinekia posterior, fibrin
1 (+)
0 0 0 1 iris atrofi diinferior 0
0 0 0 0 0 0
0 0 0 1 iris atrofi di temporal 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 iris atrofi 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 1 globi di pupil 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 IRIDODIALISIS 0
0 0 0 1 GLOBI (+), NODUL KOEPPE (+) 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
1 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 ATROFI IRIS 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA

AIN KEKERUHAN NUCLEAR KEKERUHAN SUBCAPSULAR ANT KEKERUHAN SUBCAPSULAR POST

OS
OD OS OD OS OD

KETERANGAN
0 1 1
0 1 1 0 0 0
 0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
sinekia post jam 3-6 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 1
0 0 0 0 0 0

0 1 1 0 0 0
0 0 0 0 0 0
fibrin peripupil, koeppe nodul + 1 1 0 0 0
iris flocculi + 0 0 0 0 0
koeppe + 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
1 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 1 0 0 0
0 0 0 0 0 0
0 TIDAK DAPAT DINILAI
0 1 0
0 0 0 0 0 0
KOEPPE + 1 0 0 0 1
1 0 0
0 0 0 0 0 0
MIDDILATASI, SINEKIA POST + 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 1 1 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 1 0 0 1
 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 1 0 0 0
0 0 1 0 0 0
0 0 1 0 0 0
0 1 1 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
ATROFI IRIS 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
iris atropi di superior 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 1 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
COA dangkal 1 1 0 0 0
iris atropi 0 0 0 0 0
0 1 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
 0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
atrofi iris (+) 1 0 0 0 0
0 1 0 0 0 1
0 0 0 0 0 1
membran fibrin (+) di belakang pupil 0 0
0 1 1 1 1 0
0 0 0 0 0 1
0 1 1 0 0 0
0 1 1 0 0 1
iris atrofi 1 1 0 0 0
0 1 0 0 0 0
0 1 1 0 0 1
0 0 0 0 0 0
0 0 1 0 0 0
0 1 1 0 0 0
iris atrofi 0 1 0 0 0
nodul uoppe(+), fibrin (+) 1 1 0 0 0
0 0 0 0 0 0
0 1 0 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 1 (GR III) 1 (GR III) 0 0 0
0 1 (GR II) 1 (GR. I-II) 0 0 0
0 1 (GR III-IV) 1 (GR II-III) 0 0 0
0 1 (GR II-III) 1 (GR II-III) 0 0 0
0 0 0 0 0 1
0 1 1 0 0 0
0 1 (GR II) 1 (GR II) 0 0 0
0 1 (GR I) 0 0 0 0
0 1 (GR I) 1 (GR I) 0 0 0
0 1 (GR II) 1 (GR II) 0 0 0
0 0 0 0 0 0
0 1 (GR II) 1 (GR II) 0 0 0
0 0 0 0 0 0
0 1 (GR III) 1 0 0 0
0 1 (GR I) 0 0 0 0
0 1 (GR II) 1 (GR II) 0 0 0
0 1 (GR I) 1 (GR I) 0 0 0
0 1 (GR I) 1 (GR I) 0 0 0
0 0 0 0 0 0
0 1 (GR III) 1 (GR III) 0 0 0
0 1 (GR III) 1 0 0 0
0 0 1 (GR II) 0 0 0
0 1 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 (GR II) 1 (GR II) 0 0 0
0 1 (GR III) 1 (GR IV) 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 (GR I) 1 (GR 1) 0 0 0
0 1 (GR I) 1 (GR I) 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 (GR I) 1 (GR 1) 0 0 0
0 0 0 0 0 0
0 1 (GR I) 1(GR I) 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1 (GR II)
0 1 1 0 0 0
0 0 0 0 0 0
0 1 (GR III) 1 (GR II) 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 0 0 1 (GR II) 1 (GR II) 0
0 0 1 (GR III) 0 0 0
0 1 1 0 0 0
0 1 (GR III) 1 (GRIII) 0 0 0
0 1 ( GR I) 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 (GR II) 1 (GR II) 0 0 0
0 1 1 0 0 0
0 1 (GR I) 1 (GR I) 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
 0 0 0 0 0 0
0 1 1 0 0 0
ATROFI IRIS 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 0 0 0 0
0 1 1 0 0 0
0 0 0 0 0 1
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 1 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 (GR III) 1 (GR II) 0 0 0
0 0 0 0 0 0
0 1 1 0 0 0
0 1 (GR II) 1 (GR II) 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 1 (GR I) 1 (GR I) 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA

LENSA

KEKERUHAN SUBCAPSULAR POST KATARAK MATUR KEKERUHAN KORTIKAL LAIN-LAIN

OD
OS OD OS OD OS

KODE KET
1 gr II
0 0 0 0 0 1 gr III
0 0 0 1 1 1 gr I
0 0 0 1 1 1 gr I-II
0 0 0 1 gr I-II
0 0 0 0 0 0 0
0 1 1 0 0 1 gr I
1 imatur OD gr III
0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 katarak gr III
0 0 0 0 0 0 0
0 0 0 0 0 1 katarak gr III
0 0 0 1 1 1 katarak gr I
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 katarak gr I
0 0 0 0 0 1 katarak OD>OS
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 katarak gr I
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 1 Katarak gr II
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 katarak gr I
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 LENS PRECIPITATE?
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 KATARAK
1 GR I, LENS PRESIPITAT
0 0 1 0 1 1 KATARAK MATUR
0 0 0 0 0 0 0

1 1 0 0 0 1PIGMEN IRIS DI KAPSUL ANT

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 0 0
0 0 1 0 0 iris1 tremulans + katarak morgagni
0 0 0 0 0 0 0
0 0 0 0 0 0
0 1 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 IOL +
0 0 0 0 0 0 0
0 0 0 0 0 LENS PRECIPITATE
1 (PIGMEN IRIS DI KAP ANT
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 PSEUDOFAKIA
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 1 AFAKIA
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 1 1 AFAKIA
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 membran1fibrin +, riw op katarak&retina di rs
0 0 0 0 0 0 0
0 0 0 0 0 1 KATARAK GR I-II
0 0 0 0 0 0 0
0 0 0 0 0 1 KATARAK GR I-II
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 1 katarak
1 0 0 0 0 0 0
0 0 0 0 0 1 KATARAK GR I
0 0 0 0 0 1 lens precipitaite
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 KATARAKAK GR II
0 0 0 0 0 0 0
0 0 0 0 0 1 katarak gr II
0 0 0 0 0 1 katarak gr IV
0 0 0 0 0 1 katarak gr III
0 0 1 0 0 1IOL (1 hoptic di sulcus) PCO +
0 0 0 0 0 0 0
0 0 0 0 0 1 katarak gr II
0 0 0 0 0 1 katarak gr II
0 0 0 0 0 1 katarak gr I
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 katarak gr I
0 0 0 0 0 1 katarak gr III
0 1 1 0 0 1 katarak gr IV
0 0 0 0 0 0 0
0 0 0 0 0 1 keruh gr IV
0 0 0 0 0 1 keruh gr II-III
1 0 0 0 0 0 0
0 1 0 1 IOL capture di nasal
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 1 keruh gr IV
0 0 0 0 0 1 katarak gr I
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 afakia
0 0 0 0 0 0 0
1 0 0 0 0 1 katarak keruh gr II
0 1 0 0 0 0 0
0 0 0 0 0 1 katarak gr II
0 0 0 0 0 0 0
1 0 0 0 0 1 katarak gr II
0 0 0 0 0 1 keruh gr II-III
0 0 0 0 0 1 keruh gr II
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 PSEUDOFAKIA
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 ANGLE SUPPROT
 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 IOL
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 LENSE PRECIPITAT +
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 (GR II) 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 IOL
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 GR III
0 0 0 0 0 0 0
0 0 0 0 0 1 GR I
0 0 0 0 0 1 IOL
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 GR II
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 GR I
0 0 0 0 0 1 GR I
0 0 0 0 0 1 GR II
1 0 0 0 0 0 0
0 0 0 0 0 1 GR III
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 GR II
0 0 0 0 0 1 GR III
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA

SEGMEN POSTERIOR PAPIL SARAF

LAIN-LAIN PAPILEDEMA PULSASI VENA EKSTRAVASASI PAPIL SARAF

OS
OD OS OD OS OD

KODE KET
1 gr II 0 0 0 0 0
1 gr III 0 0 0 0 0
 1 gr I 0 0 0 0 0
1 gr I-II 0 0 0 0 0
1 gr I-II 0 0 0 0 0
0 0 0 0 0 0 0
1 gr I 0 0 0 0 0
tur OD gr III
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr III 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr III 0 0 0 0 0
1 katarak gr I 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr I 0 0 0 0 0
1 katarak OD>OS 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr I 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

1 Katarak gr II 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr I 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 LENS PRECIPITATE 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 IMATUR GR II 0 0 0 0 0
0 0 0 0 0 0 0

0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 PSEUDOFAKIA DGN PCO 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 PSEUDOFAKIA DGN PCO 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
1 AFAKIA 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 KATARAK MATUR 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 PSEUDOFAKIA 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

1 AFAKIA 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 IOL + 0 0
0 0 0 0 0 0 0
1 KATARAK GR 1 0 0 0 0 0
0 0 0 0 0 0 0
1 KATARAK GR II 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0
1 katarak gr II-III sulit dinilai 0 0
0 0 0 0 0 0 0
1 KATARAK GR I 0 0 0 0 0
1 katarak gr IV
0 0 0 0 0 0 0
1 sulit dinilai 0 0 0
0 0 0 0 0 0 0
1 KATARAK GR II 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr II 0 0 0 0 0
1 katarak gr IV 0 0 0 0 0
1 katarak gr III 0 0 0 0 0
1 KATARAK MATUR 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr III 0 0 0 0 0
1 katarak gr II-III 0 0 0 0 0
1 katarak gr I 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr III 0 0 0 0 0
1 lensa brown gr IV 0 0 0 0 0
0 0 0 0 0 0 0
0 Psudoafakia 0 0 0 0 0
1 IOL (+), PCO(+) 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 keruh gr III 0 0 0 0 0
1 katarak gr I 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr I 0 0 0 0 0
1 keruh gr III 0 0 0 0 0
1 katarak gr III 0 0
1 katarak gr IV brown 0 0 0 0 0
0 0 0 0 0 0 0
1 katarak gr III 0 0 0 0 0
0 0 0 0 0 0 0
1 keruh gr II 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 IOL 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 SDE SDE SDE SDE SDE SDE
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 IOL 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 GR III 0 0 0 0 0
0 0 0 0 0 0 0
1 GR I 0 0 0 0 0
1 IOL 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 GR III 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 GR I 0 0 0 0 0
0 0 0 0 0 0 0
1 GR II 0 0 0 0 0
0 0 0 0 0 0 0
1 GR III 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 GR II 0 0 0 0 0
1 GR III 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA

POSTERIOR PAPIL SARAF OPTIK

STRAVASASI PAPIL SARAF ATROFI LAIN-LAIN PERDARAHAN SUBHIALOID

OS OD OS OD OS OD OS

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 SULIT DINILAI 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0
0 0 0 0 0 0 0
0 0 0 CWS PERIPAPILCWS PERIPAPIL 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
0 1 1 ATROFI PAPIL TOTAL RD + 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 sulit dinilai 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 sulit dinilai 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 sulit dinilai 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 sulit dinilai 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
SDE SDE SDE SDE SDE SDE SDE
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 VITRUS STRAND
VITREUS STRAND 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA

RETINA

PERDARAHAN INTRARETINA EDEMA RETINA EDEMA MACULA LA

OD
OD OS OD OS OD OS

KODE
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 sulit dinilai
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 sulit dinilai
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 00 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
SDE SDE SDE SDE SDE SDE SDE
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 VITREUS STRANDS +
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA

PEMBULUH DARAH R

LAIN-LAIN RASIO ARTERI VENA PERDARAHAN

OD OS
OD OS OD

KETERANGAN KODE KETERANGAN

0 0 0 0 0 0
0 0 0 0 0 0
 0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
pigmentary changes 0 0 1 1 0
0 0 0 0 0 0
0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 SULIT DINILAI 1 1 0
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0

0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0

0 0 1
0 0 0 0 0 0
0 0 0 1 0 0
0 0 0 1 0
0 0 0 0 0 0
ATROFI MAKULA, PPA + 0 0 1 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
 0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
VITR. STRAND + 1 VITR. STRAND+ 1 1 0
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 1 1 0
VITR.STRAND + 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0

0 0 0 1 1 0
0 1 VITR. STRAND + 1 1 0
VITR.STRAND + 1 VITR. STRAND + 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 1 0
0 0 0 0 0 0
0 0 0 1 1 0
SULIT DINILAI SULIT DINILAI
0 0 0 1 1 0
0 0 SULIT DINILAI 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 0 0
0 strand vitreous (+) 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
 0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 1 vitreous penuh 0 0 0
0 0 0 0 0 0
0 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
sulit dinilai 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 1 1 0
 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
SDE SDE SDE SDE SDE SDE
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
VITERUS STRANDS + 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 0 0 0
0 0 0 0 0 0
0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
0 0 0 1 1 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA

PEMBULUH DARAH RETINA STABILITAS AIR MATA

PERDARAHAN MIKROANEURISMA LAIN-LAIN TBUT

OS OD OS OD OS OD OS

0 0 0 15 6
0 0 0 0 0 4 5
0 0 0 0 0 6 7
0 0 0 0 0 11 13
0 0 0 0 0 5 6
0 0 0 0 0 10 10
0 0 0 0 0 15 7
0 0 0 0 0 5 5
0 0 0 0 0 15 16
0 0 0 0 0 7 3
0 0 0 0 0 10 12
0 0 10 4
0 0 0 0 0 16 14
0 0 0 0 0 9 11
0 0 0 0 0 13 15
0 0 0 0 0 10 5
0 0 0 0 0 10 6
0 0 0 0 0 5 5
0 0 0 0 0 11 8
0 0 0 0 0 12 7
0 0 0 0 0 17 8
0 0 0 0 0 1 1
0 0 0 4 5
0 0 0 0 0 10 8
0 0 0 0 0 10 10
0 0 0 0 0 2 2
0 0 0 rasio arteri vena
rasio
2/2arteri vena 2/3 7 3
0 0 0 0 0 10 7
0 0 0 0 0 10 2
0 0 0 rasio arteri vena
rasio
2/3arteri vena 2/3 7 8
0 0 0 0 0 4 4
0 0 0 0 SULIT DINILAI 12 12
0 0 0 0 0 7 8

0 0 0 0 0 10 10
0 0 0 0 0 6 7
0 0 0 0 0 3 1
0 0 0 0 0 11 12
0 0 0 0 0 1 2
0 0 0 0 0 >10 >10
0 0 0 0 0 8 5
0 0 0 0 0 10 7
10 10
0 0 <5 <5
0 0 0 0 0 10 10
0 0 0 0 0 14 13
0 0 0 0 0 10 10
0 0 0 0 0 10 6
0 0 0 0 0 10 7
0 0 0 0 0 10 10
0 0 0 0 0 <10 <10
0 0 0 0 0 10 5
0 0 0 0 0 8 8
0 0 0 0 0 8 8
0 0 0 0 0 10 10
0 0 0 0 0 10 8
0 0 0 0 0 1 1
SULIT DINILAI SULIT DINILAI
1 1
0 0 0 0 0 10 10
0 0 0 0 0 6 7
0 0 0 0 0 6 7
0 0 0 0 0 >10 >10
0 0 0 0 0 7 8
0 0 0 0 0 4 10
0 0 0 0 0 <5 10
0 0 0 0 0 1 1
0 0 0 0 0 5 8
0 0 0 0 0 >10 >10
0 0 0 0 0 3 3
0 0 0 0 0 >10 >10
0 0 0 0 0 1 2
0 0 0 0 0 4 3
<5 <5
0 0 0 - >10
0 0 0 0 0 8 9
0 0 0 0 0 1
0 0 7 <5
0 0 0 0 0 >10 >10
0 0 0 0 0 2 4
0 0 0 0 0 10 10
0 0 0 0 0 4 4
0 0 2 3
0 0 0 0 0 >10 >10
0 0 0 0 0 4 >10
0 0 0 0 0 8 10
0 0 0 0 0 3 1
0 0 0 0 0 >10 >10
0 0 0 0 0 2 1
0 0 0 0 0 >10 >10
0 0 0 0 0 >10 >10
0 0 0 0 0 >10 6
0 0 0 0 0 3
0 0 0 0 0 7 10
0 0 0 0 0 <5 <5
0 0 0 0 0 2 2
0 0 0 0 0 7 7
0 0 0 0 0 3 3
0 0 0 0 0 5 8
0 0 0 0 0 7 4
0 0 0 0 0 6 7
0 0 0 0 0 >10 >10

0 0 0 0 0 10 10
0 0 0 0 0 3 5
0 0 0 0 0 1 1
0 0 0 0 0 >10 >10
0 0 0 0 0 10 7
0 0 0 0 0 4 8
<5 <5
0 0 0 0 0 10 8
0 0 0 0 0 2 2
0 0 0 0 0 2 2
0 0 0 0 0 >10 >10
0 0 0 0 0 <5 10
0 0 0 0 0 >10 >10
0 0 sulit dinilai 0 >10 >10
0 0 0 0 0 >10 >10
0 0 0 0 0 6 > 10
0 0 0 0 0 > 10 >10
0 0 0 0 0 > 10 7
0 0 0 0 0 > 10 > 10
0 0 0 0 0 10 3
0 0 sulit dinilai 0 4 4
0 0 0 0 0 2 4
0 0 0 0 0 4 3
SULIT DINILAI SULIT DINILAI SULIT DINILAI SULIT DINILAI
0 0 0 0 0
0 0 SULIT DINILAI <5 <5
0 0 0 0 0 >10 >10
0 0 0 0 0 > 10 4
0 0 0 0 0 3 3
0 0 0 0 0 5 5
0 0 0 0 0 6 7
0 0 0 0 0 1 1
0 0 0 >10 >10
0 0 0 0 0 2 4
0 0 0 0 0 4 4
0 0 0 0 0 4 8
0 0 0 0 0 >10 6
0 0 0 0 0 1 3
0 0 0 0 0 2 2
0 0 0 0 0 3
0 0 0 0 0 <5 <5
0 0 0 0 0 4 5
0 0 0 0 0 8 8
0 0 0 0 0 5 7
0 0 0 0 0 3 2
0 0 0 0 0 1 1
0 0 4 1
0 0 0 0 0 3 4
0 0 0 0 0 3 4
0 0 0 0 0 > 10 > 10
0 0 0 0 0 3 3
0 0 0 0 0 3 5
0 0 0 0 0 3 2
0 0 0 0 0 3 4
0 0 0 0 0 3 2
0 0 0 0 0 >10 >10
0 0 0 0 0 2 3
0 0 sulit dinilai 0 7 3
0 0 0 0 0 5 7
0 0 0 0 0 7 7
0 0 0 0 0 5 8
0 0 0 0 0 6 6
0 0 0 0 0 10 7
0 0 0 0 0 3 4
0 0 0 0 0 4 10
0 0 0 0 0 8 4
0 0 0 0 0 4 4
0 0 0 0 0 2 4
0 0 0 0 0 >10 >10
0 0 0 0 0 2 2
0 0 0 0 0 10 10
0 0 0 0 0 7 9
0 0 0 0 0 3 5
0 0 0 0 0 7 8
0 0 0 0 0 3 3
0 0 0 0 0 7 4
0 0 0 0 0 >10 >10
0 0 0 0 0 7 3
0 0 0 0 0 2 4
0 0 0 0 0 2 2
0 0 0 0 0 3 4
0 0 0 0 0 3 4
 0 0 0 0 0 5 4
0 0 0 0 0 7 4
0 0 0 0 0 8 4
0 0 0 0 0 4 4
0 0 0 0 0 10 5
0 0 0 0 0 5 5
0 0 0 0 0 10 10
0 0 0 0 0 SDE SDE
0 0 0 0 0 10 10
0 0 0 0 0 4 3
0 0 10 sde
0 0 0 0 0 6 7
0 0 0 0 0 10 10
0 0 0 0 0 2 4
0 0 0 0 0 8 4
0 0 0 0 0 >10 >10
0 0 0 0 0 10 10
0 0 0 0 0 8 9
SDE SDE SDE SDE SDE SDE SDE
0 0 0 0 0 4 3
0 0 0 0 0 >10 .10
0 0 0 0 0 4 2
0 0 0 0 0 4 3
0 0 0 0 0 5 6
0 0 0 0 0 >10 >10
0 0 0 0 0 6 7
0 0 0 0 0 3 3
0 0 0 0 0 5 7
0 0 0 0 0 3 3
0 0 0 0 0 2 SDE
0 0 0 7 <5
0 0 0 0 0 2 2
0 0 0 0 0 4 10
0 0 0 0 0 7 5
0 0 0 0 0 3 4
0 0 0 0 0 >10 >10
0 0 0 0 0 >10 >10
0 0 0 0 0 4 4
0 0 0 0 0 3 3
0 0 0 0 0 3 3
0 0 0 0 0 SDE SDE
0 0 0 0 0 3 8
0 0 0 0 0 5 5
0 0 0 0 0 10 10
0 0 0 0 0 >10 >10
0 0 0 0 0 5 3
0 0 0 0 0 3 7
0 0 0 0 0 >10 5
0 0 0 0 0 >10 8
0 0 0 0 0 3 3
0 0 0 0 0 6 5
0 0 0 0 0 6 3
0 0 0 0 0 5 5
0 0 0 0 0 10 5
0 0 0 0 0 10 9
0 0 0 0 0 6 8
0 0 0 0 0 5 3
0 0 0 0 0 3 6
0 0 0 0 0 > 10 >10
0 0 0 0 0 10 10
0 0 0 0 0 10 10
0 0 0 0 0 6 5
0 0 0 0 0 >10 7
0 0 0 0 0 6 7
0 0 0 0 0 4 3
0 0 0 0 0 4 5
0 0 0 0 0 >10 >10
0 0 0 0 0 6 7
0 0 0 0 0 6 >10
0 0 0 0 0 5 6
0 0 0 0 0 10 10
0 0 0 0 0 6 7
0 0 0 0 0 >10 3
0 0 0 0 0 10 10
 PRODUKSI AIR MATA

DIAGNOSIS
SCHIRMER I SCHIRMER 2

OD OS OD OS

9 4 13 13 madarosis, katarak imatur

8 6 15 20 madarosis, entropion, trichiasis, dermatokalasis, k
24 23 15 15 dry eye ODS, katarak ODS
4 3 9 8 dry eyes ODS
5 1 8 6 madarosis, trichiasis, entropia, dermatokalasis,
9 5 17 15 madarosis ODS
15 21 16 24 katarak imatur ODS
6 6 3 4 pterigium gr III OS, afakia OS, katarak imat
6 7 >35 30 dry eyes ODS
9 5 13 11 madarosis, presbyopia
15 30 13 18 sikatriks kornea OD
10 11 15entropion ODS,
20 pterigium gr I ODS, madarosis ODS, uvetis sanata OS, katarak
4 5 20 28 pterygium grade I ODS
3 8 14 20 dry eye OD
5 3 12 10 mata tenang ODS
1 10 14 9 pterigium gr I ODS, katarak, entropion OS, tric
8 6 8 9 dry eyes OS
16 13 10 9 pterigium ODS, dermatokalasia ODS, katarak g
10 25 15 30 entropion ODS, lid retraction OS, dry eye ODS, lag
3 4 12 15 pterygium gr I ODS, presbyopia
10 13 19 20 trichiasis OS, pigmentary changes makula OD, d
1 5 25 15 MGD gr III ODS, katarak imatur ODS, dry ey
5 7 15 18 blefaritis anterior OS, katarak imatur ODS, dry
9 4 20 15 hordeolum OD
24 30 30 26
20 26 27 32 lagoftalmos ODS, trikiasis, ektropion inferior ODS,
10 20 25 lagoftalmos
31 dgn Corneal Exposure ODS, keratitis punctata ODS, epite
1 3 4 4 Pterigium gr II ODS + Madarosis ODS + dry e
10 4 10 7 lagoftalmos ODS, corneal esposure OD
3 5 5 10 MGD gr I ODS, pinguecela OD, dry eye O
14 10 19 11 pterigium ODS, dry eyes ODS, entropion + trik
28 27 20 16 MGD gr I OS, sikatriks kornea OS, katarak imatur ODS (DD/ko
35 35 17 14 pterigium gr II ODS + entropion palp superior ODS + de

9 7 21 19 lagoftalmus ODS, epiteliopati OD

16 6 23 14 lagoftalmus OD + corneal exposure, dry eye
9 17 17 27 uveitis anterior sarata ODS, madarosis ODS, lagoftalmus OD,
20 25 20 26 nevus palp sup+inf OD, iris flocculi ODS, pterigiu
9 1 10 14 uveitis sarata ODS, katarak imatur OD
22 20 14 14 papiloma palp superior OD
7 8 8 14 dry eyes ODS + dermatokalasia OS
>35 >35 20 16 dry eyes OS
17 18 14 10 katarak matur ODS
20 18 10 22 EKTROPION ODS, ENTROPION OS, PTERIGIUM GR 4 ODS, KATA
14 35 23 24
4 8 17 PTERIGIUM
29 GR II OD, GR III OS, KATARAK ODS, SUSP. RETINOPATI HIPE
16 30 14 22
16 9 10 10 DRY OS
9 8 2 4 DRY EYES ODS
23 2 20 20 MATA TENANG ODS
4 1 35 14 MGD GR I ODS, PTERIGIUM GR I OS, KATARAK GR I
15 4 17 11 DRY EYES OS
9 14 6 5 PTERIGIUM GR I OD, NEVUS KONJ OD, DRY EY
6 4 1 8 SIKATRIKS KORNEA ODS, RIWAYAT POST RUPTUR KORNEA
11 14 14 7 MADAROSIS ODS + KATARAK ODS
1 5 5 14 KATARAK MATUR OD, KATARAK SENILIS IMATUR OS, DER
10 21 10 7 MADAROSIS DERMATOKALASI ODS, DRY EYES ODS, KATA
5 2 7 5 PTISIS BULBI OD, LEUKOMA ADHEREN O
16 22 10MADAROSIS 15
ODS, MGD ODS, PINGUEKULA ODS, UVEITIS ANT SANATA ODS, KA
6 11 9 7
14 12 8 14 MADAROSIS ODS, DRY EYES ODS
25 10 29 ENTROPION
10 ODS, KATARAK ODS, DERMATOKALASIA ODS, PTERIGI
12 16 10 8 MGD GR II ODS
18 16 3 14 LAGOFTALMUS ODS TANPA CORNEAL EXPOSURE, D
11 28 13 10 EPIFORA OD, LAGOFTALMUS OD
35 8 25 15 LAGOFTALMUS OD, EKTROPION OD, DRY EY
22 17 11 9 MADAROSIS ODS, DRY EYES ODS, KATARAK IMA
1 8 8 PTOSIS INVOLUSIONAL
9 OD, MGD GR II ODS, KATARAK MATUR OD, PSEUD
8 15 15 23 KATARAK MORGAGNI OD, KATARAK MATU
5 4 10 13 DRY EYES ODS, MGD ODS
5 8 15 20 SIKATRIKS KORNEA OS
15 7 12 6 KATARAK MATUR OD, NEAR MATUR OS, MADAR
8 17 8 13 LAGOFTALMUS OS DENGAN CORNEAL EXPO
5 11 3 PTISIS
3 BULBI ODS, ENTROPION OD EKTROPION OD LAGOFTALMUS
<1 25 31 >35 PTISIS BULBI OD, KATARAK IMATUR OS, MADAROSIS OD
3 3 10 6 MGD GR I ODS, PTERIGIUM GR I ODS, DRY EY
1 20 5 10 MADAROSIS ODS, MGD ODS, SIKATRIKS KORNEA OD, UVEITIS
2 30 4 17 PTISIS BULBI OS, DERMATOKALASIA OD, PTERIGIUM O
20 5 30 30 MGD GR I OD
2 1 6 GLAUKOMA
3 SEKUNDER OD, PAPIL ATROFI OD, TOTAL RD OS, PSEUDOFA
35 35 12 10 ENTROPION ODS, KATARAK ODS, MADAROS
1 14 1 1 MGD ODS, SIKATRIKS KORNEA OS, DRY EYE
3 3 8 10 KATARAK SENILIS IMATUR
PASIEN MENOLAK DERMATOKALASIA ODS
7 MADAROSIS
12 ODS,
10 ENTROPION 10ODS, DERMATOKALASIA ODS, BAGGY EYELID, PTERIGIUM ODS,
3 2 20 19 MATA TENANG ODS
23 4 KATARAK
35 IMATUR22 ODS, UV ANT SONATA OD, PTERIGIUM GR III OD, MGD ODS, M
35 20 35 20 MADAROSIS ODS
35 30 35 KATARAK
20 IMATUR ODS, SIKATRIK KORNEA OD, PINGUEKULA 0S, PTERIG
10 2 11 11 DERMATOKALASIA ODS
3 4 2 4 DERMATOKALASIA, MADAROSIS, TRIKIASIS
14 12 15 20 MADAROSIS OD, DERMATOKALASIA OD, NEVUS PALP SU
4 <1 7 D
2 RY EYES , MADAROSIS ODS, KATARAK IMATUR ODS, ENTROPION
 6 6 6 6 PTERIGIUM GR II OD, DRY EYES OD
3 <1 2 6 TRIKIASIS ODS, PTERIGIUM ODS, DRY EYES ODS, NE
3 9 14 22 NEVUS PALP SUP OD, SIKATRIKS KORNEA OS, SUSP GANG REFR
6 2 3 5 DERMATOKALASIA ODS, PSEUDOFAKIA ODS, ENTROPION
9 8 7 MADAROSIS
3 ODS, LAGOFTALMUS ODS, KATARAK IMATUR ODS, DRY EYES O
9 <1 5 5 DRY EYES ODS, MADAROSIS ODS
4 8 15 12 LAGOFTALMUS OS DENGAN CORNEAL EXPOSURE OS, EKTRO
20 13 15 9 DRY EYES ODS
>35 14 13 10 MATA TENANG ODS

28 9 19 12 AFAKIA ODS, PTERIGIUM GR I OD, PRO 2ND IM

5 8 9 5 DRY EYES ODS
24 22 35 UVEITIS ANT 27SANATA ODS, KATARAK IMATUR ODS, MGD ODS, LAGOFTALMU
4 15 8 8 ENTROPION OS, TRIKIASIS ODS, MADAROSIS ODS, DERMATOK
2 4 7 4 ENTROPION OS, AFAKIA OD, KATARAK GR III OD, D
4 13 8 8MADAROSIS + DERMATOKALASIA ODS, MGD OS, PTERIGIUM OD
20 22 23 SIKATRIKS12KORNEA ODS (LEUKOMA ADHERENS ODS), ENTROPION ODS, DE
13 3 26 22 MATA TENANG ODS, DRY EYES OS
1 3 <1 <1 SUSP. UVEITIS POST OS, MADAROSIS O
21 22 8 22 DRY EYES ODS, SUSP UVEITIS POST OD
29 23 21 15 ANISOKORIA, PTERGIUM ODS, RIW UVEITI
4 4 1 0 DRY EYES OD
9 21 20 30 MATA TENANG ODS
20 10 20 koagulum 17+ imbibisi kornea OD (non functioned eye OD), pseudofakia OS
4 15 9 17 MATA TENANG ODS
7 24 17 26 madarosis ODS, ankiloblepharon OS, katarak matur O
6 6 4 7 lagoftalmos OD tanpa corneal exposure, hemiflac
5 9 lagoftalmos
4 ODS,5 entropion ODS, madarosis+trikiasis ODS, scar cornea OS, epite
4 9 15 21 madarosis ODS, dermatochalasis ODS
4 13 5 7 lagoftalmos + corneal exposure OS, sikatriks k
3 2 madarosis
29 IDS, trikiasi11
OD, leukoma adheren+epitelopati OD, katarak komplikata OD, ka
8 9 20 20 pinguekula ODS, katarak skp os, drye eyes
15 14 10 12 pterigium OD, KSI ODS, drye eye ODS
>35 >35 33 9 ulkus kornea ODS+ uveitis (keratouveiti
ektropion OD, dermatokalasis ODS, pseudoph
8 7 8 9 pterigium ODS, leukoma kornea ODS, KSI OD, dr
30 22 32 30 madarosis ods
2 2 12 trichiasis
20 ODS, entropion OS, ptosis ODS, pterigium OS, corneal s
9 19 14 15 uveitis sarata OS, KSI ODS, dry eyes OD
2 1 7 4 dermatokalasia ODS, KSI ODS, dry eyes O
19 17 14 19 katarak matur ODS, entropion palpebra superior OD
15 18 21 14 pterigium gr II ODS, katarak imatur ODS, Dry e
12 10 9 entropion 7 + madarosis+ trikiasis ODS, pterigium ODS, corneal scar OD, p
7 4 4 8 vitreous strand (uveitis posterior) OD, dry ey
13 13 5 4 dermatokalasis, madarosis ODS, pterigium OS, post uveitis OS
10 5 madarosis
10 ODS,8trikiasis OD, dermatochalasis ODS, pterigium gr III ODS, corneal
 2 9 1 5 Katarak imatur ODS, trikiasis OD, pterigium OD,
6 4 5 4 makula kornea ODS
6 21 15 19 high myopia ODS, dry eyes ODS
>35 >35 >35 >35 Katarak imatur ODS, ulkus kornea OD, lagofta
7 17 13 10 entropion involusional ODS, pterigium gr II OD, katarak
13 13 15 7 oftalmoplegi ODS total, dermatochalasia ODS, KSI
10 8 10 13 madarosis, trikiasis ODS, scar cornea OD, KSI ODS,
13 9 19 11 uveitis sarata OD, KSI OD, pseudoafakia OS, dry
8 23 24 24pseudofakia OS, katarak imatur OD, pinguekula ODS, dry eyes
33 26 30 32 makula kornea OS, katarak SKP ODS, dry ey
7 ptosis10ODS, ektropion
10 inferior ods,
10entropion superior ods, madarosis ods, pseudofakia dgn iol cap
10 15 7 12 dermathalasis ODS, katarak imatur ODS, pterigiumOD
3 4 17 18 katarak subkapsularis posterior, dry eyes
7 8 4 9 madarosis,entropion OS, KSI ODS, trikiasis OS, epi
9 4 12 8 katarak imatur ODS, dry eyes ODS
5 4 9 6pterigium, entropion, katarak imatur, iris atrofi, post uveitis der
5 5 13 10 pterigium ODS, KSI ODS, dry eye ODS
7 4 18 16 pinguecula ODS, katarak imatur ods, dry ey
8 9 19 10 uveitis OD, afakia OD, pseudophakia OS, pterigium OD gr II
15 14 15 18 dermatochalasis ODS, KSI IS
35 15 17 7 lagoftalmos ODS, ekropion dan entropion OD, epitelio
10 6 7 ptosis,
9 entropion OD, madarosis ODS, pterigium OD, KSI ODS, sika
5 20 19 35 madarosis ODS, KSI ODS
5 3 14 16 pinguecula ODS, dry eyes ODS
8 7 3 10 KSI ODS, dry eyes ODS
6 17 21 16 katarak imatur ODS, entropion ODS, dry eye
5 8 9 8 KSI ODS, dry eyes OS
15 6 14 17 dermatokalasis katarak ODS, dry eye OD
15 10 12 12 madarosis pterigium OS, KSI ODS, epiteliopati ODS
35 30 30 dermatochalasis
34 + madarosis ODS, katarak imatur ODS, uveitis ant
15 15 5 10 KSI ODS, corneal scar OS, dry eye ODS
10 8 15 12 Madarosis ODS, pinguekula OD, KSI ODS, dry
12 10 10 11 pterigium ODS, KSI ODS, dermatochalasis ODS, po
14 14 15 16 entropion sup OS, dermatokalasis ODS, katarak imatur
2 3 3 <1 Afakia OS, Katarak imatur OD, uveitis sana
10 3 9 4 madarosis, trichiasis, entropion ODS, MGD ODS, KSI O
9 17 11 19 KSI ODS, dry eye ODS
1 4 8 12 KSI ODS
2 2 4 5 Dermatochalasis OD, katarak imatur ODS, epiteliopati
4 3 pseudofakia
17 OD, katarak
20 imatur OS, dermatokalasis ODS, dry eye ODS
11 11 19 20 KSI ODS, dermatochalasis ODS, pterygium ODS, ep
8 10 4 10 blefaritis ant ODS, KSI OD, dry eye OD
35 35 22 23 madarosis ODS, trikiasis OS, pterigium OS, KSI ODS
7 9 13 14 Madarosis ODS, KSI ODS, dry eye ODS
3 5 5 10 pterygium, KSI ODS, dry eye ODS
10 30 5 dermatochalasis
15 ODS, pterygium ODS, pseudofakia OD, katarak matur
12 17 35 25 uveitis OD
2 3 8 6 dermatochalasis OD, KSI ODS, pterygium
35 5 35 30 dermatochalasis OS, katarak matur OD, KSi OS, d
25 10 13 5 KSI ODS, dry eye ODS
10 20 20 33 lagoftalmus + corneal exposure OS, dry ey
7 13 15 17 entropion OD, madarosis ODS, sikatriks kornea OD, p
5 5 1 1 katarak imatur ODS
5 <1 3 3 KSI ODS, Dry eye ODS
<1 <1 4 1 mata tenang ODS
6 13 6 7 lagoftalmus + corneal exposure ODS
10 14 12 15 pre physical eye OS, uveitis sanata OD
4 3 8 9 madarosis ODS, dry eye ODS
1 1 3 4 mata tenang ODS
18 18 5 3 dermatochalasis ODS, epiteliopati ODS, KSI ODS,
30 20 19 14 KSI ODS, dry eye ODS
26 20 35 30 KSI ODS
8 2 25 12 DERMATOCHALASIA ODS
5 5 15 8 DRY EYE ODS
14 19 24 30 lagoftalmus ODS, uveitis ODS
<1 4 10 5 madarosis ODS, lagoftalmus OD, sikatriks kornea OD
7 6 14 15 KSI ODS, entropion OS, madarosis OD
17 20 10 30 lagoftalmos + corneal exposure ODS, trokiasis OS, hemifacial
5 5 5 5 PTERIGIUM ODS, DRY EYE ODS
<1 <1 5 7 dry eye ODS, katarak subcapsularis posterior ODS,
10 8 4 3 pterigium ODS, epiteliopati OD, KSI OD
5 4 11 14 mata tenang ODS, dry eye ODS
<1 2 4 6 madarosis ODS, entropion ODS, trikiasis ODS, pterigium OD, KS
25 25 30 dermatochalasis,
35 entropion, madarosis, trichiasis ODS, post uveiti
4 6 4 8 KSI ODS, DRY EYE ODS
15 8 16 10 lagoftalmos OS, pterigium ODS, katarak subcapsula
15 34 19 ektropion,
32 entropion, trikiasis, corneal scar, KSI OS ; katarak matur OD
14 9 6 5 pterigium ODS, corneal scar OD, KSI ODS, dry
epiteliopati ODS, katarak imatur ODS, dry ey
35 23 32 32 madarosis ODS, KSI ODS
13 15 11 dermatochalasis
26 ODS, trichiasis ODS, lagoftalmos + corneal exposure OS, co
4 10 16 12 mata tenang ODS
30 35 26 35 pterigium ODS
30 1 18 19 DRY EYES ODS
4 2 4 2 KSI ODS, dry eye ODS
10 4 8 dermatochalasos
7 ODS, lagoftalmos OD, pinguecula OS, scar cornea OD, KSI O
14 30 35 >35 uveitis posterior ODS< KSI ODS
12 9 4 7 trichiasis OS, dermatochalais ODS, KSI ODS, dry
9 11 12 35 pseudofakia ODS
12 2 25 25 dermatochalasis, madarosis
17 21 10 8 Entropion trikiasis OS, madarosis ODS, KSI
7 4 19 10 KSI IDS, pterigium ODS, dry eye ODS
 5 33 2 14 lagoftalmos tanpa CE OS, dry eye ODS
22 25 23 20 dry eyes OS, KSI ODS, dermatochalasis O
10 14 9 6 pseudofakia ODS, dry eye OS
14 12 13 trikiasis
12 ODS, pinguecula OD, cornea scar OD, KSI ODS, lagoftalmo
<1 <1 5 9 pterigium gr II OD, gr I OS, dry eyes OD
22 35 30 15 lagoftalmos ODS, entropion ODS, KSI ODS, ektropio
15 14 10 11 dry eyes ODS
10 23 10 5 mata tenagn ODS, dry eyes ODS
9 15 4 6 dermatochalasis , pterigium, KSI ODS, dry e
1 1 12 9 KSI ODS, kista kantus lateral OD
10 25 22 3 MGD gr III-IV, KSI ODS, dry eye ODS
5 3 9 8 madarosis ODS, dry eyes ODS, pinguecula OD
29 24 17 11 KSI ODS
13 7 5 5 mata tenang ODS
3 4 30 17 mata tenang ODS
3 1 15 23 pterigium ODS
15 2 33 9 nevus palpebra OD, dermatochalasis ODS, pterigium OD,
<1 4 10 8 KSI ODS, pterigium OS, dry eyes ODS
19 11 6 26 LAGOFTALMUS ODS TANPA CORNEAL EXPO
5 7 9 26 LAGOFTALMUS ODS, EKTROPION ODS, DERMATOKALASIA OD
23 32 17 25 DERMATOKALASIA ODS, PINGUEKULA ODS, MADAROSIS ODS
6 14 15 5EKTROPION OD, DERMATOKALASIA ODS, LAGOFTALMUS ODS TA
16 13 20 12 DERMATOKALASIA + PTOSIS ODS, KSI ODS, EPITELIOPATI
13 15 18 17 KSI ODS
15 35 35 35 SIKATRIKS KORNEA OD
1 1 <1 <1 MADAROSIS ODS, DRY EYES ODS
13 5 8 8 MATA TENANG ODS, DRY EYES OS
25 15 25 30 LAGOFTALMUS OD, PTERIGIUM ODS, KSI
 DIAGNOSIS TERAPI

madarosis, katarak imatur c.lyterrs 6 x ODS

madarosis, entropion, trichiasis, dermatokalasis, katarak imatur lyters 6 x OS
 dry eye ODS, katarak ODS lyters ODS
dry eyes ODS lyters 6 x ODS
madarosis, trichiasis, entropia, dermatokalasis, kat.imatur lyters 6 x ODS
madarosis ODS lyters 6 x ODS, resep kacamata +2.00
katarak imatur ODS lyters 6 x ODS
pterigium gr III OS, afakia OS, katarak imatur OD lyters 6 x ODS
dry eyes ODS lyters 6 x ODS
madarosis, presbyopia lyters 6 x ODS, resep kacamata +1.50
sikatriks kornea OD resep kacamata addisi +1.50
m gr I ODS, madarosis ODS, uvetis sanata OS, katarak senilis ODS, sikatriks kornea OS, lyters
dry eyes
6 x ODS
pterygium grade I ODS lyters 6 x ODS
dry eye OD lyters 6 x ODS
mata tenang ODS c. lyterrs 6 x ODS, Kacamata +2.00
pterigium gr I ODS, katarak, entropion OS, trichiasis OS c.lyteers 6 x ODS, addisi +3.00
dry eyes OS c.lyterrs 6 x ODS, addisi +3.00
pterigium ODS, dermatokalasia ODS, katarak gr III ODS c.lyteers 6 x ODS, addisi +2.00
entropion ODS, lid retraction OS, dry eye ODS, lagoftalmos OS c. lyteers 6 x ODS
pterygium gr I ODS, presbyopia c. lyteers 6 x ODS
trichiasis OS, pigmentary changes makula OD, dry eye OS c. lyteers 6 x ODS, addisi +1.50
MGD gr III ODS, katarak imatur ODS, dry eye ODS c. lyteers 6 x ODS
blefaritis anterior OS, katarak imatur ODS, dry eye ODS lid hygiene OS, c. lyteers 6 x ODS
hordeolum OD levoflox 6 x OD, c.lyteers 6 x ODS, resep kacamata S +1.50

lagoftalmos ODS, trikiasis, ektropion inferior ODS, entropion OS c. lyteers 6xODS, lid taping
n Corneal Exposure ODS, keratitis punctata ODS, epiteliopati, trikiasis OS,
c. lyteers
dry eye6xODS,
ODS lid taping, kacamata +2.00
Pterigium gr II ODS + Madarosis ODS + dry eyes OS c. lyteers 6x ODS, Kacamata +2.00
lagoftalmos ODS, corneal esposure ODS c. lyteers 6x ODS
MGD gr I ODS, pinguecela OD, dry eye ODS c. lyteers 6x ODS, Kacamata +2.00
pterigium ODS, dry eyes ODS, entropion + trikiasis ODS lyters 6xODS, kacamata S+3.00
gr I OS, sikatriks kornea OS, katarak imatur ODS (DD/komplikata, dd/juvenile) lyters 6xODS
terigium gr II ODS + entropion palp superior ODS + dermatokalasia ODS lyters 6xODS

lagoftalmus ODS, epiteliopati OD C. lyters 6xODS, kacamata +3.00

lagoftalmus OD + corneal exposure, dry eyes ODS lyters 6xODS
anterior sarata ODS, madarosis ODS, lagoftalmus OD, MGD ODS, dry eye ODS lyters 6xODS
nevus palp sup+inf OD, iris flocculi ODS, pterigium OS gr III
uveitis sarata ODS, katarak imatur ODS lyters 6xODS
papiloma palp superior OD lyters 6xODS
dry eyes ODS + dermatokalasia OS lyters 6xODS
dry eyes OS lyters 6xODS + kacamata +2.00
katarak matur ODS pro phaco +IOL ODS
ON ODS, ENTROPION OS, PTERIGIUM GR 4 ODS, KATARAK SENILIS IMATUR OD lyters 6xODS, kacamata S+3.00

OD, GR III OS, KATARAK ODS, SUSP. RETINOPATI HIPERTENSI ODS, CWS PERIPAPIL ODS
 DRY OS lyters 6xODS
DRY EYES ODS lyters 6xODS, kacamata S+1.50
MATA TENANG ODS lyters 6xODS
MGD GR I ODS, PTERIGIUM GR I OS, KATARAK GR II OD, GR III OS
DRY EYES OS lyters 6xODS, kacamata S+2.00
PTERIGIUM GR I OD, NEVUS KONJ OD, DRY EYES ODS lyters 6xODS
ATRIKS KORNEA ODS, RIWAYAT POST RUPTUR KORNEA OS , PTERIGIUM OS lyters 6xODS
MADAROSIS ODS + KATARAK ODS lyters 6xODS, kacamata S+3.00
TARAK MATUR OD, KATARAK SENILIS IMATUR OS, DERMATOKALASIA ODS lyters 6xODS
ADAROSIS DERMATOKALASI ODS, DRY EYES ODS, KATARAK IMATUR ODS lyters 6xODS
PTISIS BULBI OD, LEUKOMA ADHEREN OS lyters 6xODS
ODS, PINGUEKULA ODS, UVEITIS ANT SANATA ODS, KATARAK KOMPLIKATA ODS, DRY EYES
lyters
ODS6xODS

MADAROSIS ODS, DRY EYES ODS lyters 6xODS

ODS, KATARAK ODS, DERMATOKALASIA ODS, PTERIGIUM GR I ODS, DRY EYES ODS lyters 6xODS
MGD GR II ODS lyters 6xODS
LAGOFTALMUS ODS TANPA CORNEAL EXPOSURE, DRY EYES ODS lyters 6xODS
EPIFORA OD, LAGOFTALMUS OD lyters 6xODS
LAGOFTALMUS OD, EKTROPION OD, DRY EYES OD lyters 6xOD, KACAMATA +2.50
MADAROSIS ODS, DRY EYES ODS, KATARAK IMATUR ODS lyters 6xODS
NAL OD, MGD GR II ODS, KATARAK MATUR OD, PSEUDOFAKIA OS + PCO OS, DRY EYES ODS lyters 6xODS
KATARAK MORGAGNI OD, KATARAK MATUR OS TIDAK ADA TERAPI
DRY EYES ODS, MGD ODS LYTERS 6XODS
SIKATRIKS KORNEA OS TIDAK ADA TERAPI
KATARAK MATUR OD, NEAR MATUR OS, MADAROSIS ODS LYTERS 6XODS
LAGOFTALMUS OS DENGAN CORNEAL EXPOSURE lyters 6xOS, KACAMATA +1.50
ODS, ENTROPION OD EKTROPION OD LAGOFTALMUS ODS SIKATRIKS KORNEA ODS LYTERS 6XODS
ISIS BULBI OD, KATARAK IMATUR OS, MADAROSIS ODS CORNEA SCAR OS lyters 6xOS, KACAMATA +2.00
MGD GR I ODS, PTERIGIUM GR I ODS, DRY EYES ODS LYTERS 6XODS
OSIS ODS, MGD ODS, SIKATRIKS KORNEA OD, UVEITIS ANT OD, DRY EYES ODS P.PRED 6XOD, LYTERS 6XODS
PTISIS BULBI OS, DERMATOKALASIA OD, PTERIGIUM OD, DRY EYES ODS LYTERS 6XODS
MGD GR I OD LYTERS 6XODS
NDER OD, PAPIL ATROFI OD, TOTAL RD OS, PSEUDOFAKIA OD, AFAKIA OS, DRY EYES
TIMOL ODS
2XOD, LYTERS 6XODS
ENTROPION ODS, KATARAK ODS, MADAROSIS ODS LYTERS 6XODS, KACAMATA +2.00
MGD ODS, SIKATRIKS KORNEA OS, DRY EYES ODS LYTERS 6XODS, P.PRED 4XODS
KATARAK SENILIS IMATUR LYTERS 6XODS, KACAMATA +2.50
DERMATOKALASIA ODS
RMATOKALASIA ODS, BAGGY EYELID, PTERIGIUM ODS, KATARAK IMATUR ODS, LYTERS
EPITELIOPATI
6XODS + ODS,
KACAMATA
DRY EYES
+3.00
OD
MATA TENANG ODS LYTERS 6XODS
V ANT SONATA OD, PTERIGIUM GR III OD, MGD ODS, MADAROSIS + TRIKIASIS OD, DRYLYTERS
EYES ODS
6XODS
MADAROSIS ODS TIDAK ADA TERAPI
ODS, SIKATRIK KORNEA OD, PINGUEKULA 0S, PTERIGIUM OS, MGD ODS, DRY
LYTERS
EYES 6XODS
ODS + KACAMATA +2.50
DERMATOKALASIA ODS
DERMATOKALASIA, MADAROSIS, TRIKIASIS ODS LYTERS 6XODS
ADAROSIS OD, DERMATOKALASIA OD, NEVUS PALP SUP OS, DRY EYES OS LYTERS 6XODS
MADAROSIS ODS, KATARAK IMATUR ODS, ENTROPION + TRIKIASIS PALP SUPLYTERS
ODS 6XODS + KACAMATA +2.50
 PTERIGIUM GR II OD, DRY EYES OD LYTERS 6XODS
TRIKIASIS ODS, PTERIGIUM ODS, DRY EYES ODS, NEVUS KONJ OD KACAMATA +2.50
ALP SUP OD, SIKATRIKS KORNEA OS, SUSP GANG REFRAKSI ODS, DRY EYES ODS
LYTERS 6XODS + KACAMATA +3.00
RMATOKALASIA ODS, PSEUDOFAKIA ODS, ENTROPION ODS, DRY EYES ODS LYTERS 6XODS + KACAMATA +3.00
GOFTALMUS ODS, KATARAK IMATUR ODS, DRY EYES ODS, SIKATRIKS KORNEA OD, MGDLYTERSODS 6XODS
DRY EYES ODS, MADAROSIS ODS LYTERS 6XODS + KACAMATA +1.50
TALMUS OS DENGAN CORNEAL EXPOSURE OS, EKTROPION OS, DRY EYES ODS LYTERS 6XODS
DRY EYES ODS LYTERS 6XODS
MATA TENANG ODS

AFAKIA ODS, PTERIGIUM GR I OD, PRO 2ND IMPLAN ODS LYTERS 6XODS
DRY EYES ODS LYTERS 6XODS
DS, KATARAK IMATUR ODS, MGD ODS, LAGOFTALMUS ODS, MADAROSIS ODS, LYTERS
DRY EYES
6XODS, ODSKACAMATA +1.50
ION OS, TRIKIASIS ODS, MADAROSIS ODS, DERMATOKALASIA OD, KATARAK OS
ENTROPION OS, AFAKIA OD, KATARAK GR III OD, DRY EYES OS LYTERS 6XODS, PRO SECONDARY IMPLAN OD
SIS + DERMATOKALASIA ODS, MGD OS, PTERIGIUM ODS, KSI ODS, DRY EYES ODS LYTERS 6XODS
ODS (LEUKOMA ADHERENS ODS), ENTROPION ODS, DERMATOKALASIA ODS, DRY EYESLYTERS ODS 6XODS
MATA TENANG ODS, DRY EYES OS LYTERS 6XOS
SUSP. UVEITIS POST OS, MADAROSIS OS LYTERS 6XODS
DRY EYES ODS, SUSP UVEITIS POST ODS LYTERS 6XODS
ANISOKORIA, PTERGIUM ODS, RIW UVEITIS OD LYTERS 6XODS
DRY EYES OD LYTERS 6XODS, KACAMATA +2.00
MATA TENANG ODS TIDAK ADA TERAPI
kornea OD (non functioned eye OD), pseudofakia OS, keratitis pungtata ODlyters
(epiteliopati)
6 x OD, kacamata addisi +3.0
MATA TENANG ODS lyters 6 x ODS, kacamata S +1.50
madarosis ODS, ankiloblepharon OS, katarak matur ODS, dry eye OD lyters 6x ODS, kacamata +2.50
lagoftalmos OD tanpa corneal exposure, hemiflacid spasm OS lyters 6x ODS, kacamata +2.50
n ODS, madarosis+trikiasis ODS, scar cornea OS, epitelopati ODS, katarak senilis ODS, dry lyterseye
6xOS
ODS
madarosis ODS, dermatochalasis ODS lyters 6x ods, kacamata +2.00
lagoftalmos + corneal exposure OS, sikatriks kornea OS lyters 6c ODS
ma adheren+epitelopati OD, katarak komplikata OD, katarak imatur OS, leukoma
lfx 6xod, kornea
lytersOS,6x ods,
dry eye
kacamata
ODS +3.00
pinguekula ODS, katarak skp os, drye eyes ods c lyters 6xods, kacamata +3.00
pterigium OD, KSI ODS, drye eye ODS LYTERS 6XODS, Kacamata +2.50
ulkus kornea ODS+ uveitis (keratouveitis) LFX tiap jam ODS, lyters 6x ods
ektropion OD, dermatokalasis ODS, pseudophakia ODS lyters 6xods, kacamata +3.00
pterigium ODS, leukoma kornea ODS, KSI OD, dry eyes ODS lyters 6xods, kacamata +2.50
madarosis ods kacamata +2.00
DS, entropion OS, ptosis ODS, pterigium OS, corneal scar OS, KSI ODS, dry eyes OS lyters 6xods
uveitis sarata OS, KSI ODS, dry eyes ODS lyters 6x ods, ppred 6x os
dermatokalasia ODS, KSI ODS, dry eyes ODS lyters 6x ods
katarak matur ODS, entropion palpebra superior ODS, Dry eyes ODS lyters 6x ods, kacamata +2.50
pterigium gr II ODS, katarak imatur ODS, Dry eyes ODS lyters 6x ods
osis+ trikiasis ODS, pterigium ODS, corneal scar OD, pseudophakia OD, katarak lyteers
matur6xODS,
OS kacamata +2.00
vitreous strand (uveitis posterior) OD, dry eyes ODS lyters 6xods, kacamata +2.00
okalasis, madarosis ODS, pterigium OS, post uveitis OS, KSI ODS, dry eyes ODS lyters 6xods, kacamata +2.50
D, dermatochalasis ODS, pterigium gr III ODS, corneal scar OD, katarak imatur ODS, drylyters eye ODS
6xods
 Katarak imatur ODS, trikiasis OD, pterigium OD, dry eye OS lyters 6xODS
makula kornea ODS lyters 6xODS
high myopia ODS, dry eyes ODS lyters 6xods
Katarak imatur ODS, ulkus kornea OD, lagoftalmos OS lyters 6xods, lfx 6xods
ntropion involusional ODS, pterigium gr II OD, katarak imatur senilis ODS lyters 6x ods, kacamata +3.00, lfx 4xod
oftalmoplegi ODS total, dermatochalasia ODS, KSI ODS, dry eyes lyters 6xods
madarosis, trikiasis ODS, scar cornea OD, KSI ODS, dry eye ODS lyters 6xods
uveitis sarata OD, KSI OD, pseudoafakia OS, dry eyes ODS lyters 6XODS, kacamata S +2.50
kia OS, katarak imatur OD, pinguekula ODS, dry eyes ODS, dermatocalasia ODSlyters 6xods, kacamata +3.00
makula kornea OS, katarak SKP ODS, dry eyes ods lyters 6xods
superior ods, madarosis ods, pseudofakia dgn iol capture od, epitelopati ods,lyters
katarak
6xods,
maturkacamata
os, uveitis
+3.00
anterior os
dermathalasis ODS, katarak imatur ODS, pterigiumODS, dry eye ODS Lyters 6xods, kacamata +3.00
katarak subkapsularis posterior, dry eyes ods lyters 6xods, kacamata +3.00
madarosis,entropion OS, KSI ODS, trikiasis OS, epiteliopati ODS lyters 6xods
katarak imatur ODS, dry eyes ODS lyters 6xods
, entropion, katarak imatur, iris atrofi, post uveitis dermatochalasis, dry eye ODSlyters 6xods, kacamata +3.00
pterigium ODS, KSI ODS, dry eye ODS lyters 6xods
pinguecula ODS, katarak imatur ods, dry eye ods lyters 6xods, kacamata S +2.50
s OD, afakia OD, pseudophakia OS, pterigium OD gr II OS gr III, dry eye ODS Lyters 6x ods
dermatochalasis ODS, KSI IS kacamata +1.50
agoftalmos ODS, ekropion dan entropion OD, epiteliopati OD, KSI ODS lyters 6xods
pion OD, madarosis ODS, pterigium OD, KSI ODS, sikatriks kornea OD, dry eye lytersODS 6xods, kacamata +2.50
madarosis ODS, KSI ODS lyters 6xods
pinguecula ODS, dry eyes ODS lyters 6xods
KSI ODS, dry eyes ODS lyters 6xods
katarak imatur ODS, entropion ODS, dry eyes ODS lyters 6xods
KSI ODS, dry eyes OS lyters 6xods
dermatokalasis katarak ODS, dry eye ODS lyters 6 x ODS
madarosis pterigium OS, KSI ODS, epiteliopati ODS, dry eye OD lyters 6 x ODS, kacamata +2.50
asis + madarosis ODS, katarak imatur ODS, uveitis anterior senata OD, dry eyelyters ODS 6 x ODS, kacamata +3.00
KSI ODS, corneal scar OS, dry eye ODS lyters 6 x ODS, kacamata S +2.50
Madarosis ODS, pinguekula OD, KSI ODS, dry eye ODS lyters 6 x ODS
pterigium ODS, KSI ODS, dermatochalasis ODS, post uveitis ODS lyters 6 x ODS, kacamata +2.50
ntropion sup OS, dermatokalasis ODS, katarak imatur ODS, dry eye ODS lyters 6 x ODS
Afakia OS, Katarak imatur OD, uveitis sanata OS lyters 6 x ODS, kacamata +2.50
madarosis, trichiasis, entropion ODS, MGD ODS, KSI ODS, dry eye ODS lyters 6 x ODS
KSI ODS, dry eye ODS lyters 6 x ODS
KSI ODS lyters 6 x ODS
Dermatochalasis OD, katarak imatur ODS, epiteliopati ODS, dry eye ODS lyters 6 x ODS, kacamata +3.00
r OS, dermatokalasis ODS, dry eye ODS lyteers 6 x ODS
KSI ODS, dermatochalasis ODS, pterygium ODS, epiteliopati ODS lyteers 6 x ODS
blefaritis ant ODS, KSI OD, dry eye ODS lyteers 6 x ODS, kacamata +1.50
madarosis ODS, trikiasis OS, pterigium OS, KSI ODS, dry eye ODS lyters 6 x ODS
Madarosis ODS, KSI ODS, dry eye ODS lyters 6 x ODS, kacamata +2.50
pterygium, KSI ODS, dry eye ODS lyters 6 x ODS
ODS, pterygium ODS, pseudofakia OD, katarak matur OS, iridodialisis OD, dry eye ODSlyters 6 x ODS
 uveitis OD lyters 6 x OD, pred. 6 x OD
dermatochalasis OD, KSI ODS, pterygium OS lyters 6 x ODS
dermatochalasis OS, katarak matur OD, KSi OS, dry eye ODS lyters 6 x ODS
KSI ODS, dry eye ODS lyters 6 x ODS
lagoftalmus + corneal exposure OS, dry eye OS lyters 6 x ODS
entropion OD, madarosis ODS, sikatriks kornea OD, pseufofakia ODS lyters 6 x ODS
katarak imatur ODS lyters 6 x ODS
KSI ODS, Dry eye ODS
mata tenang ODS lyters 6 x ODS
lagoftalmus + corneal exposure ODS lyters 6 x ODS, kacamata S +2.50
pre physical eye OS, uveitis sanata OD, lyters 6 x ODS, kacamata S +1.50
madarosis ODS, dry eye ODS lyters 6 x ODS
mata tenang ODS kacamata S +1.50
dermatochalasis ODS, epiteliopati ODS, KSI ODS, dry eye ODS lyters 6 x ODS, kacamata S +2.50
KSI ODS, dry eye ODS lyters 6 x ODS
KSI ODS
DERMATOCHALASIA ODS lyters 6 x ODS
DRY EYE ODS lyters 6 x ODS
lagoftalmus ODS, uveitis ODS
madarosis ODS, lagoftalmus OD, sikatriks kornea ODS, dry eye ODS lyters 6 x ODS
KSI ODS, entropion OS, madarosis ODS
mos + corneal exposure ODS, trokiasis OS, hemifacial spasm OD, dry eye ODS lyters 6 x ODS
PTERIGIUM ODS, DRY EYE ODS lyters 6 x ODS
dry eye ODS, katarak subcapsularis posterior ODS, myopia ODS lyters 6 x ODS
pterigium ODS, epiteliopati OD, KSI ODS
mata tenang ODS, dry eye ODS lyters 6 x ODS
s ODS, entropion ODS, trikiasis ODS, pterigium OD, KSI ODS, makula kornea OS lyters 6 x ODS
asis, entropion, madarosis, trichiasis ODS, post uveitis ODS, KSI ODS< dry eye ODS lyters 6 x ODS
KSI ODS, DRY EYE ODS lyters 6 x ODS
lagoftalmos OS, pterigium ODS, katarak subcapsular ODS, dry eye lyters 6 x ODS
pion, trikiasis, corneal scar, KSI OS ; katarak matur OD ; epiteliopati ODS ; dry eye ODSlyters 6 x ODS
pterigium ODS, corneal scar OD, KSI ODS, dry eye ODS lyters 6 x ODS
epiteliopati ODS, katarak imatur ODS, dry eye ODS lyters 6 x ODS
madarosis ODS, KSI ODS lyters 6 x ODS
trichiasis ODS, lagoftalmos + corneal exposure OS, corneal scar ODS, KSI ODS, dry eyelyters ODS 6 x ODS
mata tenang ODS
pterigium ODS
DRY EYES ODS lyters 6 x ODS
KSI ODS, dry eye ODS lyters 6 x ODS
lagoftalmos OD, pinguecula OS, scar cornea OD, KSI ODS, dry eye ODS, ektropion OD palp lytersinf
6 x ODS
uveitis posterior ODS< KSI ODS pred 6 x ODS, lyters 6 x ODS
trichiasis OS, dermatochalais ODS, KSI ODS, dry eye ODS lyters 6 x ODS
pseudofakia ODS lyters 6 x ODS
dermatochalasis, madarosis tidak ada terapi
Entropion trikiasis OS, madarosis ODS, KSI ODS tidak ada terapi
KSI IDS, pterigium ODS, dry eye ODS lyters 6xods
 lagoftalmos tanpa CE OS, dry eye ODS lyters 6xods
dry eyes OS, KSI ODS, dermatochalasis ODS lyters 6xods
pseudofakia ODS, dry eye OS lyters 6xods
S, pinguecula OD, cornea scar OD, KSI ODS, lagoftalmos tnpa CE ODS, dry eye ODS lyters 6xods
pterigium gr II OD, gr I OS, dry eyes ODS lyters 6xods
lagoftalmos ODS, entropion ODS, KSI ODS, ektropion, uveitis OD lyters 6xods
dry eyes ODS lyters 6xods
mata tenagn ODS, dry eyes ODS lyters 6xods
dermatochalasis , pterigium, KSI ODS, dry eyes OS lyters 6xods
KSI ODS, kista kantus lateral OD lyters 6xods
MGD gr III-IV, KSI ODS, dry eye ODS lyters 6xods
madarosis ODS, dry eyes ODS, pinguecula OD, KSI ODS lyters 6xods
KSI ODS tidak ada terapi
mata tenang ODS tidak ada terapi
mata tenang ODS tidak ada terapi
pterigium ODS lyters 6xods
us palpebra OD, dermatochalasis ODS, pterigium OD, KSI ODS, dry eye OS lyters 6xods
KSI ODS, pterigium OS, dry eyes ODS lyters 6xods
LAGOFTALMUS ODS TANPA CORNEAL EXPOSURE LYTERS 6XODS
TALMUS ODS, EKTROPION ODS, DERMATOKALASIA ODS, XANTHELASMA ODS LYTERS 6XODS
TOKALASIA ODS, PINGUEKULA ODS, MADAROSIS ODS, TRIKIASIS ODS, KSI ODS
N OD, DERMATOKALASIA ODS, LAGOFTALMUS ODS TANPA CORNEAL EXPOSURE LYTERS 6XODS
RMATOKALASIA + PTOSIS ODS, KSI ODS, EPITELIOPATI ODS, DRY EYES OD LYTERS 6XODS
KSI ODS LYTERS 6XODS
SIKATRIKS KORNEA OD TIDAK ADA TERAPI
MADAROSIS ODS, DRY EYES ODS LYTERS 6XODS
MATA TENANG ODS, DRY EYES OS LYTERS 6XODS
LAGOFTALMUS OD, PTERIGIUM ODS, KSI ODS LYTERS 6XODS
 0=
tidak/belum 0 = tidak ada
pernah reaksi
1= Pausi Basiler 1= ya release
1= yafrom 1= tipe 1
treatment
2= Multi Basiler 0= tidak 0= tidak 2= tipe 2
98 = tidak 98 = tidak 98 = tidak tahu
98= Tidak tahu
tahu tahu

Lama keluhan Tipe kusta

Riwayat reaksi
Lama sakit sebelum berdasarkan terapi Riwayat
Riwayat relaps kusta (jawaban
kusta terdiagnosis saat pertama kali putus obat
dapat >1)
kusta diberikan

2 th *98 2 0 0 1
11 th 2 th 2 0 0 3
30 th 4 th 2 1 98 0
5 th 2 th 1 0 0 0
1 3 bln 1 0 0 1
12 th 7 th 2 0 0 0
5 th 1 th 2 0 1 1
3 th 1 th 2 1 0 0
3 th 1 th 2 0 0 1
2 th 1 th 2 0 0 0
3.5 th 5 2 0 0 0
6 th 2 th 0 0 0 2
9 th 6 th 2 0 0 2
7 th 1 bln 1 0 0 0
8 th 1 bln 2 0 0 2
1 th 1 th 2 0 0 1
2 th 1 th 2 0 0 2
5 th 8 th 2 0 0 0
3 th 1 th 2 0 0 0
1 th 3 th 2 0 0 0
5 th 98 1 0 0 0
2 th 1 mgg 2 0 0 2
2 th 98 2 0 0 0
12 th 3 th 2 1 1 0
20 th 4 th 2 0 0 0
6 bln 1 th 2 1 0 1
10 th 7 th 1 0 0 0
4 th 1 th 2 0 0 2
32 th 2 bln 2 0 0 98
42 th 98 98 0 0 0
5 th 2 th 2 0 0 0
1 th 2 bln 2 0 0 2
34 th 2 0 0 0

5 th 1 th 1 0 0 0
2 th 1 th 1 0 0 1
5 th 1 th 2 0 1 0
33 th 17 th 2 0 0 0
41 th 1 th 2 98 0
4 th 6 bln 1 1 0 0
20 th 18 th 2 0 0 1
35 th 98 2 0 98 1
20 th 5 th 2 1 0 2
20 th 1 th 2 0 0 1
15 th 2 th 2 0 0 0
2 th 2 bln 2 0 0 0
1 th 8 bln 2 0 0 2
 2 th 2 bln 2 0 0 1
6 th 3 th 1 0 0 0
5 th 2 th 1 0 1 0
2 th 1 th 2 0 1 0
34 th 34 th 2 0 0
2 th 98 2 0 1 2
2 th 1 th 1 0 0 0
2 th 7 th 2 0 0 2
2 th 13 th 2 0 0 2
5 th 1 th 2 0 0 1
6 bln 1 bln 2 0 0 0
11 th 7 th 2 0 0 0
13 th 0 2 0
2 th 6 bln 6 bln 2 1 0 0
18 th 6 bln 2 1 0 2

28 th 1 th 2 0 0 0
22 th 4 th 2 1 1 1
98 98 1 0 0 1
9 th 7 th 2 0 0 0
41 th 4 th 2 0 0 1
3 th 1 bln 2 0 0 1
2 th 1 th 2 0 0 2
36 th 3 th 2 0 1 1
35 th 2 th 2 1 0 0
12 th 5 th 2 1 1 98
6 bln 5 th 1 0 0 0
5 th 2 bln 2 0 0 0
5 th 98 1 1 0 0
3 th 3 bln 2 0 0 0
6 th 5 th 2 0 0 2
1 th 6 bln 1 th 2 1 1 1
1 th 3 th 1 0 0 0
2 th 1 th 2 0 0 0
4 th 4 th 1 0 0 0
2 th 1 th 1 0 0 0
98 98 2 1 0 2
4 th 1 th 2 0 0 1
33 th 2 th 2 1 2

39 th 2 th 2 0 0 1
16 th 5th 2 1 1
1 th 0 bln 2 1 0 0
44 th 2 th 2
1 th 2 th 2 0 0 0
98 98 2 0 0 2
4 th 1 th 2 1 0 1
4 th 1 th 2 0 0 2
2 th 2 th 1 0 0 0
1 th 3 bln 2 0 1 0
20 th 3 th 2 0 98
9 th 8 th 2 0 0 1
2 th 6 th 1 0 0 0
3 th 3 th 1 0 0 0
1 th 1 th 2 0 0 1
4 th 1 th 2 0 0 0
4 th 6 bln 2 0 0 1
35 th 1 th 1 0 0 1
4 th 2 th 2 0 0 0
98 98 2 0 98
9 th 7 th 2 1 0 0
8 th 5 th 2 0 0 2
1 th 98 2 0 0 2
1 th 2 th 1 0 0 0
27 th 2 th 2 0 0 1
9 th 6 th 2 2 0 0
1 bln 10 th 2 0 0 0
98 98 98 98 98 98
22 th 3 th 2 0 0 1
2 th 4 th 1 0 0
13 th 4 th 1 0 0 0
16 th 15 th 2 0 0 0
98 4 th 1 0 0 0
24 th 24 th 1 0 0 0
98 98 2 1 1 2
6 th 1 th 2 0 0
10 th 9 th 2 0 0 0
6 th 3 th 1 0 0 0
1 th 1 th 2 0 0 0
98 1 th 2 0 0 1
3 th 3 th 2 0 0 2
20 th 1 th 1 0 0 0
2 th 98 2 0 0 0
3 th 1 th 2 0 0 2
15 th 10 th 1 0 0 0
21 th 2 th 2 1 0 0
23 th 15 th 2 0 0 2
98 98 2 0 0 0
7 th 1 th 1 0 0 0
6 bln 1 th 2 0 0 0
15 th 98 2 0 2
30 th 3 th 1 0 1 0
12 th 1 th 1 0 0 1
6 th 5 th 2 0 0 0
2 th 2 th 2 0 0 0
3 th 98 1 0 0 0
40 th 98 2 0 0 0
98 98 2 0 0 0
3 th 4 th 2 0 1 1
5 th 98 2 0 0 2
20 th 1 th 2 0 0 2
3 th 0 bln 2 0 0 0
2 th 0 bln 2 0 0 0
11 th 2 th 2 1 0 0
20 th 1 th 1 0 0 1
3 th 1 th 2 0 0 2
8 th 98 1 0 0 0
19 th 3 bln 1 0 1 2
2 th 98 2 0 0 2
4 th 2 0 0 2
4 th 1 th 6 bln 1 0 98 0
13 th 1 th 1 0 0 0
5 th 3 th 1 0 1 0
98 10 th 2 0 0 0
3 th 1 th 2 0 0 1
98 5 th 2 0 0 1
6 th 98 2 0 1 2
3 th 2 bln 2 0 0 0
12 th 3 bln 1 1 0 0
5 th 3 th 2 1 0 2
10 th 0 bln 2 0 0 1
15 th 5 th 2 0 0 0
6 th 98 2 0 0 0
3 th 1 th 2 0 0 1
2 th 5 th 1 0 0 0
6 th 1 th 2 1 0 0
48 th 2 th 2 0 1 2
30 th 98 2 0 0 2
30 th 98 1 0 0 0
3 th 1 th 2 0 0 0
98 15 th 1 0 0 0
10 th 15 th 2 0 0 2
3 th 3 th 2 1 98 2
2 th 1 th 1 0 0 0
5 th 2 th 2 1 0 2
12 th 10 th 2 0 0 0
5 th 2 th 2 0 0 0
2 th 2 bln 1 0 1
 98 98 2 0 0 0
2 th 1 th 1 0 0 0
35 th 98 1 0 0 0
4 th 2 th 1 0 0 0
1 th 2 th 1 0 0 0
40 th 15 th 2 1 1 2
11 th 1 th 1 0 0 0
5 th 3 th 2 0 0 2
6 th 4 th 1 0 0 0
6 th 3 th 1 0 0 0
3 th 2 th 2 0 0 0
18 th 12 th 2 0 0 0
2 th 3 bln 2 0 0 0
18 th 98 1 1 0 0
10 th 2 th 1 0 0 0
13 th 3 th 2 0 0 2
98 3 bln 1 0 0 0
5 th 3 th 1 1 0 0
2 th 5 th 1 0 0 0
9 th 8 th 1 0 0 0
8 th 6 bln 2 0 0 1
1 th 98 2 0 0 2
22 th 20 th 1 0 0 0
6 th 2 th 1 0 0 0
44 th 98 1 0 0 1
1,5 th 3 th 1,2 0 1 0
10 th 1 th 2 0 0 0
1 th 98 2 0 0 2
36 th 5 th 1 0 0 0
10 th 5 th 1 0 0 0
20 th 14 th 1 0 0 0
26 th 22 th 2 0 0 1
17 th 98 2 0 0 2
3 th 6 th 1 0 0 0
10 th 3 th 1 0 0
2 th 5 bln 2 1 1 0
16 th 5 th 2 0 0 2
2 th 2 bln 2 1 1 2
11 th 3 th 2 0 2
6 bln 3 th 1 0 0 0
4 th 2 1 0 2
98 1 th 1 0 0 0
3 th 9 th 1 0 0 0
6 th 1 th 2 0 1 0
14 th 1 th 2 1 0 0
10 th 98 2 0 0 0
 98 98 2 1 0 0
1 th 4 th 2 0 0 2
53 th 98 1 0 0 0
44 th 1 th 2 0 0 0
18 th 98 1 0 0 98
15 th 5 th 2 0 0 0
2 th 2 th 2 1 1 2
2 th 1 th 2 0 0 1
20 th 10 th 2 0 1 1
4 th 2 th 2 0 0 0

2 th 3 th 2 0 0 0
40 th 10 th 2 0 0 2
6 th 6 bln 2 0 1 2
2 th 2 th 2 0 0 1
3 th 1 th 2 0 0 2
3 th 1 th 2 0 0 0
28 th 25 th 2 0 0 0
3 bln 3 th 1 0 0 0
98 2 th 1 1 0 1
18 th 13 th 2 0 0 1
6 bln 98 2 0 0 1
6 bln 20 th 2 0 0 0
1 th 1 th 1 0 0 0
8 th 10 th 2 1 0 2
48 th 1 th 2 2 0 0
2th 1 th 2 0 0 2
30 th 98 2 0 98
 1 = ya/pernah 1= ya
mendapat 0= tidak
98 = tidak tahu 98 tahu
modifikasi = tidak
0 = tidak 98 = tidak tahu

RIWAYAT PENYAKIT KUSTA

Jika ada reaksi,

apakah ada di
wajah?

Bila Ya, Bila Ya, lama

Riwayat Bila Ya, jenis Riwayat
lama pemberian
1 Jika ya modifikasi terapi yang pemberian
modifikasi kortikosteroid
terapi diberikan kortikosteroid
terapi (dalam bulan)

0 Jika tidak

0 1 1
0 1 48
 0 1 3 mgg
0 0
0 1 bila nyeri
0 0
0 1 1 bln
0 0
0 98 98 1 36
0 1 6 bln
0 98 98 0
0 1 24 bln
0 1 24 bln
1 6 bln 1 1 mgg
0 1 3 hari, tidak teratur
0 1 2 bln
1 INH 24 bln 1 12 bln
0 0
0 1 bila nyeri
0 1 2 bln
0 0
0 1 2.5 bln
0 0
0 1 120 bulan
0 0
0 0
0 1 1 minggu
0 1 24 bln
0 1 2 hari
1 DDS 500 98 1 3 hari
Lepasan1 klofazimin 100 mg berubah4jadi
bln 50 mg 1 3 bln
0 0 98 98 1 12 bln
1 1

0 98 98 1 1 bln
1 0 1 1 bln
0 1 bila nyeri
0 0
1 DDS, lampren 12 bln 0
0 1 3 bln
0 1 12 bln
0 1 1 bln
0 1 3 bln
0 1 2 bln
0 1
0 1 1 bln
0 1 2 bln
 0 1 1 bln
0 1 3 bln
0 1
0 1 tidak rutin
1 DDS, lampren 12 bln 0
1 0 1 2 bln
0 0
0 1 2 bln
0 1 6 bln
0 1 tidak rutin
0 1 7 hari
0 1 12 bln
0 1 1 bln
0 0
0 1 3 bln

0 0
0 0
1 0 1
0 1 6 bln
0 1 48 bln
0 1 bila nyeri
0 1 6 bln
0 1 6 bln
0 1 12 bln
0 0
0 0
0 1 6 bln
0 1 3 hari beli sendiri
0 1 6 bln
0 1 6 bln
0 0 1 3 bln
0 0
0 1 6 bln
0 0
0 0
0 1 tidak tahu
0 0 1 tidak rutin
0 0

0 0
0 1 1 bln
0 1 1 minggu/beli sendiri
1 DDS, Lampren 12 bln 1 1 bln
0 0
0 1 7 hari
1 1 DDS, Lampren 24 bln 1 6 bln
0 1 1 bln
0 0
0 1 6 bln
0 1 2 bln
0 1 tidak rutin
0 0
0 1 2 bln
0 0 1 3 bln
0 1 12 bln
1 DDS+rifampisin 12 bln 1 7 hari
1 DDS+rifampisin 98 1 tidak tahu
0 1
0 1 1 bln
0 1 12 bln
1 0 1 3 bln
0 1 2 bln
0 0
0 1 1 bln
0
0 0
0 1 tidak rutin
0 0
0 1 lupa
0 0
0 1 12 bln
0 0
0 1 24
0 0 1 12 bln
0 98 98 1 1x/bulan
0 0
0 0
0 1 5 bln
0 0 0
0 1 setengah bulan
0 1 1-2 hari
0 1 3 hari
0 1 4 bln
0 0
1 DDS+lampren+Rif 12 bln 0
1 0 1 120 bln
0 0
0 1 3 hari
0 0
0 1 2 bln
0 0
1 0 1 tidak rutin
0 0
0 0
0 0
0 0
0 1 5 bln
0 1 1 bln
0 1 12 bln
1 0 1 48 bln
0 1 18 bln
0 1 12 bln
1 2-3 minggu
0 1 3 bln
0 1 1 bln
0 0
1 lampren 6 tahun 1 1 bln
0 1 12 bln
0 1 1 bln
0 0
0 0
0 1 5 th
0 1 36 bln
0 1 1 th
1 0 1 tidak rutin
0 0 1 2 bln
0 1 bila nyeri
1 12 bln
0 1 2 hari
1 0 0
0 1 24 bln
0 1 12 bln
1 0 1 3 bln
0 0
0 1 bila nyeri
1 DDS monoterapi 2 tahun 98
0 1 2 hari
0 1 3 hari
1 lampren, dapson 1bln 1 tidak rutin
0 0
0 1 < 1 bln
0 1 5 bln
0 0
0 1 1 bln
0 1 24 bln
0 0
0 0
 0 1 tidak ingat
0 0
1 monoterapi DDS 4 th 0
0 0
0 0
1 12 bln
0 1 tidak rutin
1 0 1 3 bln
0 0
0 0
0 0
0 1 72 bulan
0 1 9 bln
0 1 3 hari
0 0
0 1 12 bln
0 1 <1 bln
0 1 5 hari
0 0
0 1 1 bln
0 1 6 bln
0 0
0 1 tidak rutin
0 0
0 0
0 1 bila nyeri
0 1 bila nyeri
1 1 minggu
1 DDS 5 th 0
0 1 60 bln
0 0
1 0 1
1 0 1 17 th
0 1 3 bln
0 0
1 MDT PB 1 bln 1 3-4 bln
1 0 1 tidak rutin
0 1 6 bln
1 0 1 3 bln
0 1 1 bln
0 98
0 0
0 1 1 minggu
0 1 1 bln
1 DDS 6 bln 0
0 1 tidak rutin
 0 1 3 bln
1 0 1 12 bln
0 0
0 0
0 1 bila perlu
0 1 120 bln
1 0 0
0 0
1 0 0
0 0

0 0
0 1 beberapa bulan
0 1
1 0 1 6 bln
1 0 1 tidak rutin
0 1 3 bln
0 1 1 bln
0 0
0 1 5 hari
1 0 0
0 1 1 th
0 1 2 bln
0
0 1 8 th
0 0
0 0 1 6 bln
0 1 bila sakit
 1 = sebelum
2pengobatan
= 0-6 bulan
1= 0.25-6tab 3 = 6-12
sesudah 1 = instruksi
2= 6-10 tab 4bulan
pengobatan
= > 12 1= ya 2 = instruksi 1= ya
sesudah
bulan dan latihan
3 = > 10 tab 1= ya pengobatan 0= tidak 3 = imobilisasi 0= tidak
sesudah
98 = tidak 98 = tidak tahu 98 = tidak tahu 98 = tidak
98 = tidak tahu 0= tidak pengobatan
tahu tahu

Apakah pernah Onset

Bila iya, dosis mengalami terjadinya
Apakah pernah Jenis
kortikosteroid/ neuritis (nyeri neuritis (Jika Riwayat
mendapat fisioterapi imunisasi BCG
hari yang menjalar di siku, YA pernah
fisioterapi yang diterima
didapat: lutut, dan mata mengalami
kaki)? neuritis)

1 1 3 1 2 0
1 0 0 0
1 1 2 1 2 1
1 1 1 2 1
1 0 0 0
1 1 1 2 1
1 0 0 1
0 0 1
1 1 4 1 2 0
1 1 2 1 2 1
0 1 2
1 1 2 1 2 0
1 0 0 0
1 1 4 1 2 1
1 98 0 1
1 1 1 1 2 1
1 1 2 1 2 1
1 98 0 0
1 0 2 0 0
1 1 1 1 2 1
0 1 2 1
1 0 1 2 0
0 1 2 0
2 1 1 1 2 0
1 2 1 2 98
0 1 2 0
1 1 1 1 2 1
1 0 1 2 0
1 1 98 1 2 0
1 0 1 2 0
2 1 1 1 2 1
1 1 1 1 2 0
1 1 2 1 2 0

1 1 1 1 2 1
1 1 1 1 2 0
2 1 1 1 2 1
0 1 2 98
0 0 0
2 1 2 0 0
1 1 1 1 2 0
1 1 1 1 2 1
1 1 1 1 2 0
1 0 1 2 1
1 1 2 1 2 1
1 0 1 2 0
2 1 2 1 3 0
1 1 1 1 2 1
1 1 1 1 2 0
1 1 1 1 2 1
98 1 1 1 2 0
1 1 1 2 1
1 1 2 1 2 0
0 1 2 98
2 1 4 1 2 0
1 0 0 0
1 1 1 0 0
1 0 1 2 0
1 1 1 1 2 0
1 1 2 1 2 1
1 2 1 2 0
1 1 2 0 0

0 1 2 98
1 4 1 2 0
1 0 1 2 0
1 1 1 1 2 0
1 1 1 1 2 0
1 0 1 2 0
1 1 1 1 2,3 98
1 1 1 1 2 0
1 1 1 1 2 1
1 1 1 2 0
0 1 2 0
2 1 2 0 1
1 0 1 2,3 1
1 0 1 2 0
1 0 1 2 0
1 1 2 1 2 1
0 1 2,3 0
1 1 1 0 0
0 0 0
1 3 1 3 0
1 1 2 0 98
1 1 1 1 2,3 0
1 2 1 2 98

1 2 0 1
2 1 2 0 0
1 1 4 1 1 0
1 1 2 1 2 0
0 0 1
1 1 2 1 2 0
98 1 1 1 2 0
1 1 2 1 2 1
1 2 1 2 1
1 0 0 0
1 1 2 0 98
1 1 1 1 2 98
0 1 2,3 1
1 bersamaan
1 dengan DDS, rifampisin
1 2,3 0
1 0 1 2 1
1 1 2 1 2 0
1 1 4 1 1 0
1 1 2 1 2 98
1 1 2 1 1 0
1 1 2 0 98
2 1 2 1 2 0
1 1 1 1 2 0
1 0 1 2 0
0 1 2,3 0
1 1 1 1 2 0
1 1 2 0 0
0 0 0
1 0 0 0
1 1 1 2 0
1 1 1 1 2 98
0 1 3 1
1 1 1 0 0
1 1 1 2,3 1
1 1 1 1 3 0
1 0 0 0
1 0 1 2,3 0
1 1 1 2,3 1
0 0 0
1 0 1 2 1
1 1 1 2 98
1 1 2 2 0
1 1 1 1 2 98
1 0 0 1
1 1 1 0 0
0 1 2,3 1
0 0 98
1 1 1 1 2 0
1 2 1 2 1
1 0 0 0
1 2 0 1
1 1 4 0 0
0 1 2,3 0
1 1 1 1 2,3 0
0 1 2,3 0
0 1 2,3 0
0 1 2,3 1
0 0 98
1 0 0 0
1 1 1 1 2 98
1 1 2 0 0
1 1 1 1 2 0
1 1 2 1 2,3 1
1 0 0 1
1 1 1 1 2,3 1
1 1 1 1 2,3 0
1 1 4 1 2 0
0 1 2,3 0
1 1 1 0 0
1 1 1 1 2 0
1 1 1 1 2 0
1 4 1 2,3 0
0 0 1
1 1 3 1 2 1
1 0 1 2 0
1 1 4 0 0
1 1 1 0 0
1 1 1,2 1 2,3 1
1 1 4 1 2 0
1 0 0 1
1 1 2 1 2 0
1 2 1 2 1
1 0 1 2 0
1 0 1 2,3 0
1 1 1 1 2,3 1
0 1 2,3 98
1 1 2 1 2 0
98 1 2 0 1
1 1 1 0 98
1 1 1 0 1
1 1 3 1 2,3 0
0 1 2,3 0
1 1 1 1 3 98
1 1 4 1 1 98
0 1 2,3 0
1 1 1 1 2 0
1 0 1 2 0
1 2 1 2,3 1
0 0 0
2 1 2 1 2 0
1 1 1 3 1
0 1 2 98
1 1 1 2,3 0
0 1 2,3 1
1 1 selama pengobatan 1 2 0
2 1 1 1 2,3 1
1 0 1 2,3 0
1 1 1 2,3 1
0 1 2,3 98
0 1 2 0
1 1 1 1 2 0
2 0 1 2 0
1 1 1 1 2,3 1
1 1 1 2,3 1
1 1 1 1 2 98
1 1 2 1 2 1
1 1 1 1 2,3 1
1 2 1 2 98
1 1 3 0 98
1 1 1 1 2 98
1 1 1 2 0
1 0 1 2 0
0 1 2 1
1 2 1 2 0
1 1 2 1 2,3 1
1 0 0 98
1 0 1 2 0
0 1 2 0
1 1 2 0 0
1 1 0 98
1 1 1 1 2,3 0
1 1 98 1 2,3 1
1 1 98 1 2,3 0
1 4 1 2,3 1
1 1 4 1 2,3 0
1 1 1 1 2 0
2 1 2 1 2 0
1 1 1 1 2,3 1
1 1 1 1 2 1
1 4 0 0
1 4 1 2,3 0
1 0 1 2,3 0
1 1 1 0 0
1 4 1 2 0
1 1 2 1 2 0
98 1 1 1 2 98
1 1 2 1 2 1
0 0 0
1 2 0 0
98 1 2 1 2 0
1 0 0 0
0 1 2,3 98
1 2 1 2,3 0
1 1 1 2,3 0
1 1 1 2 1

1 2 1 2,3 1
1 1 2 1 2 98
1 1 1,2,4 1 2,3 98
1 1 2 1 2 1
3 1 2 0 0
1 0 1 2 0
1 0 0 0
0 0 98
1 1 1 1 2,3 98
0 1 1 0
1 1 1 1 2,3 1
1 0 1 2 0
0 1 2 0
1 1 1 1 2,3 0
2 3 2 3 2
1 1 1 1 2 0
98 1 2 1 2 0
 1 = belum/akan 1= ya 1= ya 1= ya
mendapat terapi
2= dalam terapi PB 2=tidak 2=tidak 2=tidak
3 = dalam terapi
MB
4 = putus obaat
5 = release from
treatment
98 = tidak tahu

Pasangan Apakah pasien

pasien memiliki Komorbiditas dan k
(MH/tidak) keturunan?

Status
1 Ya 1 Ya pengobatan kusta
saat ini

Diabetes melitus Hipertensi Tuberkulosis

0 Tidak 0 Tidak

5 2 1 2
5 2 1 2
 5 1 2 2
5 2 1 2
5 2 1 2
5 2 2 2
5 2 2 2
5 2 1 2
5 2 2 2
1 5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 1 1 2
5 2 2 2
5 2 2 1
5 2 1 2
5 2 2 2
5 2 2 2
5 2 1 2
5 2 2 2
5 2 1 2
5 2 2 2
5 2 1 2
4 2 2 2
5 2 2 2
5 2 1 2
5 2 1 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2

5 2 2 2
5 2 1 2
5 2 2 2
5 2 1 2
5 2 2 2
5 2 2 2
5 2 1 2
5 2 2 2
4 2 1 2
5 2 2 2
5 2 2 2
5 2 1 2
5 2 2 2
 5 2 2 2
5 2 2 2
5 2 1 2
1 5 2 2 2
2 2 2
5 2 2 2
5 2 1 1
5 2 2 2
5 2 1 1
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 1 2

5 2 2 2
5 2 2 2
98 1 1 2
5 1 2 2
98 2 2 2
5 2 1 2
5 2 2 2
5 ? 2 2
5 2 1 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 1
5 1 1 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
0 1 5 2 2 2
5 2 2 2

5 2 2 2
5 2 2 2
5 2 1 2
5 2 2 2
5 2 2 2
5 2 1 2
 5 1 2 2
0 5 2 1 1
5 2 1 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 1
5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
1 2 1 2
1 5 2 2 2
5 2 2 2
0 1 5 2 2 2
5 2 2 2
1 1 5 2 2 2
0 1 5 2 2 2
5 1 1 2
5 2 2 2
1 1 5 2 2 2
5 2 1 2
5 2 2 2
1 1 5 2 2 2
5 2 1 2
5 2 2 2
5 2 2 1
1 5 1 1 2
5 2 2 2
1 1 5 2 2 2
1 0 5 2 2 2
5 2 2 2
1 0 5 2 1 2
5 2 2 2
5 2 1 2
5 2 1 2
1 1 5 2 2 2
5 2 2 2
1 1 5 2 2 2
1 1 5 2 2 2
5 2 2
5 2 2 2
5 2 2 2
1 1 5 2 2 2
1 1 5 2 1 2
5 1 1 2
5 2 2 2
5 2 2 2
1 1 5 2 2 2
0 0 5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
1 1 5 2 2 2
1 1 5 2 2 2
1 1 5 1 1 2
5 2 2 2
0 1 5 2 2 1
5 2 2 2
5 2 1 2
5 1 1 2
5 2 1 2
1 1 5 2 2 2
0 1 5 2 2 1
0 1 5 2 1 2
0 1 5 2 1 2
1 1 5 2 2 2
1 1 5 2 2 2
0 1 5 2 2 2
5 2 2 2
5 1 1 2
5 2 2 2
5 2 2 2
1 1 5 2 1 2
0 1 5 2 1 2
5 2 2 2
5 2 2
1 1 5 1 1 2
5 2 2 2
1 1 5 2 2 2
5 2 2 2
1 1 5 2 2 2
 5 2 2 2
0 1 5 2 1 2
5 1 2 2
1 0 5 2 1 2
1 1 5 2 2 2
5 2 1 2
1 1 5 2 2 2
5 2 2 2
0 1 5 2 1 2
5 2 1 2
1 1 5 2 2 2
5 1 2 2
0 1 5 2 2 2
5 2 1 2
5 2 2 2
1 1 5 2 2 2
5 2 2 2
5 2 2 2
5 2 2 2
1 1 5 2 2 2
5 2 2 2
5 2 2 2
1 1 5 2 2 2
0 1 5 2 2 2
5 2 2 2
5 2 1 2
5 2 2 2
5 1 1 2
5 2 2 2
0 0 5 2 2 2
0 1 5 2 1 2
1 1 5 1 2 2
5 1 2 2
1 1 5 2 2 2
5 1 2 2
5 1 1 2
1 1 5 2 2 2
1 1 5 2 2 2
1 1 5 2 1 2
1 1 5 2 2 1
5 2 2 1
5 2 1 2
5 1 1 2
1 1 5 2 2 2
5 2 2 2
5 2 1 2
0 1 5 2 2 2
5 2 2 2
5 2 2 2
5 2 1 2
5 2 2 2
0 1 5 2 2 2
0 1 5 2 2 2
5 2 2 2
0 1 5 2 2 2
1 1 5 2 1 2

1 5 2 2 2
5 2 2 2
0 1 5 2 2 2
5 2 1 2
1 1 5 2 2 2
1 1 5 2 2 2
1 1 5 2 2 2
1 1 5 2 2 2
5 2 2 2
0 1 5 2 2 2
5 1 2 2
5 2 2 2
1 1 5 2 1 2
5 2 2 2
5 2 1 2
1 1 5 2 2 2
5 2 2 2
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak
99 = lainnya

RIWAYAT PENYAKIT KUSTA SAAT INI DAN KOMORBIDITAS

Komorbiditas dan ko-infeksi

Lainnya
HIV Hepatitis B/C Infeksi cacing Keganasan Prednison

Kode Keterangan
2 2 2 2 0 1
2 2 2 2 0 1
2 2 2 2 0 2
2 2 2 2 0 2
2 2 2 2 99 as.urat 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 99 OA 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 gastritis 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1

2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 asam urat, kolesterol 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 gastritis 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 asam urat 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 asma 2
2 2 2 1 asma 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2
2 2 2 2 2
2 2 2 2 1

2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 sakit dada kanan 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 asam urat 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2

2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 infeksi jamur di kaki 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 1 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 penyakit jantung 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 rematik 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 penyakit jantung 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 batu 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 asma 2
2 2 2 2 2
2 2 2 2 gastritis 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 penyakit jantung 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 penyakit ginjal 2
2 2 2 2 gastritis 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 batu ginjal 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 gastritis 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 gastritis 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 1 1 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2

2 2 2 2 2
2 2 1 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 1
2 2 2 2 asma 2
2 2 2 2 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak
99 = lainnya

RBIDITAS

Pengobatan lain selain MDT yang diresepkan oleh dokter

Lainnya
anti nyeri Anti depressan Antibiotik Anti hipertensi Anti diabetes

Kode
1 2 1 1 2 0
2 2 2 2 2 0
2 2 2 2 2 99
1 2 1 2 2 0
2 2 2 2 2 99
1 2 1 2 2
2 2 2 2 2 98
2 2 2 2 2
1 2 2 2 2
1 2 1 2 2
1 2 2 2 2 99
2 2 2 2 2
1 2 1 2 2
2 2 1 2 2
1 2 1 1 1
1 2 1 2 2
1 2 1 2 2
1 2 1 1 2
1 2 1 2 2
1 1 1 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2 RFT MB (1987-1992)
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2

2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 1 1
1 1 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 1 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
1 2 2 2 2
1 2 1 2 2
1 2 2 2 2 salbutamol
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 1 2 2

2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
2 2 1 2 2
2 2 2 2 2
2 2 2 1 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 2 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 1 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 2 2

2 2 2 2 2
2 2 2 2 2
1 2 1 1 2
2 2 1 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 2 2 2
2 2 1 2 2
2 2 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
2 2 1 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
1 2 2 2 2
1 2 1 2 2
1 2 1 1 2
1 2 1 2 2
2 2 2 2 2
2 2 2 1 1
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 1 2
2 2 2 1 2
1 2 1 2 2
2 2 1 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
1 2 2 2 2
1 2 2 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2 DDS
2 2 2 2 2
1 2 2 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2 DDS
1 2 1 2 2
2 2 2 2 2 DDS
2 2 2 1 2
1 2 2 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
1 2 2 2 2
1 2 1 1 2
1 2 1 2 2
1 2 1 2 2 5 macam obat jantung
1 2 2 2 2 kortison injeksi
1 2 1 2 2
1 2 1 1 1
1 2 1 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 1 2
2 2 2 2 1
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 1 2
2 2 2 2 2
1 2 2 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 1 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 1
1 2 1 2 2
2 2 2 2 2
2 2 2 1 1
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 1 2
1 2 1 1 1
1 2 1 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
2 2 2 2 2 vitamin B,C
1 2 1 1 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 1 2 2
1 2 2 2 2

2 2 2 2 2
1 2 1 2 2 ctm
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
1 2 2 2 2
1 2 1 2 2
1 2 1 2 2
1 2 1 2 2 antasida
1 2 1 2 2
1 2 1 2 1
1 2 1 2 2
1 2 1 1 aspilet
1 2 1 2 2
2 2 2 2 2
1 2 1 2 2
2 2 2 2 2
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

Keluhan pada mata

Lainnya Alis/bulu Penglihatan Penglihatan Mata kering Mata berair Mata merah
mata rontok silau buram

Keterangan
1 1 1 1 2 2
1 1 1 2 2 2
 vit B 2 1 1 2 1 2
2 2 2 2 2 2
RFT 1 2 1 2 1 1
1 1 1 2 1 2
RFT 2 2 1 2 2 2
2 1 1 2 1 1
2 2 2 1 2 2
1 1 1 1 2 2
DDS 2 2 1 1 2 2
1 2 1 2 2 1
1 2 2 1 1 1
2 1 1 1 1 1
1 1 1 1 1 1
2 2 1 1 1 1
2 1 1 2 1 2
2 2 1 1 2 2
1 1 1 2 1 1
2 1 1 2 1 1
2 2 2 2 2 2
2 2 2 2 2 2
1 2 2 1 2 1
B (1987-1992) 2 2 1 2 1 2
2 1 2 1 2 2
2 1 1 2 1 1
2 2 1 2 1 1
1 1 1 1 2 1
2 2 1 2 2 2
2 2 2 2 2 2
1 2 1 2 1 1
1 1 1 2 2 1
1 2 1 1 2 2

2 2 1 1 1 1
2 1 1 2 2 2
1 1 1 2 2 1
1 1 1 2 2 2
1 2 2 2 2 2
2 2 2 2 2 2
1 1 1 2 1 1
2 2 2 2 2 2
2 1 1 2 2 2
2 1 1 1 1 1
2 1 2 1 1 1
2 1 1 2 2 2
1 2 2 2 2 1
2 1 1 1 1 2
2 1 1 1 2 1
2 2 1 1 2 2
2 1 2 1 1 2
2 2 2 1 1 2
2 1 1 2 1 1
2 1 1 2 2 1
1 1 2 2 1 1
1 1 1 2 1 1
2 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
2 1 1 1 2 2
2 2 2 2 2 2
1 2 2 2 1 2

2 1 2 1 1 2
1 1 1 1 1 2
2 1 1 1 1 2
2 2 1 1 2 2
1 1 1 1 1 2
1 2 1 1 2 2
2 1 1 2 2 2
2 1 2 2 2 1
1 2 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 2 2 2 1 1
2 2 1 1 2 2
1 2 1 1 1 1
2 2 2 2 2 1
2 2 1 2 2 1
1 1 1 1 2 2
2 1 1 2 1 2
2 2 2 1 2 1
1 2 2 2 2 2
1 1 2 2 1 1
2 1 2 2 2 2

1 1 1 2 2 2
2 1 1 1 2
2 2 2 2 2 2
1 1 2 1 2 2
1 1 1 2 1 2
1 1 1 2 1 2
1 1 1 1 1 1
1 1 1 2 1 1
2 2 2 2 1 1
1 1 1 1 1 2
2 1 2 1 2 2
2 1 1 1 1 1
1 2 2 2 1 2
2 2 1 1 2 2
2 1 1 2 1 1
1 1 1 1 2 2
2 2 2 1 2 2
2 2 2 1 2 2
2 1 1 2 1 2
1 1 2 2 1 2
1 1 1 2 2 2
1 1 1 1 1 1
1 blind blind 2 2 1
2 2 2 2 2 2
1 1 1 1 2 2
2 2 2 1 1 2
1 2 1 1 2 1
2 2 2 2 2 2
2 2 1 2 2 2
2 1 1 2 1
2 1 1 2 2 2
1 1 1 2 1 2
2 2 2 2 1 2
1 1 1 1 1 2
1 2 2 2 1 2
2 2 2 1 1 1
2 2 1 2 1 2
2 1 2 2 2 2
2 2 1 2 2 2
1 1 1 2 1 1
1 2 1 2 1 1
2 2 1 1 2 2
1 2 1 2 2 2
1 2 2 2 1 2
2 1 1 2 1 2
1 1 1 1 1 1
1 1 1 2 1 2
1 1 1 2 1 2
1 2 1 2 1 2
2 2 1 2 2 2
1 2 2 2 1 1
2 2 1 2 1 2
 2 1 1 1 1 1
2 2 1 2 2 1
2 2 2 1 2 2
2 2 1 2 2 2
1 1 1 2 1 2
1 2 2 1 2 2
1 2 1 2 1 2
1 2 1 2 2 2
1 1 1 1 1 2
1 2 2 2 2 2
1 2 1 1 1 1
2 2 2 2 2 2
2 1 1 2 2 1
1 2 1 2 2 1
1 2 1 2 1 2
1 2 2 1 2 1
2 2 2 2 1 2
1 2 1 2 1 1

2 2 2 2 1 2
1 1 1 2 1 1
1 1 1 2 1 2
1 1 1 2 1 2
1 1 1 2 2 2
1 2 1 2 1 1
1 1 1 1 1 2
2 2 2 1 2 2
1 1 1 1 1 2
1 1 2 1 1 1
1 2 1 2 1 2
2 1 2 2 2 1
2 2 2 2 2 2
2 2 1 1 2 2
1 1 1 1 1 1
1 2 1 2 2 2
1 1 1 2 1 2
1 1 1 2 1 2
2 2 1 2 2 1
2 2 2 2 2 2
m obat jantung 2 2 1 1 2 1
tison injeksi 1 1 1 2 1 2
2 1 1 1 1 2
1 1 1 2 1 1
1 1 1 1 1 1
2 2 2 2 2 2
1 1 1 2 2 2
2 1 1 1 2 1
2 2 1 2 1 1
2 2 1 2 2 2
1 2 1 2 2 2
2 2 1 2 1 1
1 2 2 2 2 2
2 1 1 2 2 2
1 2 2 2 1 2
2 2 2 2 2 2
2 1 1 1 1 1
1 1 1 2 1 2
1 1 1 1 1 2
2 2 2 2 2 2
2 2 1 2 2 2
2 2 1 2 2 2
1 1 1 2 2 2
2 2 2 2 1 2
2 2 2 2 2 2
2 2 1 2 1 2
2 1 1 1 2 2
1 1 1 2 1 1
2 1 2 2 1 2
1 2 1 1 1 2
2 2 1 2 2 2
2 1 1 2 1 1
2 2 1 2 1 1
1 1 2 2 2 2
1 1 2 2 1 2
2 2 2 1 2 2
1 2 2 2 1 2
1 1 1 2 1 2
1 1 1 1 1 2
1 2 1 1 1 1
2 1 2 1 2 1
2 1 2 2 1 1
2 1 1 2 1 2
2 1 1 1 1 1
2 1 1 2 1 2
1 1 1 1 1 2
2 1 1 2 1 1
1 2 2 2 1 2
2 2 1 2 1 2
2 2 2 2 1 2
2 1 1 2 1 2
1 2 1 2 1 2
2 2 2 2 2 2
 1 2 1 1 1 1
1 2 1 2 2 2
1 2 2 2 1 2
2 2 2 2 1 1
2 2 1 1 2 2
1 1 1 2 1 2
2 2 2 1 2 1
2 1 1 2 2 2
1 1 1 2 2 2
2 1 1 1 1 2

1 1 1 2 2 2
1 1 1 2 2 2
2 2 1 2 2 1
1 2 1 2 2 2
2 2 1 2 2 1
1 2 1 2 2 2
1 1 1 2 1 2
2 1 1 2 1 1
obat asma 2 1 2 2 1 2
1 1 1 2 2 2
1 1 1 2 1 2
1 2 2 2 1 2
obat cacing berkala 2 1 2 1 2 2
2 1 1 2 1 2
2 2 1 1 2 2
1 1 1 1 1 2
1 1 1 2 1 2
 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 0=tidak 0=tidak

Mata tidak dapat Riwayat operasi Bercak/infiltrate/plak yang mati rasa Kontraktur lemas (clawing)
menutup rapat mata

Ya / Tidak Lokasi Ya / Tidak

2 2 1 Tungkai Bawah DS 1
2 2 0 0
2 2 1 lengan bawah, kaki 0
2 2 1 telapak tangan & kaki 1
2 2 0 0
2 2 1 kedua tangan 0
2 2 0 0
2 2 0 0
2 2 1 banyak di batang tubuh 0
2 2 1 kedua kaki 0
2 2 0 0
2 2 0 0
2 2 1 kaki kanan 0
2 2 1 pipi kanan 1
2 2 0 0
1 2 1 jari tangan 1
2 2 0 0
2 2 0 1
1 1 0 0
2 2 1 telapak tangan dan jari tangan 1
2 2 0 0
2 2 0 0
1 2 0 0
2 2 1 lengan kiri bawah 0
2 2 1 telapak tangan 1
1 2 1 telapak tangan 1
2 2 1 lengan kiri bawah 0
2 2 1 kedua tangan dan kaki 1
1 2 0 0
2 2 0 0
2 2 1 jari-jari tangan 1
2 2 0 0
2 2 0 0

1 2 0 0
1 2 1 kedua tangan dan kaki 0
2 2 0 0
2 2 1 kedua tangan dan kaki 1
2 2 0 0
2 2 1 kedua kaki, tangan kanan 0
2 2 1 kedua tangan 1
2 2 0 0
2 2 1 tangan kanan, kedua kaki 1
1 1 0 0
1 0 0
2 2 0 0
2 2 1 telapak tangan kiri 1
2 2 0 0
2 2 1 0
2 2 1 kedua kaki tangan 0
2 2 1 kedua tangan 1
2 2 0 0
2 2 0 0
1 2 0 1
2 1 1 lengan 0
1 2 0 0
2 2 1 kedua tangan, kaki 1
2 1 0 0
2 2 1 kedua tangan dan kaki 1
2 2 1 pipi, lengan, badan 0
2 2 0 0
2 2 1 tangan kanan 1

2 1 1 wajah, lengan kanan 0

2 2 0 1
1 1 0 0
2 2 0 1
2 1 1 kedua tangan dan kaki 1
2 2 0 0
2 2 1 tangan kanan 0
2 2 0 1
2 2 0 0
1 2 1 lengan kiri 1
1 1 0 0
2 2 1 kaki kiri 1
1 2 0 0
2 2 0 0
2 2 0 0
2 2 0 0
2 1 0 0
2 2 1 1
2 2 0 0
2 2 1 tangan dan kaki 0
2 2 1 wajah, lengan, tungkai 0
2 1 1 kaki kanan 0
2 2 0 0

2 2 1 wajah, lengan, tungkai 0

2 2 0 0
2 2 1 makula hiperpigmentasi 0
2 2 0
2 2 0 0
1 2 1 lengan 0
2 2 1 kedua tangan dan kaki 0
1 2 1 hidung 0
2 2 1 kedua lengan, badan 0
2 1 0 0
2 2 0 0
2 2 1 kedua tangan dan kaki 1
2 2 0 0
2 2 0 0
2 2 0 0
2 2 1 kedua tangan dan kaki 1
2 1 1 periaurikula dextra dan pipi kiri 0
2 2 1 tangan 0
1 2 1 kedua tangan dan kaki 1
2 2 0 0
2 1 1 kedua tangan dan kaki 1
2 2 1 kedua tangan dan kaki 1
2 1 1 tangan kaki 0
2 2 0 0
2 2 1 punggung, kaki, muka 0
2 2 0
2 1 0 0
2 2 0 1
2 2 0 1
2 1 1 bokong 1
2 2 1 kedua tangan dan kaki 0
2 1 1 kedua tangan dan kaki 0
2 2 1 tangan kiri, kedua kaki 0
1 2 1 kedua tangan dan kaki 0
2 2 0 0
1 2 1 kedua lengan 0
2 2 1 kedua tangan dan kaki 0
2 2 0 0
2 2 0 0
1 2 1 tangan kiri 0
2 1 1 telapak tangan, kaki 0
2 2 1 tangan kanan 0
2 2 0 0
2 2 0 0
2 2 0 0
2 2 1 kedua tangan dan kaki 0
2 2 0 0
2 2 0 0
2 1 1 kedua kaki dan tangan 0
2 2 0 0
2 2 1 jari tangan 0
2 1 0 0
2 2 1 kedua tangan dan kaki 0
2 2 0 0
2 2 1 tangan kanan 0
2 2 0 0
2 2 1 lengan dan tungkai 0
2 2 0 0
2 2 0 0
2 1 0 0
2 2 1 kedua tangan dan kaki 0
2 2 0 0
2 1 0 0
2 2 1 tangan, kaki 0
2 2 1 tungkai bawah 0
2 2 1 telapak kaki 0
2 1 0 0
2 2 0 0
2 2 1 bokong 0
2 2 1 dosum dan palmar manus 0

2 2 1 kedua kaki 0
1 2 0 0
2 2 0 0
2 2 1 tangan kiri 0
2 2 1 kaki kiri dan tangan kiri 0
2 2 1 tungkai kanan 0
2 2 0 0
2 2 telapak
1 kaki kiri dan digiti II-IV kiri manus
0
2 2 1 tungkai kanan dan kiri 0
2 2 0 0
2 2 1 kedua kaki 1
2 2 0 0
2 2 1 kedua tangan dan kaki 0
2 2 0 0
2 2 0 1
2 1 0 0
2 2 0 0
2 2 1 wajah pipi kiri 0
2 2 1 tungkai kanan 0
2 2 1 kaki kiri 0
2 1 1 telapak tangan 0
2 2 0 0
2 2 0 0
2 2 1 tangan kaki 0
2 2 0 0
2 2 0 0
2 1 0 0
2 2 0 0
2 2 0 0
2 2 1 lengan dan tungkai 1
2 2 1 kedua tangan dan kaki 0
1 1 0 1
2 1 0 1
2 2 1 kedua tangan, kaki kanan 0
2 2 0 0
2 2 1 tangan kiri 0
1 1 0 0
2 2 1 tangan kanan 0
2 2 1 kedua tangan dan kaki 0
2 2 1 tangan kanan kiri, kaki kiri 1
2 2 0 0
2 2 2 2
2 2 1 kedua tangan 0
2 2 1 paha 1
2 2 0 0
1 2 0 0
2 2 1 kedua tangan dan kaki 0
1 2 1 lengan bawah bilateral 0
1 2 1 tangan kiri kanan dan badan 0
2 2 1 kedua tangan dan kaki 0
2 2 0 0
1 2 0 1
2 2 0 0
2 2 0 0
2 1 1 tangan dan kaki 0
2 2 0 1
1 2 0 0
2 2 1 kedua tangan dan kaki 0
2 2 1 kedua kaki dan tangan 0
2 2 0 0
2 2 1 lengan
1 1 0 0
2 2 0 0
2 2 1 tangan kiri 0
2 2 punggung
1 tangan kiri, kelingking tangan kanan
1
2 2 0 0
2 1 0 0
1 2 1 lengan bilateral 0
2 2 1 siku kiri 0
1 1 1 pinggul kanan 0
2 2 1 kedua tangan dan kaki 0
2 2 0 0
2 2 0 0
2 2 1 tangan dan kaki kanan 0
2 2 0 0
2 1 0 1
2 2 0 0
2 2 0 1
2 2 1 kedua tangan dan kaki 0
2 2 0 0
2 2 0 0
2 2 1 kedua kaki 0
2 2 1 kedua tangan 0

2 2 0 0
2 2 0 0
2 2 1 tangan kanan atas. bokong 0
2 2 0 0
2 2 1 kedua tangan, kaki kiri 0
2 2 1 tangan kiri 0
2 2 1 kaki kanan, kedua tangan 0
2 2 0 1
1 2 0 0
2 2 0 0
1 2 0 0
2 2 0 0
2 2 1 lengan 0
2 2 1 badan 0
1 2 0 1
2 2 1 kedua tangan dan kaki 0
2 2 0 1
 1= ya 1= ya
0=tidak 0=tidak

IDENTIFIKASI KELUHAN SUBJEKIF

Kontraktur lemas (clawing) Kontraktur kaku tangan (stiffness) Kontraktur kaku kaki

Lokasi Ya / Tidak Lokasi Ya / Tidak

Jari Tangan & Kaki 1
1 kedua tangan 0
 1 jari IV-V DS 0
kedua tangan 0 0
1 tangan kanan 0
1 kedua tangan 0
0 0
1 tangan kanan 0
0 0
0 1
1 tangan kiri 0
1 kelingking kanan 0
0 0
tangan ki dan ka 1 tangan ki dan ka 1
0 0
jari tangan 1 jari tangan 1
1 tangan kanan dan kiri 1
palmar dekstra 1 palmar dekstra dan sinistra 0
0 0
jari tangan V kanan 1 jari tangan V kiri 0
1 tangan kanan dan kiri 1
0 0
1 tangan kanan dan kiri 0
1 0
kedua tangan 1 kedua tangan 1
digiti V kiri 1 digiti V kanan, II kiri 0
1 seluruh jari tangan 1
kedua tangan 1 kedua tangan 1
1 tangan kiri dan kanan 0
1 1
digiti V manus bilateral 1 digiti IV, V manus bilateral 0
1 tangan kiri dan kanan 0
1 palmar dekstra dan sinistra 1

1 tangan kiri dan kanan 1

1 kedua tangan 1
0 0
tangan kanan 1 tangan kanan 1
0 1
0 1
kedua tangan 1 kedua tangan 0
1 jari I-IV tangan kiri dan kanan 0
kedua tangan 1 kedua tangan 1
1 1
1 tangan kanan dan kiri 1
0 0
digiti I manus sinistra 1 digiti V manus sinistra 0
 0 0
1 kedua tangan 0
0 1
kedua kaki 1 kedua tangan 1
1 kelingking kanan
0 0
tangan kiri dan kanan 1 1
1 jari tangan 1
0 0
kedua tangan 1 kedua tangan 0
0 0
tangan kiri 1 tangan kiri 1
1 kanan 1,4,5; kiri 4,5 1
1 tangan kanan 0
kedua tangan 1 kedua tangan 0

1 tangan kanan 1
1 1
0 0
kedua tangan 1 kedua tangan 1
kedua tangan 0 1
1 tangan kiri kanan 0
0 0
tangan kanan 0 0
1 0
tangan kiri 1 tangan kanan 1
1 tangan kiri kanan 0
tangan kanan 0 0
1 1
0 0
0 0
0 1
1 tangan kiri kanan 0
tangan kiri 1 tangan kiri kanan 0
1 tangan kiri kanan 1
1 jari tangan 1
0 1
1 tangan kanan 1
1 1

0 1
1 kelingking kanan 0
1 jari tangan dan kaki 1
1 kaki kiri 0
1 tangan kanan dan kiri 0
1 tangan kanan dan kiri 0
 0 0
1 jari tangan kiri dan kanan 1
1 tangan kiri kanan 1
1 jari-jari kiri 0
0 0
tangan kanan 1 tangan kanan 1
1 tangan kiri dan kanan 1
1 1
1 tangan kanan 0
kedua tangan 0 0
1 0
1 0
tangan kanan 1 tangan kiri 1
0 1
kedua tangan 1 kedua tangan 0
kedua tangan 1 kedua tangan 1
1 tangan 1
0 1
0 0
1 tangan kanan dan kiri 1
1 jari IV tangan kanan 0
tangan kanan 1 tangan kanan 0
tangan kiri 0 1
ibu jari kiri 1 0
1 tangan kanan 1
0 0
1 0
1 kedua tangan 0
1 tangan kiri dan kanan 1
1 0
1 kedua tangan 1
1 tangan kanan 0
0 0
1 kedua tangan 0
1 1
1 tangan kanan jari III-V 1
0 1
0 0
1 1
0 0
0 0
0 1
1 kedua tangan 0
0 1
0 1
1 tangan kiri kanan 1

kedua tangan
jempol tangan kanan dan kiri
1 kedua tangan 1
1 jari V kiri kanan 1
1 1
1 tangan kiri kanan 1
1 jari V tangan kiri 0
1 jempol kiri 1
1 tangan kaki kiri kanan 1
0 0
1 kedua tangan 1
1 jari V kiri kanan 1
0 0
1 jari tangan 1
1 jari tangan V kiri 1
1 jari tangan 0
1 jari 1
1 bilateral 1
0 0
1 jari tangan kiri 0
0 0
1 jempol 1
1 kedua tangan 0
0 0
0 1
1 tangan kiri kanan 0
0 1
0 0
0 0
0 0
0 0
1 tangan kiri kanan 0
1 kedua tangan 1
1 tangan kiri kanan 1
1 tangan kiri kanan 1
0 0
1 1
0 0
0 0
0 0
1 jari tangan kaki 1
1 jari II-IV kanan 1
1 tangan kiri dan kanan 0
1 jari tangan kaki 1
1 tangan kiri 0
1 tangan kiri kanan 1
0 0
 1 tangan kiri kanan 1
1 tangan kiri 0
tangan kiri kanan 1 tangan kiri kanan 1
1 kedua tangan 1
jari V tangan kanan 0 1
jari tangan 1 jari tangan 1
1 kedua tangan 1
0 0
0 1
1 tangan kanan kiri 1
1 kedua tangan 0
1 tangan kanan kiri 0
jari tangan kiting 1 jari tangan kaku 1
1 jari seluruhnya 1
1 kiri kanan 1
1 kedua tangan 0
jari tangan 0 0
1 kiri dan kanan 1
1 jari-jari tangan bilateral 1
1 kedua tangan 1
1 jari tangan dan kaki 1
1 jari-jari 1
1 kedua tangan 0
1 tangan kiri kanan 1
1 1
1 tangan kanan 0
1 kaki kiri 0
1 tangan 1
0 0
1 tangan kiri kanan 0
1 kedua tangan 1
1 kedua tangan 1
0 1
1 clawing jari tangan 1
1 1
1 jari-jari 1
1 kedua tangan 1
jari tangan 1 jari tangan 1
1 kedua tangan 1
0 1
0 0
0 0
1 jari-jari bilateral 1
1 1
1 jari-jari tagan bilateral 1
0 0
 1 kedua tangan 0
1 tangan kiri kanan 1
kedua tangan dan kaki 0 0
0 0
tangan dan kaki 1 tangan dan kaki 0
0 0
1 tangan kanan 1
1 jari jari tangan kanan 1
0 1
0 0

1 tangan kiri kanan 1

0 0
0 0
0 0
1 kedua tangan 1
0 0
1 kedua tangan 1
jari tangan 0 0
1 seluruh jari 0
1 tangan kiri 0
1 jari-jari seluruhnya 1
1 kelingking bilateral 1
1 clawing dan kaku tangan kiri 0
1 jari-jari bilateral
kedua jari tangan dan kaki 1 kedua jari tangan dan kaki 1
1 tangan kiri 0
1 1
 1= ya 1= ya
0=tidak 0=tidak

KASI KELUHAN SUBJEKIF

Keluhan pada ekstremitas

Kontraktur kaku kaki Luka/borok Tangan lunglai (drop hand)

Lokasi Ya / Tidak Lokasi Ya / Tidak

Jari Tangan & Kaki 1 Telapak Kaki 0
0 0
 1 jari II kaki kanan 0
1 kaki kiri 0
0 0
0 0
0 0
0 0
1 telapak kaki kiri 0
kedua kaki 0 0
1 telapak kaki kanan 1
1 telapak kaki kiri 0
1 kaki kanan 0
kaki kanan 1 kaki kanan 0
0 0
jari kaki 1 tungkai kanan 0
1 telapak kaki kanan 0
0 0
0 0
1 0
kaki kanan dan kiri 0 0
0 0
0 0
1 kaki kanan 0
kaki kiri 0 0
0 1
seluruh jari kaki 1 telapak kaki kanan 0
kedua kaki 1 kaki kanan 0
1 telapak kaki kiri dan kanan 0
1 kaki kiri 0
1 tungkai bawah kiri 0
0 0
kaki kanan dan kiri 1 jari kaki kanan 0

kaki kiri dan kanna 0 0

kaki kiri 1 tangan kanan 0
0 0
kaki kiri 1 kaki kiri 0
kiri 1 kaki kanan dan kiri 0
kedua kaki 1 kaki kanan 0
0 0
0 0
kedua tangan 1 kaki kanan 0
1 tangan dan kaki 0
1 0
0 0
0 0
 1 tangan kiri 0
0 0
1 kaki kanan 0
kedua kaki 1 kedua kaki 0
1 telapak kanan 0
0 0
0 0
jari kaki 1 tungkai kanan 1
0 0
1 kaki kanan, tangan kanan 0
1 kaki kiri 0
kedua kaki 1 kaki kiri 0
kanan 1,2,5; kiri 1 1 telapak kaki kanan dan kir 0
1 kaki kanan 0
1 kaki kiri 0

kedua kaki 1 kedua telapak kaki 0

1 0
1 tangan kiri, kaki kanan 1
kaki kiri 1 kaki kiri 0
kedua kaki 1 kedua kaki 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
deformitas 1 telapak kaki 0
0 0
0 0
kelingking kaki kiri 0 1
0 1
0 0
kaki kiri 1 telapak kaki kanan 0
jari kaki 1 kaki 0
kaki kiri 1 kaki kiri 0
kedua kaki 1 kaki kanan 0
1 kaki kanan 0

jari kaki kiri 1 kaki kanan, amputasi 0

0 0
jari kaki 1 telapak tangan dan kaki 1
1 kaki kanan 0
0 0
0 0
 0 0
1 dorsum pedis dibawah digiti pedis I 0
kaki kiri kanan 1 telapak kiri 0
0 0
0 0
kaki kanan 0 0
kaki kiri dan kanan 1 telapak kaki kiri 0
0 0
1 kaki kanan 1
1 kedua kaki 0
1 palmar manus dextra 0
0 0
kedua kaki 1 kedua kaki 0
kaki kiri 0 0
0 0
kedua kaki 1 kedua kaki 0
kedua kaki 1 telapak kaki kanan 0
jari IV, V kaki kanan 1 kaki kanan 0
1 kaki kiri 0
kaki kiri 1 lengan kanan 0
0 0
0 0
1 telapak kaki kiri 0
0 0
kaki kiri 1 kaki kanan 0
0 0
0 0
1 kaki kiri 0
kaki kanan 1 kaki kanan 0
1 tumit kiri 0
kaki kanan 1 kaki kiri 0
0 0
1 kaki kiri 0
1 kaki kanan 0
1 sekitar tumit 0
jari tengah kaki kanan 1 kaki kiri 1
kaki kiri kanan 1 telapak kaki kiri 1
1 telapak kaki kanan 0
kaki kiri 1 kaki kiri 0
0 0
0 0
kaki kiri kanan 1 kaki kiri 1
1 kaki kiri 0
jari II kaki kanan 0 0
jari kaki 1 telapak kaki 0
kaki kiri kanan 1 kaki kanan 0
 kaki kanan 1 kaki kiri 1
kaki kiri 1 kaki kiri 0
kaki kiri 1 kaki kiri 0
kaki kanan 1 kaki kanan 0
1 telapak kaki kiri 0
jempol kiri dan kanan 1 kaki kiri 0
tangan kaki kiri kanan 1 kaki kanan 1
0 0
kaki kanan 0 0
kaki kiri kanan 0 0
1 kaki kiri 0
jari kaki 1 dorsum manus kiri 0
1 0
0 0
jari 1 kaki kiri 1
bilateral 1 kaki kiri bawah 0
1 kaki kanan 0
0 0

0 0
1 di tangan kiri kanan 0
0 0
0 1
kaki kiri 0 0
1 telapak kaki kanan 0
kaki kiri dan kanan 0 0
0 0
0 0
0 0
0 0
1 kaki kiri 1
kedua kaki 1 kaki kiri 1
kaki kiri 1 luka kaki kanan 0
kaki kiri kanan 0 0
0 0
kaki kiri dan kanan 1 kaki kiri dan kanan 0
1 kaki kiri 0
1 luka post amputasi berjamur 0
1 kaki kiri 0
jari kaki 1 telapak kaki kanan 0
jari V kanan 0 0
1 telapak kaki kiri 1
jari kaki 1 punggung kaki kiri 0
0 0
kaki kanan 1 kaki kanan 0
0 0
 kaki kiri kanan 1 kaki kanan 0
0 0
kaki kiri 1 tangan kiri dan kanan, telapak kaki kiri 0
kedua kaki 1 kaki kiri 0
kaki kanan 1 kaki kanan 0
jari kaki 0 0
kedua kaki 0 1
0 0
kaki kanan 1 kaki kanan 0
kaki kanan kiri 1 kaki kiri 0
0 0
1 kaki kanan 0
jari kaki 1 telapak kaki kanan 0
jari seluruhnya 0 1
kiri kanan 1 kaki kiri kanan 0
1 kaki kanan 0
1 luka post op amputasi 0
kiri dan kanan 1 telapak kaki kiri dan kanan 0
jari-jari bilateral 1 kaki kanan 0
kedua kaki 1 kaki kiri dan kanan 0
jari tangan dan kaki 1 tangan kanan dan kiri 0
jari-jari 1 kaki kanan telapak 0
1 kaki kiri 0
kaki kiri 1 tangan kiri, kaki kiri 0
0 0
1 kaki kanan 0
2 kaki kiri 0
kaki 1 kaki kanan 0
1 kaki kanan 0
1 kaki kiri kanan 0
kedua kaki 0 0
kaki kanan 1 kaki kanan 0
kaki kiri kanan 0 0
0 0
0 0
jari-jari kanan 1 kaki kanan 0
kaki kiri 0 0
kaki kanan 1 kaki kanan 0
kedua kaki 1 kaki kanan 0
kaki kiri 1 kaki kiri, tangan kanan 0
1pergelangan kaki kiri dan telapak kaki kiri0
1 lutut kanan 0
jari-jari bilateral 1 telapak kaki kiri 1
kedua kaki 1 kaki kanan 0
jari-jari bilateral 1 kaki kanan 0
0 0
 0 0
kaki kiri kanan 1 kaki kiri kanan 0
1 kaki kanan 0
0 0
1 tangan dan kaki 0
0 0
kaki kanan 1 telapak kaki kanan 0
jari-jari tangan kanan 1 telapak kaki kiri dan kanan 0
kaki kiri 0 0
0 0

kaki kiri kanan 1 telapak kanan, tangan kiri 0

0 0
1 kering, sembuh 0
0 0
kedua kaki 0 0
0 0
kedua kaki 0 0
0 0
1 lutut kiri lecet 0
1 kaki kanan 0
1 kaki kiri 1
jari kaki 0 0
1 telapak kaki kiri 0
1 tangan kanan, kaki kiri 0
kedua jari tangan dan kaki 1 kedua jari tangan dan kaki 0
0 0
1 0
 1= ya 1= ya
0=tidak 0=tidak

Tangan lunglai (drop hand) Kaki semper (drop foot) Hilang jari-jari atau anggota gerak

Lokasi Ya / Tidak Lokasi Ya / Tidak

0 0
0 0
 0 1
1 kedua kaki 0
0 0
0 1
0 0
0 0
0 0
0 0
tangan kiri 0 0
0 1
0 0
0 1
0 0
1 1
1 kaki kiri 0
1
0 1
0 0
1 kaki kiri 0
0 0
0 1
0 0
0 1
pergelangan kiri 0 0
1 tungkai kanan
0 0
0 0
0 0
0 1
0 0
0 1

0 0
1 kaki kanan 1
0 0
0 1
0 1
0 0
0 0
0 1
0 1
0 1
0 1
0 0
0 0
 0 1
0 1
0 1
1 kedua kaki 0
0 0
0 0
0 1
pergelangan tangan kanan 0 0
0 0
0 1
0 0
0 0
0 1
0 1
0 1

1 kaki kiri, setelah operasi 1

1 kanan 1
tangan kanan 1 kaki kiri, setelah operasi 0
0 1
0 0
0 0
0 0
0 0
0 1
0 1
0 0
1 kaki kiri 0
0 0
0 0
0 0
tangan kanan 0 1
tangan kiri 1 kaki kanan 0
0 0
0 0
1 pergelangan kaki kanan 0
0 0
0 1
0 0

0 1
0 0
pergelangan tangan kiri 0 1
0 0
0 1
0 1
 0 1
0 1
0 1
0 0
0 0
0 0
0 0
0 0
tangan kanan 1 kaki kanan 0
0 1
0 0
0 0
0 0
0 0
0 1
0 0
0 1
1 kaki kanan 0
0 0
0 1
0 0
0 0
1 kaki kiri 1
0 0
0 1
0 1
1 kaki kanan 1
1 kedua kaki 1
0 0
1 kanan 1
1 kaki kiri 1
0 0
0 0
0 1
0 1
1 bilateral 1
tangan kiri kanan 0 0
0 0
0 1
0 1
0 0
tangan kanan 0 0
0 1
0 0
0 0
0 0
 tangan kiri 0 1
1 kaki kiri 1
0 0
0 1
0 0
0 1
kiri kanan 0 0
0 0
0 1
0 0
0 0
0 1
1 post-op pedis bilateral 1
0 0
tangan kiri 0 0
0 1
0 0
0 0

1 kaki kiri 1
1 kaki kiri 1
0 0
kiri dan kanan 1 kiri dan kanan 0
0
0 1
0 0
0 0
0 0
0 0
0 1
tangan kanan 1 kaki kanan 0
tangan kanan 0 0
0 1
0 0
0 0
0 1
0 1
1 tungkai kanan, sudah amputasi 0
1 kaki kiri 1
0 0
0 0
tangan kiri 1 kaki kanan 0
9 0
1 kaki kiri 0
1 kaki kanan 1
0 0
 0 0
0 1
1 kaki kanan 1
0 1
1 kaki kanan 1
0 0
tangan kiri 1 kaki kanan 0
0 1
1 kaki kanan 1
0 0
0 0
0 0
1 kaki kiri 0
1 0
0 1
0 0
0 0
0 1
1 kanan 1
0 1
0 0
0 1
1 kaki kanan 1
0 1
0 1
1 kaki kanan 1
0 0
0 0
sudah operasi 1 1
0 0
0 1
0 1
0 0
0 0
0 1
0 1
0 1
0 0
1 kaki kiri 0
0 1
0 1
0 1
bilateral 1 kiri 1
0 1
0 0
1 kedua kaki 0
 1 kaki kanan 0
0 0
0 1
0 0
1 kedua kaki 1
0 1
1 kaki kanan 0
1 riwayat operasi, perbaikan 1
0 0
0 1

0 0
0 0
0 0
0 0
1 kaki kiri 0
0 0
0 0
0 0
1 kiri 1
0 0
kaki kanan 1 kaki kiri, betis ke bawah 1
0 0
1 0
0 0
0 1
0 0
0 1
 1= ya 1= ya 1= ya
0=tidak 2=tidak 2=tidak

Bercak/m

Hilang jari-jari atau anggota gerak Susutnya jari-jari atau anggota gerak

Dahi Pipi kanan

Lokasi Ya / Tidak Lokasi
1 Jari tangan & kaki 2 2
0 2 2
 kaki S amputasi bawah lutut 0 2 2
1 kedua kaki 2 2
1 tangan kanan, jari kaki kiri kanan 2 2
tangan kanan 0 2 2
0 2 2
0 2 2
1 jari kaki kiri 1 1
0 2 2
1 kaki kiri kanan 2 2
amputasi kaki kanan 1 kaki kiri 2 2
0 1 1
kaki kanan 1 kaki kanan 2 1
0 2 2
jari tangan V kiri dan jari kaki 1 jari tangan II kiri dan jari tangan V kanan2 2
1 kaki kanan dan kiri 2 2
palmar dekstra 1 palmar dekstra, kelingking dan telunjuk 2 2
tangan kanann dan kiri, kaki kiri 0 2 2
1 jari tangan V kanan dan hipotenar 2 2
1 tangan kanan dan kiri, kaki kanan 2 2
0 2 2
kaki kanan dan kiri 0
0 2 2
kaki kanan 1 tangan keduanya, kaki kiri 2 1
1 jari tangan 2 2
1 jari kaki kanan dan jari kedua tangan 2 2
1 kedua tangan 2 2
1 jari-jari tangan kiri dan kanan 2 2
1 2 2
digiti III pedis dextra 1 2 2
1 tangan kiri dan kanan, kaki kiri dan kanan2 2
kaki kiri dan kanan 1 kaki kiri dan kanan 2 2

0 2 2
tangan kiri, kaki kanan 1 kaki kiri 2 2
0 2 2
kedua kaki 1 kaki kiri
kaki kiri 1 kaki kiri 2 2
1 kedua kaki 2 2
1 kedua tangan 2 1
kaki kiri amputasi 1 jari-jari tangan kanan dan kiri 2 2
kedua kaki 1 2 2
tangan dan kaki bilateral 1 tangan dan kaki bilateral 2 2
kaki kiri 1 kaki kiri 2 2
0 2 2
1 digiti V manus sinistra 2 2
jari tangan kiri dan kanan 1 jari tangan kiri dan kanan 2 2
kedua kaki 1 kedua tangan 2 2
kaki kanan 0 2 2
1 kedua kaki 2 2
0 2 2
0 2 1
jari kaki kiri dan kanan 1 jari kaki kiri dan kanan 2 2
1 jari tangan dan jari kaki 2 2
0 2 2
kedua kaki 0 2 2
0 2 2
0 2 2
kaki kanan dan kiri 1 kaki kanan jari 1 2 2
kaki kanan 0 2 2
kaki kanan 0 2 2

kaki kiri dan kanan 0 2 2

kaki luka bakar 1 kanan 2 2
1 tangan kiri, kaki kanan 2 2
kaki kanan 1 kedua tangan 2 2
0 2 2
0 2 2
0 2 1
1jari II kaki kanan, operasi jari II-IV tangan kiri
2 2
jari tangan kiri dan kanan 1jari tangan kiri dan kanan dan kaki kiri kanan 2 2
kaki kanan 1 kaki kanan 2 2
1 kaki kiri kanan 2 2
0 2 2
1 seluruh jari tangan dan kaki 2 2
0 2 2
0 2 2
amputasi kaki kanan 0 2 2
1 kaki kanan 2 2
0 2 2
1 kaki kanan 2 1
1 jari kaki 2 2
0 2 2
tangan kiri 1 kedua kaki 2 1
1 kaki kanan kiri 2 2

jari kaki V kiri 1 jari kaki I-IV kiri 2 2

0 2 2
digiti I pedis sinistra 1 digiti manus dan digiti pedis V dextra 2 1
0 2 2
kaki kiri dan kanan 1 tangan kiri dan kanan 2 2
digiti I manus 1 digiti manus 2 1
 kedua tangan dan kaki 0 2 2
jari tangan kiri dan kaki 1 tangan 2 2
jari manis kiri 1 kaki kiri kanan 2 2
tangan
1 kiri dan kanan jari V, kaki kiri dan kanan
2 2
0 2 2
0 2 2
1 tangan kanan kaki kiri 2 2
1 jari tangan bilateral 2 1
1 kaki kanan 2 2
1 kedua tangan 2 2
digiti 1V manus dextra dan sinistra, digiti II manus2sinistra 1
1 2 2
0 2 2
0 2 2
tangan kanan 0 2 2
1 kedua kaki 2 1
digiti manus V bilateral 1 2 2
0 2 2
0 2 2
1 2 2
0 2 2
0 2 2
kaki kiri dan kanan 1 kaki kiri dan kanan 2 2
1 jari-jari tangan 2 2
kaki kanan 1 kaki kanan 2 2
kedua tangan dan kaki 0 2 2
kedua kaki 1 kaki kanan 2 2
kaki kanan 1 kedua tangan 2 2
1 jari V tangan kanan, kaki kiri dan kanan 2 2
amputasi 1 jari kaki 0 2 1
kaki kiri 1 kedua tangan 2 1
0 2 2
0 2 2
kedua tangan 1 kedua kaki 2 2
digiti 3 manus sinistra 1 jari tangan dan kaki 2 2
digiti IV pedis dextra 0 2 2
0 2 2
0 2 2
kaki kiri kelingking 1 kaki dan tangan kiri 2 2
kedua tangan, kaki kanan 1 tangan kiri 2 2
0 2 2
1 kaki krii kanan 2 2
kedua tangan dan kaki 0
1 jari II tangan kiri 2 2
1 jari kaki kiri IV-V 2 2
0 2 2
 kaki kiri 1 tangan kanan 2 2
kaki kanan 1 tangan kiri kanan, kaki kiri 2 2
1 jari tangan dan kaki kiri 2 2
kaki kiri 1 tangan kiri kanan, kaki kanan 2 2
0 2 2
jari-jari tangan dan kaki 0 2 2
0 2 2
0 2 2
kaki kanan 0 2 2
0 2 2
1 tangan kiri kanan, kaki kiri kanan 1 1
digiti pedis 1 dextra 1 jari tangan dan kaki
jari kaki 0 2 2
1 jari tangan 2 2
1 jari tangan dan kaki 2 2
1 kelingking kiri kanan 2 1
0 2 2
1 digiti manus V kiri 2 2
2 2
kaki kanan 0 2 2
jari II-V ki ka, amputasi kaki kanan lutut ke bawah
0 2 1
0 2 2
0 1 1
1 tangan kiri 2 2
jari V kaki kiri 0 2 2
0 2 2
0 2 2
1 jari tangan dan kaki 2 2
0 2 2
kaki kanan 0 2 2
1 tangan kiri kanan, kaki kiri kanan 2 1
1 tangan kiri 2 2
amputasi kaki kanan 1 tangan kiri kanan dan kaki kiri 2 2
0 2 2
0 2 2
jari kaki kiri dan kanan 1 jari kaki kiri dan kanan 2 2
jari-jari tangan dan kaki 0 2 2
1 jari kaki kiri 2 2
kedua tangan, kedua kaki 0 2 2
1 jari tangan dan kaki 2 2
0 2 2
1 kedua kaki dan kedua tangan 2 2
1 jari-jari kaki 1 1
0 2 2
amputasi kaki kiri, jari kaki kanan 90 2 2
0 2 2
 1 kaki kanan kiri 2 2
amputasi kaki kiri kanan 0 2 2
jari-jari kaki kanan 1 jari-jari tangan kiri kanan, jari-jari kaki kiri2 2
kedua kaki dan tangan 1 kedua kaki 2 2
kaki kanan 0 2 2
1 jari tangan 2 2
0 2 2
kaki kiri 0 2 2
kaki kanan 0 2 2
1 tangan kanan kiri, kaki kanan kiri 2 1
0 2 2
0
0 2 2
0 2 2
telunjuk tangan kanan 1 jari-jari tangan kiri kanan 1 1
1 kedua kaki 2 2
1 jari tangan dan kaki 2 2
telunjuk tangan kanan, jempol kaki kanan0 2 2
kelingking kanan 0 2 2
kaki kiri 0 2 2
1 seluruh jari tangan dan kaki
jari manis kaki kanan 0 2 2
kaki kiri 0 2 2
amputasi kaki kanan 1 tangan kiri 2 2
1 2 2
amputasi kaki kiri 1 kaki kanan 2 2
0 2 2
1 jari tangan dan kaki 2 1
1 2 2
1 tangan kiri kanan, kaki kiri kanan 2 2
kaki kiri 0 1 1
kaki kiri 0 2 2
0 2 2
1 jari tangan dan kaki 2 2
betis kanan ke bawah jari
1 2 dan 3 manus dextra, 3 dan 4 manus sinistra 2 2
lutut kaki kiri ke bawah 1 jari II-III manus dextra 2 2
tangan kiri 0 2 2
1 jari tangan IV-V kiri 2 2
0 2 2
kaki kanan 1 tanga kiri kanan 2 2
jari V pedis sinistra 0 2 2
lutut kanan ke bawah 0 2 2
jempol dan kelingking kaki kiri kanan 1 jari-jari tangan kiri dan kanan 2 2
tangan kanan 0 1 1
0 2 1
0 2 2
 0
1 tangan kiri kanan, kaki kiri kanan 2 2
tangan 1 tangan 2 2
0 2 2
tangan kanan 1 jari tangan kiri dan kanan 2 2
kedua tangan 0 1 1
1 kaki kanan dan kiri 2 2
jempol kaki kiir 1 jari-jari tangan kiri 2 2
0 2 2
kedua kaki 1 tangan kiri 2 2

1 kaki kiri kanan 2 2

0 2 2
0 2 2
0 2 2
0 2 2
0 1 1
0 2 2
1 jari tangan 2 2
kaki kanan 1 jari-jari tangan 2 2
0 2 2
kaki kanan 1 jari II-IV manus sin, jari I manus dex 2 2
0 2 2
1 jari III tangan kiri 2 2
1 jari V pedis sinistra, jari III-IV pedis dextra2 2
kedua jari tangan dan kaki 1 kedua jari tangan dan kaki 2 2
0 2 2
1 2 2
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

Inspeksi pada wajah

Bercak/makula Bintil/nodulus

Pipi kiri Dagu Lainnya Dahi Pipi kanan Pipi kiri

2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 alis bulu rontok 2 2 2
1 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 hidung 2 2 2
2 2 2 1 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2

2 2 2 2 2
1 1 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 lipodistrofi multipel 2 2 2
2 2 2 2 2

2 2 2 2 2
2 2 2 2 2
2 2 2 2 2

2 2 2 2 2
2 2 2 2 2
1 1 hidung, alis madarosis
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2

2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2

2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 1 2 2 2
1 2 hidung 2 2 2
2 2 hidung hipopigmentasi 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 madarosis +/+ 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
1 1 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
flap alis, madarosis+, tanam alis+/+
2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2

2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
2 2 2 2 2
1 1 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 1 semua wajah, difus 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 1 2 2 2
2 2 2 2 2

2 2 2 2 2
2 2 2 2 2
1 1 2 2 2
2 2 2 2 2
1 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
madarosis +
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 madarosis + 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 1 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 anestesi pipi kiri 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 1 2 2 2
1 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 1 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2

2 2 2 2 2
2 2 madarosis alis kanan 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 1 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak

dulus

Bercak/Makula bintil/nodulus
Dagu Lainnya

Ya/Tidak Keterangan Ya/Tidak

2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 1
2 2 2
2 2 2
2 2 2
2 1 lengan kanan atas 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2

2 2 2
2 2 2
2 2 2
2 1 makula hipopigmentasi lengan atas 2
2 2 2
2 2 2
2 2 2
2 1 makula hipopigmentasi, numuler 2
2 1makula-plak hipopigmentasi bilateral2
2 2 2

2
2 2 2
2 2 2

2 2 2
2 2 2
2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 lengan bawah kiri 2
2 1 lengan kanan bawah 2
2 1 lengan atas bilateral 2
2 2 2
2 1 hiperpigmentasi 2
2 2 2
2 1 siku kanan 2
2 2 2
2 2 2
2 2 2
2 2 2
2 hipopigmentasi
1 paska inflamasi ec DKI bawang
2
2 2 2
2 2 2
2 0 0
2 2 2

2 2 2
2 2 2
2 1 2
2 1makula hiperpigmentasi kanan dan kiri1
2 1 hipopigmentasi 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 makula
1 hipopigmentasi pergelangan tangan 2 kiri
2 2 2
2 2 2
2 2 2
2 2 2
2 1 2
2 2 2
2 2 2
2 2 2
2 1 hiperpigmentasi 2
2 2 2

2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 makula
1 plak hiperpigmentasi lengan kanan
2
2 1 makula hipo-hiperpigmentasi 2
2 2 2
2 1 hipopigmentasi 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 makula
1 hiperpigmentasi, numular lengan bawah
2
2 2 2
2 1 hiperpigmentasi 2
2 2 2
2 1 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 hipopigmentasi 2
2 2 2
2 2 2
2 1 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 hiperpigmentasi kiri dan kanan 2
2 1 hiperpigmentasi 2
2 2 2
2 2 2
2 1 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 hiperpigmentasi 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 2
2
2 1 hiperpigmentasi 2
2 2 2
2 1 2

2 2 2
2 2 2
2 2 2
2 1 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 PV 2
2 2
2 2 2
2 1 lengan kanan 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 hiperpigmentasi 2
2 2 2
2 2 2
2 2 2
2 1 2
2 1 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 hiperpigmentasi 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
1 2
2 2 2
2 2 2
2 1 2
2 2 2
1 2
2 1 2
2 1 2
2 2 2
1 hiperpigmentasi bilateral 2
2 1 hipo dan hiperpigmentasi 2
2 2 2
2 2 2
2 2 2
2
2 2 2
2 1 2
2 2 2
2 1 kedua lengan 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 hipopigmentasi 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 lengan kiri 2
2 2 2
2 1 2
2 1 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 2
2 2 2
2 2 2
2 1 kedua lengan 2
2 2 2

2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 lengan kiri 2
2 2 2
2 2 2
2 2 2
 1= ya 1= ya
2=tidak 2=tidak

Inspeksi pada tangan

bintil/nodulus jaringan parut kulit keriput

Keterangan Ya/Tidak Keterangan Ya/Tidak Keterangan

2 1
1 1
 2 2
1 2
2 2
1 di buku/jari tangan 1 punggung tangan
2 2
2 1
2 2 2
kiri, bekas operasi 1 kiri, kanan 2
1 telapak tangan ka dan ki 1 tangan ka dan ki
1 1
2 2
1 lengan kiri bawah 2
2 2
1 punggung tangan kanan 1 tangan kanan dan kiri
2 1 kering
1 tangan kanan 1
1 2
2 1
1 terkena panas 2
1 punggung tangan kanan dan kiri 2

1 1
1luka bekas operasi, bekas skin graft2
1 sekitar buku jari 2
2 2
1 1
1 lengan dan tangan kanan 1
2 1
2 1
1 skar atrofik-eutrofik pada lengan 1 lengan bilateral
2 2

1 jari dan telapak tangan kanan kiri1 kanan dan kiri

1 riwayat pasang pen (skin graft) 2
1 1

2 2
2 2
1 1 kanan kiri
1 jari-jari tangan kanan 2
1
1 2
1 2
1pasca operasi tangan kiri dan kanan1
1 pasca ENL memerah 2
 2 2
1 bekas luka 2
1 punggung tangan kanan dan kiri 2
1 dextra 1 bilateral
2 1
2 2
2 2
2 1 kedua lengan
2 2
1 1
2 2
2 2
2 2
1 tangan kiri 1 tangan kanan dan kiri
2 2

2 2
1 operasi 2
1 1
kanan dan kiri 1 2
2 2
1 pasca KLL 2
2 2
1 pasca operasi 2
2 2
2 2
1 punggung tangan kanan kiri 1 tangan kanan dan kiri
2 2
2 2
2 2
2 1
2 2
2 2
2 1
2 1
1 2
1 lengan, tungkai 1 wajah
1 2
2 1

2 2
2 2
pasca operasi release
1 nervus ulnaris dextra dan drop
2 hand sinistra
1 tangan kanan 2
1 kanan dan kiri
2 2
1 2
2 1 lengan kanan dan kiri
2 2
2 2
2 2
2 1 dextra
1 1
2 2
2 2
1 kiri kanan 1 kiri
2 1
2 2
2 2
2 2
1 1
1 1
2 1
1 biopsi 2
2 2
1 tangan kanan kiri
2 2
1 palmar dextra 2
2 2
1 jari-jari tangan kanan kiri 1
2 2
1 1
2 2
1 2
1 bekas nodus 1 punggung tangan
2 2
1 1
2 2
2 1 usia
2 2
2 1 usia
1 kanan dan kiri 1 kanan dan kiri
2 2
2 1 usia tua
2 2
1 bekas luka bakar 2
1 siku 1 lengan bawah
1 1
1 bilateral 1 bilateral
1 bilateral 1 dorsum manus bilateral
2 1
2 2
1 dorsum manus bilateral 1 dorsum manus bilateral
2 2
1 sekitar jari 1
1 bekas luka 2
1 1
2 1 usia
1 1

2 2
2 2
1 1

2 1 kiri kanan
2 2
2 2
1 1
2 2
2 1
2 1 kedua lengan
2 2
1 1
1 bilateral, dorsum manus 2
2 1
2 1 usia
1 dorsum manus kiri kanan
2 1 dorsum manus bilateral
2 2
2 2
2 1
2 1 bilateral
1 1
2 2
2 1
2 2
2 2
2 1 geriatri
1 skar eutrofik pada tangan 2
2 2
1 2
2 2
2 2
2 2
1 1
2 1
2 2
2 2
2 2
2 2
1 bekas luka 2
2 1
2 2
2 1 dorsum manus sin
1 1
2 2
2 2
1 bekas luka 2
1 jari III tangan kanan 1
2 1
2 1 xerotic
1 telapak tangan kiri 1
1 1
2 2
2 2
1 1
1 1
2 1 xerotic
1 dorsum manus bilateral 2
1 2
1 buku jari kanan dan kiri
2 2
2 2

2 1
1 1
2 1 bekas lesi
2 1
1 1
2 2
2 1 bilateral
2 2
2 1 dorsum manus bilateral
1 kedua jari tangan 2
1 1
2 2
1 1
1 di proksimal phalang I-X 1 di proksimal phalang I-X
2 2
2 2
2 2
1 1
1 1
2 2
1 jari tangan 2
1 bekas luka 1
2 2
2 2
1 1
2 2
1 dorsum manus dextra
2 1
2 2

2 1
2 2
2 2
2 2
2 1 dorsum manus bilateral
2 1
2 1
1 kanan kiri 1 kanan
2 2
1 bekas luka 2
1 eutofik kedua jari tangan 2
2 1 dorsum manus bilateral
2 2
2 2
2 2
1 skar ENL 2
1 bekas luka 1 geriatri
 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak

Inspeksi pada

a tangan

penebalan kulit ulkus ekstremitas BCG scar

Ya/Tidak Keterangan Ya/Tidak Keterangan Ya/Tidak

2 2 1
2 2 1
1 telapak tangan & kaki 2 2
2 2
2 2 1
2 2 1
2 2 2
2 2 1
1 tangan kiri 2 2
2 2 2
1 jari tangan ka dan ki 2 1
1 kanan dan kiri 1
2 2 2
2 2 1
2 2 1
1 tangan kanan dan kiri 2 2
1 telapak tangan kiri 2 2
1 2 2
1 1 telapak kanan dan kiri 1
1 2 1
1 digiti V dextra 2
2 2 1

1 1punggung tangan kiri, jari 4 tangan kanan

2
2 2 2
2 2 1
1digiti manus I dan II, interdigiti I dan II 2 1
2 2 1
1 telapak kaki kiri dan kanan 1 telapak tangan kiri dan kanan 2
1 2 2
2 1 maleolus lateral dextra 1
1 bekas luka pada lengan kanan bawah 2 2
1 kaki kiri 1 kaki kanan dan kiri 2

1 2 1
1 punggung tangan kanan 1 telapak kanan 2
1 1 2

2 1 2
2 2 1
2 2 2
1 telapak tangan 2 2
2 2 2
1 1 2
1 2 1
2 2 2
2 2 2
2 1 dorsum manus sinistra 2
1 bekas luka 2 2
1 punggung jari tangan kanan 2 1
1 bilateral 1 dextra 1
1 kaki kanan 1
2 2
2 2 1
2 2 2
2 2 2
1 1 1
2 2 1
1 1 digiti II manus dextra 2
1 telapak tangan kanan kiri 1 jari 1 tangan kanan 2
1 buku-buku jari tangan kiri 2 2
2 2 2

2 2 2
2 2 2
1 1 2
2 2 1
2 2 2
2 2 2
2 2 2
2 2 2
2 2 1
2 2 2
1 jari tangan kanan kiri 1 jari tangan kanan kiri 2
2 2 1
2 2 2
2 2 2
1 telapak tangan kiri 2 2
2 2 1
2 2 2
2 2 2
1 buku jari 2 2
2 1 telapak kaki kanan dan kiri 2
1 kaki 2 2
1 1 2
1 2 1

2 2 2
2 2 2
1 palmar manus 2 2
2 2 2
1 2 2
1 bekas luka pada dorsum manus 2 2
1 kiri kanan 1 dextra 1
2 2 1
2 2 1
2 2 2
2 2 2
1 palmar dextra 2 2
1 1 jari III tangan kiri 1
2 2 2
2 2 2
1 kiri 1
1 callus 1 digiti I manus dextra, dursum manus 2
1 telapak tangan 2 2
1 tangan dan kaki 2 2
2 2 2
1 1 1
1 1 telapak tangan kiri 2
2 2 2
2 2 2
2 2 2
1
2 2 2
2 2 2
2 2 2
2 1 dig I manus dextra 1
2 1 1
1 1 buku-buku jari tangan kanan 1
2 2 2
1 1 1
1 2 2
1 2 1
1 2 1
2 2 2
2 2 2
1 1 2
2 2 2
1 kanan dan kiri 2
2 2 1
1 telapak tangan 2 2
2 2 2
1 2 2
2 1 telapak tangan kiri 2
1 2 2
2 1 dextra 2
2 2 2
2 2 1
2 2 2
2 2 2
2 1 kedua telapak tangan 2
2 2 2
1 1 lepuh kena penggorengan 1
2 2 2
2 2 2
1 1 1

2 2 1
2 2 2
1 2 1

2 2 2
1 geriatri 2 2
2 2 2
1 2 1
2 2 2
2 2 1
2 1 kedua tangan 2
2 2 2
1 1 1
2 2 2
1 2 1
1 kalus 2 1
1 ujung jari I-X 2 2
2 2 2
2 2 2
2 2 2
2 2 1
2 2 2
1 1 1
2 2 2
2 2 2
2 2 2
2 2 2
1 telapak tangan 2 2
2 2 2
2 2 2
1 1 2
2 1 jari tangan kanan 2
2 2 2
2 2 2
1 2 1
2 2 2
2 2 2
2 2 2
2 2 2
2 1
1 telapak tangan 1 tangan kiri kanan 2
1 2 2
2 2 2
1 2
2 2 1
2 2 2
2 2 1
1 2 2
1 jari I tangan kiri 2 1
1 2 2
1 tangan kanan 2 2
2 2 1
1 2 1
2 2 2
2 2 1
1 2 1
1 1 1
1 2 2
1 numular 1 multipel, dorsum manus 1
2 2 2
1 jari III-V kanan 2 2
2 1 kedua tangan 2
1 2 2
1
2 2 2
1 1 2
2 2 2
2 2 2
1 2 1
2 2 2
2 2
2 2 1
1 dorsum, buku jari kiri kanan 2 2
2 2 2
2 2 2
2 2 2
1 1 1
1 di proksimal phalang I-X 1 di proksimal phalang I-X
2 2 2
2 2 2
2 2 1
1 1
1 2 1
2 2 2
 2 1 tangan kanan 1
2 2 2
2 2 2
2 1 kedua jari tangan 2
1 2 2
2 2 2
2 2 2
2 2 2
2 1 jari tangan kiri 2

2 1 2
2 2 2
2 2 1
1 buku jari kiri 2 2
2 2 1
2 2 1
2 2 1
1 kanan kiri 2 2
2 2 2
1 kalus 1 kena rokok 1
2 2 2
us bilateral 2 2
2 2 2
1 1 2
1 jari tangan kiri 2 2
2 2 2
1 tangan 2 2
 1= ya 1= ya
2=tidak 2=tidak

Inspeksi pada ekstremitas

BCG scar Bercak/makula bintil/nodulus

Keterangan Ya/Tidak Keterangan Ya/Tidak

2 2
2 2
 2 2
2 2
2 2
2 2
r tidak ada tapi pernah disuntik BCG di lengan
2 kanan 2
2 2
2 2
1 hiperpigmentasi 2
deltoid kanan 2 2
2 2
deltoid kiri 2 2
lengan kiri atas 2 2
2 2
2 2
2 2
2 2
2 2
2 2
mengaku BCG saat kecil tapi tidak ditemukan2scar 2
deltoid kiri 2

1 1
1 hiperpigmentasi tungkai bawah kiri 2
2 2
lengan kiri atas 2 2
2 2
2 2
2 2
lengan kiri atas 1 makula hipopigmentasi 2
1 makula-plak hipopigmentasi 2
2 2

2 2
1 hiperpigmentasi 2
2 2

2 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
 2 2
1 hiperpigmentasi 2
deltoid kiri 2 2
dextra 1 hiperpigmentasi bilateral 2
2 2
1 pinggul dan lutut 2
2 2
1 makula plak hipo hiperpigmentasi 2
2 2
amputasi amputasi
1 hiperpigmentasi 2
1 hiperpigmentasi 2
2 2
2 2
2 2

2 2
2 2
1 2
skar 2 2
1 hiperpigmentasi 2
2 2
2 2
2 2
2 2
2 2
1 2
2 2
2 2
2 2
2 2
2 2
2
1 2
1 2
2 2
2 2
1 hiperpigmentasi 2
2 2

2 2
2 2
1 hiperpigmentasi tungkai bawah 2
2 2
amputasi amputasi
makula
1 hipopigmentasi tungkai bawah dextra
2
 1 hiperpigmentasi 2
2 2
1 hiperpigmentasi 2
1 hiperpigmentasi 2
2 2
2 2
1 2
2 2
2 2
kiri 1 hiperpigmentasi kiri kanan 2
1 makula hiperpigmentasi 2
2 2
2 2
2 2
2 2
1 2
1 1
1 hiperpigmentasi 2
2 2
2 2
2 2
2 2
2 2
deltoid kiri 2 2
lengan kanan atas 2 2
deltoid kanan 1 LSK 1
makula
1 hiperpigmentasi tungkai bawah kanan
2
1 hiperpigmentasi 2
1 hiperpigmentasi 2
deltoid kiri 1 2
1 2
2 2
2 2
2 2
2 2
2 2
1 hiperpigmentasi 2
2 2
2 2
1 hiperpigmentasi 2
2 2
1 denum 2

2 2
1 1
2 2

riwayat positif, skar tidak ada
deltoid kiri
1 hiperpigmentasi bilateral 2
2 2
2 2
1 hiperpigmentasi 2
1 2
1 tungkai kanan 2
1 2
1 hiperpigmentasi 2
2 2
1 2
1 hiperpigmentasi, dorsum 2
2 2
2 2
1 2
2 2
2 2
2 2
1 hiperpigmentasi sin 2
1 tinea, PV 2
2 2
1 2
2 2
1 hiperpigmentasi 2
2 2
2 2
2 2
1 tarsal bilateral 2
2 2
1 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
1 2
2 2
2 2
2 2
1 1
1 2
2 2
2 2
 2 2
2 2
2 2
2 2
2 2
2 2
1 2
2 2
dextra 2 2
1 hiperpigmentasi 2
lengan atas kiri 2 2
1 2
2 2
2 2
deltoid kiri 1 2
2 2
1 2
1 2
1 2
2 2
lengan atas kanan 1 hiper dan hipopigmentasi 2
1 hipopigmentasi 2
2 2
2 2
2 2
2 2
1 hiperpigmentasi sinistra 2
1 2
2 2
1 kedua tungkai 2
1 2
2 2
1 hiperpigmentasi 2
2 2
2 2
2 2
2 2
2 2
1 hiperpigmentasi 2
2 2
2 2
2 2
lengan kiri atas 2 2
1 2
2 2
2 2
 2 2
1 hiperpigmentasi 2
2 2
2 2
1 2
2 2
1 hiperpigmentasi 2
1 kedua tungkai 2
2 2

2 2
2 2
2 2
2 2
scar lengan atas kiri 2 2
2 2
1 kedua tungkai 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
 1= ya 1= ya
2=tidak 2=tidak

Inspeksi pada kaki

bintil/nodulus jaringan parut kulit keriput

Keterangan Ya/Tidak Keterangan Ya/Tidak

2 2
2 1
2 1
2 2
2
1 jari kaki 2
2 2
2 1
2 2
1 kiri, kanan 1
1 kaki ka dan ki 1
2 1
1 punggung kaki kanan dan kiri 1
2 2
2 2
1 2
2 1
2 1
1
2 2
1 2
1 punggung kaki kanan dan kiri 2

1 1
1 bekas luka, telapak kaki kiri 2
2 2
1 parut pasca operasi drop foot 2
1 1
2 1
1 1
1 skar eutrofik tungkai bawah bilateral 1
1 tungkai bawah bilateral 1
2

1 1
1 tungkai kiri 2
1 1

2 2
1 1
1 kanan kiri 1
2 2
1 2
1 2
1 kaki kiri 1
2 1
2 2
 1 amputasi 2
1 bekas luka 2
1 jari 4 dan 5 kaki kanan 2
1 dextra 1
2 2
2 2
2 2
1 periulkus pada tungkai bawah 1
2 2
amputasi amputasi
1 1
1 2
1 kaki kiri 2
1 1
2 2

2 2
1 kaki kiri luka bakar 2
1 1
1 dorsum pedis sinistra 2
1 2
2 2
2 2
2 2
2 2
1 2
1 1
2 2
1 pasca operasi knee replacement 2
2 2
2 1
1 kaki kiri 2
1 kaki kanan 2
2 1
1 2
1 kaki kanan dan kiri
2 2
1 1
2 1

2 2
2 2
1 pasca trauma infraknee dextra 2
2 2
amputasi amputasi
2 2
1 1
2 1
1 2
1 kalus di digiti III pedis sinistra 1
2 2
2 2
1 1
2 2
2 2
1 kanan 1
2 1
2 2
2 1
1 1
2 1
1 1
1 2
1 2
1 bekas luka bakar 1
1 kaki kanan 1
2 2
2 2
1 2
2 1
2 2
1 1
2 2
1 1
1 2
1 1
1 1
2 2
2 2
2 1
2 1
1 1
1 1
2 1
2 2
1 bekas luka 2
1 1
1 1

2 1
1 1
2 2
2 2
2 2
1 dorsum pedis sinistra 1
1 1
1 1
2 1
1 1

1 1
2 2
1 1

2 2
2 2
2 2
1 1
2 2
1 1
2 1
1 sinistra, dorsum pedis 1
1 1
2 1
1 1
2 1
2 1
2 1
1 skar eutrofik pada lutut kiri 2
2 2
2 1
2 1
1 1
2 2
2 1
2 1
2 2
1 tungkai 1/3 bawah kiri dan kanan 1
2 2
2 2
1 2
2 2
2 2
2 2
1 1
2 1
2 2
2 2
2 2
2 2
1 bekas luka 2
2 1
2 2
2 2
1 1
2 2
1 2
1 2
2 1
1 1
2 1
2 1
1 1
2 2
2 2
1 1
1 1
2 1
1 dorsum pedis bilateral 2
1 2
2 2
2 2
2 2
2 2
1 sinistra 1
1 1
1 bekas luka 2
2 1
1 1
2 2
1 dorsum pedis 1
2 2
2 2
1 amputasi below knee kiri 2
1 2
2 2
1 1
2 2
2 2
2 2
2 2
1 1
1 1
2 2
2 2
1 1
2 2
2 2
1 1
2 2
1 dorsum pedis bilateral 1
2 1
2 2

2 1
2 2
1 1
2 2
2 1
1 1
2 1
1 1
2 2
1 2
2 2
2 2
2 2
1 tungkai kanan 2
2 2
1 skar ENL 2
2 2
 1= ya 1= ya
2=tidak 2=tidak

KULIT

ada kaki

kulit keriput penebalan kulit ulkus ekstremitas

Keterangan Ya/Tidak Keterangan Ya/Tidak

2 1
1 2
 kering di bag.depan 2 1
1 plantar & dorsum pedis 1
1 2
2 2
2 2
kaki kanan dan kiri 1 kaki kanan dan kiri 1
2 1
1 dan penipisan 2
kaki ka dan ki 1 kaki ka dan ki 1
1 1
kedua kaki 1 telapak kaki kanan dan kiri 1
1 telapak kaki kanan dan kiri 1
2 2
1 1
kering keriput di kedua tungkai 1 telapak kaki kanan dan kiri 1
1 tumit kann dan kiri 2
1 telapak kanan dan kiri 1
1 2
1 1
1 maleolus medial kanan dan kiri 2

1 1
2 2
1 1
2 1
1 1
kering 1 telapak kaki kiri dan kanan 1
1 1
xerotic 2 1
tungkai bawah bilateral 1 tungkai bawah bilateral 2
1 1

1 1
1 maleolus lateral 2
1 2

1 kanan dan kiri 1

1 1
kanan kiri 2 2
1 telapak kaki kanan 2
1 2
1 telapak kaki kiri 1
2 1
1 tumit kiri 2
2 2
 2 2
2 1
1 ibu jari dan maleolus 1
bilateral 1 plantar bilateral 1
1 palmar dekstra 1
2 2
1 telapak kaki kiri 1
kedua tungkai 1 kedua tungkai bawah 1
2 2
amputasi amputasi
kering 1 1
1 kalus di maleolus lateral 1
1 kaki kanan dan kiri 1
2 1
2 1

1 kedua telapak kaki 1

1 telapak kiri dan kanan 2
1 1
1 plantar sinistra 1
2 1
2 2
2 2
1 kaki kanan 2
2 1
1 2
1 1
2 2
2 1
2 2
1 1
2 2
2
telapak kaki kiri 1 xerosis (+) 2
1 1
1 1
1 1
kering 1 1
2 1

2 2
2 2
2 1
2 2
amputasi amputasi
1 plantar pedis 2
 1 plantar dekstra 1
1 plantar pedis sinistra dan dextra 1
1 1
1 2
2 2
2 2
1 1
2 2
2 1
kanan 1 plantar kanan, dorsum kiri 1
xerotic, keriput 1 2
1 telapak kaki 2
1 kaki kiri dan kanan 1
1 2
1 2
1 1
2 1
1 kalus sekitar ulkus 1
1 1
1 kaki kanan 2
1 dorsum pedis 2
2 2
1 telapak kaki kiri dan kanan 1
kedua tungkai 1 maleolus medial kanan 2
2 1
1 1
2 1
1 1
1 1
1 1
1 1
2 2
1 telapak kaki kiri 1
2 1
usia 2 1
2 1
1 1
kering 1 telapak kaki 1
2 1
1 2
kedua tungkai 2 2
1 2
1
bilateral 2 1
1 1
2 1
 2 1
2 1
dorsum pedis sinistra 1 plantar pedis sinistra 1
kering 1 1
1 1
usia 2 1
1 1

kering 1 2
2 2
1 1

1 kiri kanan 1
1 2
2 2
1 1
2 1
2 2
kedua tungkai 2 1
dextra 1 bilateral 2
1 1
dorsum pedis bilateral 2 2
1 2
usia 1 kalus 1
dorsum pedis kiri kanan 1 dorsum pedis kiri kanan 1
dorsum manus bilateral 2 2
2 2
2 2
2 1
dorsum pedis bilateral 2 2
1 1
2 1
2 1
geriatri 2 2
2 2
geriatri 1 telapak kaki 1
2 1
2 2
1 1
2 1
2 2
geriatri
1 1
2 2
1 1
2 2
 2 1
2 2
2 1
1 1
2 1
1 jari-jari kaki 2
1 1
2 2
1 1
1 1
dorsum pedis bilateral 2 2
2 1
xerotic 1 1
1 2
1 1
2 1
2 2
1 1
1 1
xerotic 1 1
1 dorsum pedis/lateral 1
1 1
2 1
2 1
2 2
2 2
sinistra dextra 1 sinistra 1
1 1
1 1
2 1
1 1
2 1
sinistra dextra 1 sinistra dextra 2
2 2
1 sinistra, ujung jari 2
2 1
1 2
2 1
kering 1 1
1 dorsum pedis 1
2 1
2 2
2 1
1 1
1 1
2 2
 2 1
1 1
2 2
2 1
1 2
2 1
dorsum pedis bilateral 2 1
1 1
2 1

2 1
2 2
1 1
2 2
2 2
1 2
1 2
kiri kanan 1 kiri kanan 1
2 2
1 1
2 1
1 dorsum pedis bilateral 2
2 2
1 1
2 2
2 2
2 1
 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

IT

Pemeriksaan
Pem
mata

Lagoftalmus Atrofi otot Kitting

ulkus ekstremitas
OD OS dextra sinistra dextra

Keterangan
Tumit D & S 2 2 2 2 1
2 2 2 2 1
 jari kaki II kanan, diameter 1 cm 2 2 1 1 1
dorsum pedis D, plantar pedis S 2 2 1 1 1

2 2 1 1 1
2 2 2 2 2
kaki kanan 1 1 1
telapak kaki kiri 2 2 2 2 2
2 2 1
kaki ka dan ki 2 2 1 1 1
kanan kaki palsu, kiri ulkus tumit kiri 2 2 1
ri, area maleolus medial sampai telapak kaki kanan (tertutup
2 perban) 2 2
telapak kaki kiri 2 2 1 1 1
2 2 2 2 2
kaki kanan dan kiri 2 2 1 1 1
kaki kanan sisi lateral 2 2 2 1 2
2 2 2 2 1
tumit kiri 1 1 1 1 1
2 2 2 2 2
2 2 1 1 1
2 2 2 2 1

tungkai bawah kanan, telapak kaki kanan dan 2 kiri 2 1 1 1

2 2 1 1 1
plantar sinistra, kaki kanan amputasi 1 1 1 1 1
ulkus soliter telapak kaki kiri 2 2 1 1 1

telapak kaki kiri dan kanan 2 1 1 1 1

jari I kaki kiri 2 2 1 1 1
soliter, maleolus lateral dextra 2 2 1 1 1
2 2 2 2 1
kaki kanan 2 2 2 2 2

kaki kanan 1 1 1 1 1
1 1 1 1
2 2 2 1 1

2 2 2 2 2
telapak kaki kanan 2 2 2 2 2
2 2 2 2 1
2 2 1 1 1
2 2 1 1 1
telapak kaki kiri 1 1 2 1 1
kaki kir 2 1 2 2 1
2 2 1 1 1
2 2 1 1 1
 2 2 1 1 2
mata kaki kanan 2 2 1 1 1
tumit kanan 2 2 2 2 1
plantar bilateral 2 2 1 1 1
palmar dekstra 2 2 1
2 2 2 2 2
telapak kaki kiri 2 2 1 1 1
tungkai bawah 2 2 1 1 1
2 2 2 2 2
2 2 1 1 1
dorsum pedis sinistra 2 2 2 2 2
ulkus dari plantar menembus ke dorsum pedis
2 2 1
kaki kanan dan kiri 2 2 1 1 1
telapak kaki kanan 2 2 1 1 1
kaki kiri 2 2 2 1 2

kedua telapak kaki 1 1 1 1 1

2 2 1 1 1
1 2 1 1 1
plantar sinistra 2 2 1 1 1
bekas operasi 2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
1 1 1
sisi lateral kaki kanan 2 2 1 1 1
1 1 1 1
1 1 1 1 1
2 2 2 2 2
telapak kaki tangan 2 2 1 1 1
2 2 2 2 2
punggung kaki kanan 1 2 1 1 2
2 2 2 2 1
2 1 2 2 1
2 2 1 1 1
2 2 1 1 1
kaki kanan dan kiri 2 2 2 22 1
kaki kiri 2 2 2 2 2
2 2 2 2 1
kaki kanan 2 2 2 2 1

2 2 1 1 2
2 2 2 2 1
telapak kaki dan tangan kiri 2 2 1 1 1
2 2 1
2 2 2 2 1
2 2 1 2 1
 2 1 1 1 1
jari I-V kanan 2 2 1 1 1
2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
2 2 2 2 1
telapak kaki kiri 2 1 1 1 1
2 2 1 1 1
kedua kaki 2 2 1 2 1
plantar kanan, dorsum kiri 2 2 1 1 1
2 2 1 1 1
2 2 1 1 1
kaki kiri dan kanan 1 1 1 1 2
2 2 2 2 2
2 2 1 1 1
2 2 1 2 1
kaki kanan kiri 1
plantar pedis dextra 2 2 2 2 2
luka di punggung kaki kiri 2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
2 2 1 2 1
telapak kaki kiri 2 2 1 1 1
2 2 1 1 1
kedua telapak kaki 2 2 2 2 1
punggung kaki kanan 2 2 2 2 2
telapak kaki kanan 1 2 2 1 2
2 1 1 1 1
2 1 2 1
telapak kaki kiri 2 1 1 1 2
1 2 1 1 1
2 2 1 2 2
nyeri 2 2 2 2 2
1 1 2 2 1
1 2 2 2 1
kiri 2 2 1 2 1
2 2 2 2 1
jari kelingking kaki kiri, jempol kaki kanan
2 2 2 2 2
2 2 2 2 1
2 2 1 2 1
2 2 2 2 2
2 2 1 1 1
2 2 1 1 2
dorsum pedis sinistra 2 2 2 2 1
2 2 2 2 2
telapak kaki kanan 2 1 1 1 1
plantar dextra. jari i sinistra 2 2 1 1 1
tungkai bawah kaki kiri 2 2 1 1 1
plantar pedis sinistra 2 2 2 2 2
1 1 1
2 2 1 1 1
telapak kaki kiri 2 2 2 2 1
2 2 1 1 1
2 2 1 1 1
2 2 1 1 1
2 2 2 2 1
1 1

plantar pedis 2 2 1 1 2
2 2 1 1 1
2 2 2 2 1
2 2 1 1 1
tungkai kanan 2 2 2 2 2
2 2 1 1 1
kedua telapak kaki 2 2 1 1 1
2 2 2 1 2
maleolus med kaki kiri 1 2 1 1 1
2 2 1 1 1
2 2 1 1 2
2 2 2 1 2
plantar dextra 2 2 1 1 1
2 2 2 2 2
2 2 2 2 2
2 2 1 1 1
mata kaki kanan 2 2 2 2 2
2 2 2 2 2
2 2 1 1 1
telapak kaki kiri 2 2 1 1
jempol kiri 2 2 2 2 1
2 2 1 1 1
2 2 2 2 2
luka terkena sandal 2 2 1 1 1
telapak kaki kiri 2 2 1 1 1
2 2 1 2 2
2 1 1 1 1
telapak kaki kanan 2 2 1 1 1
2 2 2 2 1
2 2 1 1 1
2 2 1 1 1
2 2 2 2 2
2 2 2 2 1
2 2 2 2 2
 telapak kaki kanan 2 2 1 1 1
2 2 2 2 2
telapak kaki kiri 2 2 1 1 1
telapak kaki kiri 2 2 2 2 1
tungkai bawah dan kaki kanan 2 1 2 2 1
2 2 1 1 1
2 2 1 1 1
2 2 2 2 2
2 2 2 2 2
1 1 1 1 1
2 2 2 2 1
luka DM 2 2 2 2 1
telapak kaki kiri 2 2 2 2 1
2 2 2 2 1
1 1 1
tumit kanan 2 2 2 2 1
2 2 2 2 2
2 2 1 1 1
1 1 1 1 1
kedua telapak kaki 2 2 2 2 1
bilateral 2 2 2 2 1
1 1 1 1 1
kaki kanan 2 2 1 1 1
kedua kaki 2 2 1 1 1
2 2 1 1 1
2 2 2 2 2
sinistra 2 2 2 2 2
2 2 1 1 1
kaki kanan 2 2 1 1 1
2 1 2 2 1
2 2 1 1 1
telapak kaki kanan 2 2 2 2 2
2 2 1 1 2
2 2 2
2 1 1 1 1
telapak kaki kanan 2 2 1 2 1
2 2 1 1 1
ibu jari kaki kanan 2 2 1 1 1
2 2 1 1 1
sinistra: multipel 2 2 2 2 1
telapak, punggung kaki kiri 1 2 2 2 2
2 2 2 2 2
kedua tungkai 2 2 1 1 1
2 2 1 1 1
2 2 1 1 1
2 2 2 2 2
kedua telapak kaki 2 2 1 1 1
2 2 1 1 1
2 2 2 2 2
kedua jari kaki 2 2 1 1 1
1 1 1 1 1
telapak kaki kanan 2 2 2 2 1
bilateral 2 2 1 1 1
kedua telapak kaki 2 2 2 2 2
telapak kaki kiri 2 2 2 2 2

telapak kaki kanan 2 2 2 2 1

2 2 2 2 2
2 2 1 1 2
2 2 2 2 2
2 2 2 2 1
2 2 1
2 2 2 2 1
kiri 2 1 2 2 1
1 2 1 1 1
2 2 2 2 2
telapak kaki kiri 2 2 1 1 1
2 2 1 1 1
2 2 2 1 2
kedua tungkai 2 2 2 2 1
2 2 2 2 1
2 2 2 2 2
kedua kaki 2 2 1 2 1
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

Pemeriksaan tangan

Kitting Lunglai Ulkus Pemendekan jari

sinistra dextra sinistra dextra sinistra dextra sinistra

1 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 2 2
1 2 2 2 2 1 1

1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 1 1
2 2 1 2 2 2 2
1 2 2 2 2 2 2
1 2 2 2 2 1 1
2 1 1 2 2 1 1
1 1 2 2 2 2 2
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 2 2
2 2 2 2 2 1 2
1 1 1 2 2 1 1
1 2 2 2 2 2 2
1 2 2 1 2 1 1
2 1 2 2 2 2 2

1 2 2 1 1 1 1
1 1 1 2 2 1 1
1 2 1 2 2 1 1
1 1 1 2 2 1 1

1 2 2 1 1 1 1
1 2 2 2 2 1 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2

1 2 2 2 2 1 1
1 1 2 1 2 1 1
1 2 2 2 2 1 1

2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 1 1 1
1 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 2 2 1 1
2 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 2 2
1 2 2 1 2 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 2 2 1 1
1 1 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 1 2 2 2
1 2 2 1 2 2 2
1 2 2 2 2 1 2
1 2 2 2 2 2 2

2 2 2 2 2 2 2
1 1 1 2 2 2 2
2 2 1 2 1
1 2 2 2 2 1 1
1 2 2 2 2 2 2
1 2 2 1 1 2 2
2 2 2 2 2 2 2
1 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 1 2 2 1 1
1 2 2 1 1 1 1
2 2 2 2 2 2 2
1 2 2 2 2 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 2 2 2 2
1 2 2 2 2 2 2
1 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 1 2 1 1
1 2 2 2 2 2 2

2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 1 2 1 2 1
1 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 1 2 1 1
1 2 1 2 2 1 1
1 2 2 2 2 2 2
1 2 2 2 2 1 1
2 2 2 2 2 2 2
2 1 2 2 2 1 2
1 2 2 1 1 1 1
1 2 2 2 2 2 1
2 1 2 1 2 1 2
1 2 1 2 1 1 1
1 2 2 1 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 1 1 1 1
1 2 2 1 2 1 1
1 2 2 1 1 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 1 2 1 1
2 2 2 2 2 2 2
2 2 2 2 2 1 2
1 2 2 2 2 2 1
1 2 2 1 2 2 2
2 2 2 2 2 1 2
2 2 2 1 2 1 1
1 2 2 2 2 2 2
1 1 1 2 2 1 1
2 2 2 2 2 1 2
2 2 2 2 2 2 2
1 2 2 2 2 1 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 1 1 1 1
1 2 2 2 2 1 1
2 2 2 1 2 1 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 2 2 1 1
2 2 2 2 2 1 1
2 2 2 2 1 2 2
1 2 2 2 2 2 2
2 2 2 2 2 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 1 2 2 1 1
1 2 2 1 1 1 1
2 2 2 2 2 1 1
1 2 2 1 1 1 1
1 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 1 1 1 1
1 2 2 2 2 2 2
1 2 2 2 2 2 2
1 2 2 2 2 2 2
2 2 2 2

2 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 1 2 2 2 2
1 2 2 1 1 1 1
2 1 2 2 2 2
1 2 2 1 2 1 1
1 2 2 2 2 2 2
2 2 2 2 2 1 1
1 2 2 2 2 2 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 1 1 1 1 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 1 1 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 2 2
1 2 2 2 2 1 1
2 2 2 2 2 2 2
2 2 2 1 1 1 1
1 2 2 1 1 1 1
1 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 2 1
1 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 1 1 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 1
2 2 2 2 2 1 2
1 2 2 2 2 1 1
1 2 2 1 2 1 1
1 2 2 2 2 1 1
1 2 2 1 1 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 1 1 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 2 1 1 1
1 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 2 1
2 2 2 2 2 2 2
2 1 1 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 2 1 2
1 2 2 2 2 2 1
1 2 2 2 2 1 1
1 2 2 2 2 2 2
1 2 2 1 1 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 1 1 2 2 1 1
1 2 2 1 1 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 1 2 1 1
1 2 1 2 2 1 1
1 2 2 2 2 2 2
1 2 2 1 1 1 1
1 2 2 2 2 1 1
2 2 2 2 2 1 2
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 2 1

1 2 2 2 1 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 2 2 2 2 2 2
2 2 2 2
2 2 2 2 2 1 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 1 1
1 2 2 2 2 1 1
1 2 2 2 1 2 1
1 2 2 1 1 1 1
1 2 2 2 2 1 1
2 2 2 2 2 2 2
1 2 2 2 2 2 1
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

PEMERIKSAAN KLINIS KULIT

Pemeriksaan kaki

Atrofi otot Kitting Lunglai Ulkus

dextra sinistra dextra sinistra dextra sinistra dextra

2 2 2 2 2 2 2
 2 amputasi 2 amputasi 2 amputasi 2
2 2 1 1 2 2 1

1 1 2 1 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 1
2 2 2 2 2 2 2
1 1 1 1 1 1 2
1 1 1 1 1 1 1

1 1 1 2 2 2 1
1 1 1 1 1 2 1
1 2 1 2 2 2 2
1 1 1 1 2 2 1
1 1 1 1 2 2 1
2 2 2 2 2 2 2
2 2 2
2 2 2 2 2 2 2
1 1 1 1 2 1 1
2 2 1 2 2 2 2

1 1 2 2 2 2 1
amputasi 1 amputasi 1 amputasi 1 amputasi
amputasi 1 amputasi 1 amputasi 2 amputasi
1 1 1 2 1 2 1

2 2 2 2 2 2 1
2 2 2 2 2 2 2
2 2 1 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 1

1 1 1 1 2 2 1
amputasi 1 amputasi 1 amputasi 1 amputasi
1 1 1 1 2 2 2

2 2 2 2 2 2 1
2 2 1 2 2 2 1
2 2 2 2 2 2 2
2 amputasi 2 amputasi 2 amputasi 2
1 1 1 1 2 2 2
1 1 1 1 2 2 1
kaki palsu 2 kaki palsu 1 kaki palsu 2 kaki palsu
1 1 1 1 2 2 2
2 2 2 2 2 2 2
amputasi 1 amputasi 2 amputasi 2 amputasi
amputasi 1 amputasi amputasi amputasi 2 amputasi
2 2 1 2 2 2 1
1 1 1 1 1 1 1
2 2 2 2 2 2 1
2 2 2 2 2 2 2
1 1 1 1 2 2 2
1 1 1 1 1 1 1
2 2 2 2 2 2 2
amputasi amputasi amputasi amputasi amputasi amputasi amputasi
2 2 2 2 2 2 2
2 2 1 2 2 2 2
1 1 2 2 2 2 1
1 1 1 1 2 2 1
amputasi 2 amputasi 2 amputasi 2 amputasi

1 1 1 1 2 1 1
2 2 1 2 1 2
1 1 1 1 2 2 1
amputasi 1 amputasi 1 amputasi 2 amputasi
2 2 1 1 2 2 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 1
1 1 1 1 1 1 2
1 1 1 1 2 2 2
2 2 2 2 2 2 2
2 2 1 1 2 2 1
2 2 2 2 2 2 2
1 1 2 2 2 2 1
amputasi 2 amputasi amputasi amputasi
2 2 1 1 2 2 1
1 1 1 1 1 1 2
1 1 1 1 2 2 1
2 1 1 1 2 2 1
2 2 2 1 2 2
2 2 1 1 2 2 1
2 2 1 1 2 2 1

2 2 2
2 2 2 2 2 2 2
1 1 1 1 2 2 1
2 2 2 2 2 2 2
amputasi amputasi amputasi amputasi amputasi amputasi amputasi
2 2 2 2 2 2 2
1 amputasi 1 amputasi 1 amputasi 1
1 1 1 1 2 2 1
2 2 1 1 2 2 2
2 2 1 1 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 1 1 1 2 1 2
1 1 1 1 2 2 2
2 2 1 2 2 1
1 1 1 1 1 1 1
1 1 1 1 2 2 2
2 1 2 2 2 2 2
2 2 1 1 2 1 1
2 2 2 1 2 2 2

1 1 1 1 2 2 1
2 2 2 2 2 2 2
2 2 2 2 1 2 1
2 2 2 2 2 2 2
2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
1 1 1 1 2 1 2
1 1 2 2 2 2 2
2 2 1 1 2 1
2 2 2 2 2 2 2
1 1 2 1
2 2 1 1 1 1 2
2 2 1 1 2 2 1
1 1 1 1 1 2 2
1 1 1 1 2 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 1 1 2 2 1
2 2 1 2 2 2 2
1 1 2 2 2
2 2 1 1 1 1 2
2 2 2 2 2 2 1
2 2 1 1 2 2 2
2 2 2 2 2 2 2
1 1 1 2 2 2
1 1 1 1 2 2 2
1 1 2 2 2 2 2
2 2 2 1 2 2 2
1 1 1 1 2 2 1
1 1 1 1 2 2 1
 2 2 2 2 2 2 1
amputasi 1 amputasi 1 amputasi 2 amputasi
amputasi 2 amputasi 2 amputasi 2 amputasi
1 amputasi 1 amputasi 2 amputasi 1
1 1 1 1 2 2 1
2 2 1 1 2 2 2
1 1 1 1 2 2 1
1 1 2 2 2 2 2
2 2 1 1 2 2 2
2 2 1 1 2 2 2
1 1 2 2 2

1 1 2 2 1 1 1
2 2 2 2 2 2 2
2 2 1 1 2 2 2
1 1 1 1 2
2 2 2 2 2 2 1
1 1 1 1 2 2 2
1 1 1 1 2 2 1
2 post op semper 1 1 2 1 2
protese 1 protese 2 protese 1 protese
2 2 2 2 2 2 2
1 1 1 1 2 2 2
2 1 2
1 1 2 2 2 2 1
2 2 2 2 1 1 2
2 2 2 2 2 amputasi 2
1 2 1 2 2 2 2
2 2 2 1 2 2 1
2 2 2 2 2 2 2
1 1 1 1 2 2 2
2 2 1 1 2 1
2 1 2
2 2 2 2 2 2 2
2 2 2 2 2 1 2
1 1 1 1 2 2 1
1 1 2 1 1 2 2
amputasi 1 amputasi 1 amputasi 2 amputasi
amputasi 2 amputasi 1 amputasi 1 amputasi
1 1 1 1 2 2 1
2 2 2 2 2 2 2
1 1 1 1 1 2 2
1 1 1 1 2 2 1
2 2 1 1 2 2 2
2 amputasi 1 amputasi 2 amputasi 2
2 2 2 2 2 2 2
 1 1 1 1 2 2 1

amputasi 1 amputasi 1 amputasi 2 amputasi

2 2 1 1 2 2 2
1 2 2 2 1 2 1
2 2 2 2 2 2 2
1 1 1 1 1 2 1
2 amputasi 2 amputasi 2 amputasi 2
1 2 1 2 1 2 1
2 2 1 1 1 1 2
2 2 2 2 2 2 2
2 2 2 2 2 2 1
1 1 2 1 1
2 2 1 2 2 2
1 1 1 1 2 2 1
2 2 1 1 2 2 1
2 tidak dinilai 2 tidak dinilai 2 tidak dinilai 2
1 1 1 1 2 2 1
1 1 1 1 1 2 1
2 2 1 1 2 2 1
2 2 1 1 2 2 1
2 1 2 2 2 2 1
2 amputasi 2 amputasi 1 amputasi 1
amputasi 1 amputasi 1 amputasi 2 1
1 1 1 1 2 2
2 2 1 kaki palsu 2 kaki palsu 2
1 1 1 1 2 2 2
1 amputasi 1 amputasi 1 amputasi 1
1 1 1 1 1 1 1
2 2 1 1 2 2 1
1 amputasi 1 amputasi 2 amputasi 1
kaki palsu 2 kaki palsu 1 kaki palsu 2 kaki palsu
1 1 1 1 2 2 2
kaki palsu 2 kaki palsu 1 kaki palsu 2 kaki palsu
amputasi 2 amputasi 1 amputasi 2 amputasi
1 amputasi 1 amputasi 2 amputasi 1
2 2 2 2 2 2 2
1 2 1 2 2 2 1
2 1 1 1 2 1 1
amputasi 2 amputasi 1 amputasi 2 amputasi
1 1 1 1 2 2 2
kaki palsu 2 kaki palsu 2 kaki palsu 2 kaki palsu
2 2 1 1 2 1 1
1 1 1 1 2 2 1
1 1 1 1 2 2 1
1 1 2 2 1 1 2
 2 2 1 1 2 2 1
2 2 2 2 2 2 1
2 2 2 2 2 2 2
1 1 2 2 2 1 1
1 1 1 1 2 2 2
2 2 1 2 2 2 1
1 1 1 1 2 1 1
2 2 1 1 2 2 1
1 1 1 1 2 2 2

2 2 1 1 2 2 1
2 2 2 2 2 2 2
1 1 2 2 2 2 2
2 2 2 2 2 2 2
2 2 2 1 2
1 1 2 2 1 1 2
2 2 1 1 2 2 2
2 2 1 1 2 2 2
amputasi 2 amputasi 2 amputasi 1 amputasi
2 2 2 2 2 2 1
amputasi 1 amputasi 2 amputasi 1 amputasi
2 2 1 1 2 2 2
2 2 2 2 1 2 2
2 2 1 2 2 1
2 2 1 1 2 2 1
2 2 2 2 2 2 2
2 2 2 2 2 2 1
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

Palpasi

Ulkus Pemendekan jari Anestesi pada lesi Anestesi pada tangan

sinistra dextra sinistra dextra sinistra dextra sinistra

2 2 2 2 2 1 1
amputasi 2 amputasi 1 1 1 1
1 1 1 2 2 1 1

2 2 2 2 2 1
2 2 2 2 2 2 2
2 1 1 2 2 1 1
1 1 2 2 2 2
2 1 1 2 2
1 1 1 2 2 1 1
1 1 1 1 1
1 1 1 1 1 1 1
2 1 1 1 1 2 1
2 1 2 2 2 1 1
1 1 1 2 2 1 1
2 1 1 2 2 1 1
2 2 2 2 2 2 2
1 1 2 2 1 1
2 2 2 2 2 1 1
1 1 1 2 2 1 1
2 2 2 1 2

1 2 2 1 1 2 1
2 amputasi 1 2 2 1 1
1 amputasi 1 2 2 1 1
2 1 1 1 1 1 1

1 2 2 2 2 1 1
1 1 1 1 1 1 1
1 1 1 2 2 1 1
2 1 1 1 1 2 2
2 1 1 2 2 1 1

2 1 1 2 2 1 1
2 amputasi 1 1 1 1 1
2 1 1 2 2 1 2

1 1 1 2 2 1 2
2 1 1 2 2 2 2
2 2 2 1 1 1 1
amputasi 2 amputasi 1 1 1
2 1 1 2 2 1 1
1 1 1 2 2 1 1
1 kaki palsu 1 2 2 1 1
2 2 2 2 2
2 2 2 1 1 1 1
 2 amputasi 1 2 2 2 2
1 amputasi amputasi 1 1 1 1
2 1 2 2 2 1 2
1 1 1 2 1 1 1
2 1 2
2 2 2 1 1 2 2
1 1 1 1 1
1 1 1 1 2 1 2
2 2 2 2 2 2 2
amputasi amputasi amputasi 2 2 1 1
1 2 2 1 1 2 2
1 1 2 1 1 1 1
1 1 1 1 1 1
2 1 2 2 2 1 1
1 amputasi 2 2 1 2 1

1 2 2 1 2 1 2
1 1 2 1 1 1 1
1 1 1 2 2 1 1
1 amputasi 1 2 2 2 2
1 1 1 1 1 1
2 2 2 1 1 1 1
2 2 2 1 1 2 2
2 1 2 2 1 1
2 1 1 2 2 2 2
2 2 1 1 1
2 1 1 2 2 1 1
2 2 2 2 2 2 2
2 1 1 1 1 1 1
1 2 2 2 2 2 2
2 2 2 2 2
1 amputasi 1 2 2 1 1
1 1 2 2 2 1 1
2 1 1 1 1 2 2
2 1 2 1 1 2 2
1 1 2 1 1 1 1
2 2 1 2 2 2 2
2 1 1 1 1 1 1
2 1 1 2 2 1 1

2 1 2 1 2 2
2 2 2 2 2 2 2
1 1 1 1 1 1 1
2 2 2 2 2 1 1
amputasi amputasi amputasi 2 2 1 1
2 2 2 1 1 1 1
amputasi 1 amputasi 2 1 1 1
2 1 1 2 2 1 1
1 1 1 1 1 1 1
2 1 1 1 1 1 1
2 2 2 2 2 2 2
2 2 2 2 1 2
1 1 1 1 1 1 1
2 1 1 1 1 1 1
2 1 2 1 2 1 2
1 1 1 2 2 1 1
2 1 1 1 1 1 1
2 2 2 2 2 1 1
1 1 1 1 1 1 1
2 2 2 2 2 2 2
2 2 1 1
1 1 1 1 1 1 1
2 1 1 2 2 1 1
2 1 2 2 2 1 1
1 2 2 1 2 2 2
2 2 1
2 2 2 2 2 2 2
2 2 2 2 2 1 2
1 1 1 2 2 2 1
2 2 2 2 2 1 1
1 1 1 2 2 1 1
2 1 1 1 1
1 2 2 1
1 1 1 1 1 1 1
2 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 1 1 1 1
2 2 2 1 2
1 1 1 2 2 1 1
1 1 1 2 2 1 1
1 1 2 1 2 1 1
1 1 1 1 1 1 1
1 2 2 1 1 1 1
1 2 1 2 2 1 1
2 2 1 1 1 1 1
2 1 1 2 2 2 2
2 1 1 2 2 1 1
1 1 1 2 2 1 1
1 2 1 1
1 1 1 2 2
2 1 1 2 2 1 1
 1 2 1 1 1
1 amputasi 1 2 2 1 1
1 amputasi 1 1 1
amputasi 1 amputasi 1 1 1 1
2 1 1 2 2 1 1
1 1 1 1 1 1 1
2 1 1 2 2 1 1
2 2 2 2 2
2 1 2 1 1 1 1
2 2 1 2 2 2 2
1 1 1 1 1

1 1 1 2 2 2 2
2 1 1 2 2 1 1
1 1 1 2 2 1 1
2 1 1 1 1
2 2 2 2 2 2 2
2 2 2 2 1
1 1 1 2 2 1 1
2 1 1 2 1
2 protese 1 1 1
2 2 2 2 2 2 2
2 1 1 1 1 1 1
1 1 1 2 1 1
1 1 2 2 1 1
2 2 1 2 2 2 2
amputasi 2 amputasi 2 2 2 1
2 2 2 2 2 2 2
2 1 1 2 2
2 1 2 2 2 2
1 1 1 1 1 1
1 1 1 2 1 1
1 1 1 1
2 1 1 2 2 1 1
2 2 2 2 2 2 2
1 1 1 1 1 1 1
1 1 1 2 2 1 1
2 amputasi 1 2 2 1 2
1 amputasi 1 amputasi 1 amputasi 1
2 1 1 2 2 1 1
2 1 2 2 2 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 1 1 2 1
amputasi 1 amputasi 1 1
2 2 2 2 2 2 2
 2 1 1 2 2 1 1
2 1
1 amputasi 1 1 1 1 1
1 1 1 1 1 1 1
2 1 2 2 2 2 2
2 2 2 2 2 2 2
2 1 2 2 2 1 1
amputasi 2 amputasi 2 2 2 2
2 1 2 2 2 1
2 1 1 1 1 1 1
2 2 2 2 2 1 1
1 1 1 1 1
2 1 1 1 1 1 1
2 1 1 1
1 1 1 1 1 1 1
2 1 1 1 1
tidak dinilai 2 tidak dinilai 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 1 1 1 1 1 1
amputasi 1 amputasi 1 1 1
1 amputasi 2 2 2 1 1
2 1 1 2 2 1 1
kaki palsu 1 kaki palsu 2 2 1 2
1 2 1 2 2 2 2
amputasi 1 amputasi 1 1
1 1 1 1 1 1
1 1 1 1 1 1 1
amputasi 1 amputasi 2 2 1 1
1 kaki palsu 1 1 1 1 1
2 2 2 2 2 1 1
2 kaki palsu 1 1 1 1 1
2 amputasi 1 2 1 1 1
amputasi 1 amputasi 2 2 1 1
2 2 2 1 1 1 1
2 1 2 2 2 1 1
2 1 1 1 1 1 1
1 amputasi 1 1 1
1 1 1 2 2 1 1
2 kaki palsu 2 1 2 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 1 1 1 1 1 1
2 2 2 2 2 2 2
1 1 1 2 2 1 1
2 2 2 1 1 1 1
2 2 2 2 2 2 2
1 1 1 2 2 1 1
2 1 1 1 1 1 1
2 1 2 1 1 1 1
1 1 1 1 1
1 1 1 1 1 2 2
1 1 1 2 2 2 1

1 1 1 1 1 1 1
2 2 2 2 2 1 1
1 2 2 2 2 2 2
2 2 2 2 2 1
2 2 2 2 2 1 1
2 1 1 2 2 2 2
2 1 1 1 1 2 2
1 1 1 1 1
2 amputasi 2 2 2 1 1
2 2 2 1 1 2 2
1 amputasi 1 2 2 1 1
2 2 2 1 1
1 2 2 2 2 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 2 2 1 1
1 1 1 2 2 1 1
 1= ya 1= ya 1= ya 1=lunak 1= ya 1= ya 1=lunak
2=tidak 2=tidak 2=tidak 2= keras 2= tidak 2=tidak 2= keras

Anestesi pada kaki N. auricularis magnus

dextra sinistra
dextra sinistra

Ada/tidak konsistensi nyeri Ada/tidak konsistensi

2 2
1 1 2 2
 1 1 2 2
1 1 2 2

2 2 2
2 2 1 1 2 1 1
1 1 2 2
2 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2 1 2
1 1 1 2 2 1 2
1 2 2 2
1 1 2 2
1 1 1 2 2 1 2
1 1 2 2
2 2 2 2
1 2 2
1 1 2 2
1 1 1 1 1 1
1 1 1 2 2 1 2

1 1 1 2 2 1 2
amputasi 1 1 1 2 2
amputasi 1 2 2
1 1 1 1 2 1 1

1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2

1 1 2 2
1 1 2 2
1 1 1 2 2 1 1

1 1 1 2 2 1 2
2 1 2 2
1 1 1 1 1 1
1 1 2 2
1 1 2 2
1 1 2 1
1 1 2 2 1 2
1 1 2 2
1 1 1 1 2 1 1
amputasi 2 1 1
1 amputasi 2 2
1 2 1 1 2 1 2
1 1 2 2
1 2 2 1 2
2 2 1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2
amputasi amputasi 2 2
1 1 2 2
1 1 2 2
1 2 2
1 1 1 2 1 1 2
2 2 2 2

1 1 2 2
2 1 2
1 1 1 2 2 1 2
amputasi 1 2 2
1 1 2 1 2
2 1 2 2
2 2 2 2
1 1 1 1 2 1 1
2 2 2 1 2
1 1 2 2
1 1 1 2 2 1 2
2 1 1
1 1 2 2
2 2
1 2 1 2 2 2
1 1 2 2
1 1 1 2 2 1 2
1 1 1 2 2 1 2
1 1 2 2
1 1 2 2
1 2 2
1 1 2 1 1
1 1 2 2

2 1 2 2
2 2 2 2
1 1 2 2
2 2 2 2
amputasi amputasi 2 2
1 2 1 1 2 2
1 1 1 1 2
1 1 1 1 1 1
1 1 2 2
1 1 2 2
2 2 2 2
1 2 2 2
1 1 2 1 1
1 1 2 2
1 2 2 2
2 2 2 2
1 1 1 1 2 1 1
1 1 2 2
1 1 2 2
2 2 2 2
1 1 2 2
1 1 1 2 2 1 2
1 1 2 2
1 1 2 2
1 1 2 2
1 2 2
2 2 2 2
2 2 1 1 2 1 1
1 1 2 2
1 2 2 2
1 1 2 2
1 1 1 2 2 1 2
1 2 2
1 1 2 2
1 1 2 2
1 1 1 1 2 1 1
2 2
1 1 2 2
1 1 2 1 1
1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2
1 1
1 1 1 1 2 1 1
1 2
1 1 2 2
1 1 1 1 2 1 1
 1 1 2 1 1
amputasi 1 1 1 2 1 1
amputasi 1 1 1 2 1 1
1 amputasi 1 1 2 1 1
1 1
1 1 1 1 2 2
1 1 1 1 2 1 1
2 2 1 1 2 1 1
1 1 2 1 1
1 1 2 2
1 1 2 1 1

1 1 2 1 1
1 1 2 2
1 1 2 2
1 1 2 2 1 2
2 1 1 1 2 1 1
1 1 2 1 1
1 1 2 2
1 1 2 2
protese 1 1 2 2 1 2
2 2 1 1 2 1 1
1 1 2 1 1
2 2
1 1 1 1 2 1 1
1 1 2 2
2 amputasi 2 2
1 1 1 1 2 1 1
1 1
1 1 2 2
1 1 1 2 2 2
1 1 1 1 2 1 1
1 1
2 2
2 2 2 2
1 1 2 2
1 1 1 1 2 1 1
2 2 2 2
amputasi 1 2 1 1
1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2
1 2 2 2
1 1 1 1 2 2
2 2 1 1 2 1 1
 1 1 1 1 2 1 1
2 2
amputasi 1 2 2
1 1 1 1 2 2
1 1
2 2 1 1 2 1 1
1 2 2 1 2
2 amputasi 2 2
1 2 2 2
1 1 1 2 2 1 2
2 2 2 2
1 1 2 2
1 1 2 1 1
1 1
1 1 1 1 2 1 1
1 1 2 2
1 tidak dinilai 2 2
1 2 2
1 1 1 1 2 1 1
1 1 1 2 1 1
1 1 2 2
1 1 1 1 2 1 1
1 amputasi 2 2
1 1 1 1 2 1 1
1 1 2 2
1 2
2 1 2 2
1 1 1 2 1 1
1 1 2 2
1 1 2 2
1 1 2 1 1
kaki palsu 1
1 1 1 1 2 1 1
1 1 2 2
amputasi 1 2 2
1 amputasi 1 1 2 1 1
1 1 2 1 1
1 2 2 2
1 1 1 1 2 1 1
amputasi 1 2 1 1
1 1 2 2
1
1 1
1 1 1 1 2 1 2
2 2
2 2 2 2
 1 1 1 1 2 2
1 1 1 1 2 1 1
2 2 2 2
1 1 2 1 1
1 1 1 1 2 1 1
1 1 2 2
1 1 2 2
1 1 2 2
1 1 2 2

1 1
1 1 2 2
1 1 1 2 2 1 2
2 2 2 2
2 1 2 2
1 1 1 1 2 1 2
1 1
1 2 2
amputasi 1 2 2
1 1 2 1 1
amputasi 1 1 1 2 1 1
1 1 2 2
1 1 2 2
1 1
1 1
1 1 2 2
1 1 2 2
 1= ya 1= ya 1=lunak 1= ya 1= ya 1=lunak 1= ya
2= tidak 2=tidak 2= keras 2= tidak 2=tidak 2= keras 2= tidak

Pembesaran saraf tepi

N. ulnaris

sinistra dextra sinistra

nyeri Ada/tidak konsistensi nyeri Ada/tidak konsistensi nyeri

2 2
2 2
 2 2
2 2

2 2
2 2 2 2 2
1 2 2 1 2 2
2 2
2 2
1 2 2 1 2 2
2 1 1 2 1 1 2
2 1 2 2 1 2 2
2 2
2 2
2 1 2 2 1 2 2
2 2
2 2
2 2
2 2
2 2 2 2
2 1 2 2 2 2

2 1 2 2 1 2 2
2 1 2 2
2 2
2 1 1 2 1 1 2

2 2
2 2
1 1 2 1 1 2
1 1 2 1 1 2
2 2

1 2 2 1 2 2
1 1 2 1 2 2
2 1 2 2 1 2 2

2 2 2
2 2
2 2
2 2
2 2
2 2
2 1 1 1 2
1 2 2 1 2 2
2 1 1 2 1 1 2
 2 2
1 1 2 1 1 2
2 1 1 2 1 1 2
1 1
2 2 2
1 1 2 1 1 2
2 2
2 2
1 1 2 1 1 2
1 2 2 1 2 2
2 2
2 1 1 2
1 2 1 1 2 1
1 1 2 2 1 2 2
2 1

2 2
2 2 2
2 1 2 2 1 2 2
2 2
2 1 1 2 1 1 1
1 1 2 1 1 2
1 2 1 1 2 1
2 1 2 2 1 2 2
1 2 2
2 1 2
2 1 2 2 1 2 2
2 1 1 2 1 1 2
1 1 2 1 1 2
2 2
1 2 2 1 2 2
2 2
2 1 2 2 2
2 1 2 2 1 2 2
1 2 2 1 2 2
1 2
2 2
2 2 1 1
2 2

1 2 2 1 2 2
2 2
1 1 2 2
2 2
2 2
2 2
 2 2
2 2
2 1 1 2
2 1 1 2
2 2
2 2
2 1 1 2 1 1 2
1 1 2 1 1 2
2 2
2 2
2 1 1 2 1 1 2
1 2 2 1 2 2
2 2
2 2
1 2 2 1 2 2
2 1 2 2 1 2 2
2 2
2 1 1 2
1 2 2 2
2 2
2 2
2 2 2
1 1
1 2 2 1 2 2
2 2
2 1 2 2 1 2 2
1 1 2 1 1 2
1 1 2 1 1 2
2 2
2 1 2 2 1 2 2
1 2 2 1 2 2
2 2
2 2 2
2 2
2 1 1 2
2 2
2 1 1 2
2 2
2 2
1 1 2 1 1 2
1 1 2 1 1 2

2 1 1 1 1 1 1

1 1 2 1 1 2
2 1 1 2 1 1 2
1 2 2
2 1 1 2 1 1 2
2 1 1 2 1 1 2
2 1 1 2 1 1 2
1 2 2 1 2 2
2 1 1 2
2 1 2 2 1 2 2
2 1 2 2 1 2 2
2 1 1 2 1 1 2
1 1 2 1 1 2
2 1 1 2 1 1 2

2 1 1 2 1 1 2
1 2 2 1 2 2
2 2
2 1 2 2 1 2 2
2 1 1 2 1 1 2
2 1 1 1 1 1 1
1 1 2 1 1 2
2 2
2 1 2 2 1 2 2
2 2 2
2 1 1 2 1 1 2
2 2
2 2 2
2 2
2 2
2 1 1 2 1 1 2

2 2
1 2 2 1 2 2
2 1 1 2 1 1 2

2 2
2 2
2 2
2 1 1 2 1 1 2
2 2
1 2 1 1 1
1 1 2 1 1 2
1 1 2 1 1 2
2 2
1 2 2 1 2 2
2 1 1 2
1 1 2 2
2 1 1 2 1 1 2
2 1 1 2 1 1 2
2 2
2 2
2 2

2 1 1 2 2
2 1 2 2 1 2 2
1 1 2 1 1 2
1 1 2 2
2 1 1 2 1 1 2
2 2
1 1 2 2
2 2 1 1 2

2 1 1 2 1 1 2
2 1 1 2
1 1 2 1 1 2
1 2 2 1 1 2
2 1 1 2 1 1 2
2 2 1 1 2
1 1 2
2 1 1 1 1
2 2
2 1 1 2 1 1 2
2 2

2 2
2 1 2 2 1 2 2
2 2
1 1 2 1 1 2
2 1 2 2 1 2 2

2 1 2
1 2 1 2
2 2
2 1 1 2 1 1 2
2 1 1 2 2
1 1 2 1 1 2
2 1 1 2 1 1 2
2 1 1 2 1 1 2
1 1 2 1 1 2

2 1 2 2 1 2 2
1 2 2 1 2 2
2 2
 1 1 2 1 1 2
2 1 1 2 1 1 2
2 1 1 2
2 1 1 2 1 1 2
2 1 1 2 1 1 2
2 1 1 2
2 2
2 1 1 2
2 2

1 2 2 1 2 2
2 1 2 2 1 2 2
2 2
1 1 2 1 1 2
2 1 2 2 1 2 2

2 2
1 1 2 1 1 2
2 2 2
2 1 1 2 1 1 2
2 2
1 1 2 1 1 2

1 1 2 1 1 2
2 2
 1= ya 1=lunak 1= ya 1= ya 1=lunak 1= ya 1= ya
2=tidak 2= keras 2= tidak 2=tidak 2= keras 2= tidak 2=tidak

Pembesaran saraf tepi

N. peroneus komunis

dextra sinistra dextra

Ada/tidak konsistensi nyeri Ada/tidak konsistensi nyeri Ada/tidak

2 2 2
2 1 2
 2 2 2
2 2 2

1 2 2 1 2 2 2
1 1 2 1 1 2 2
1 2 2 1 2 2 1
2 2 2
1 2 2 1 2 2 2
1 2 2 1 2 2 1
2 2 2 2 2
1 2 2 1 2 2 1
2 2 2
2 2 2
1 2 2 1 2 2 1
2 2 2
2 2 2
2 2 2
2 2 2
1 1 2 1 1 2 1
1 2 2 1 2 2 1

1 2 2 1 2 2 1
amputasi 2 amputasi
2
1 1 2 1 1 2 1

2 2 2
2 2 2
2 2 1
2 2 1
2 2 2

1 2 2 1 2 2 1
amputasi 2 amputasi
1 2 2 1 2 2 1

2 2 2
2 2 2
1 1 1 1 2
2 2 2
2 2 2
2 2 2
2 2 2
1 2 2 1 2 2 1
1 1 1 1 1 1 1
amputasi 2 amputasi
2 amputasi 1
1 1 2 1 1 2 2
1 1 1
2 2 2
2 2 1
1 1 2
2 2 2
1 2 2 1 2 2 1
amputasi amputasi amputasi
2 2 2
2 1 1 2 2
2 2 fibrosis
1 2 2 1 2 2 1
2 2 2

2 2 2
1 1 2 1 2 2 2
1 2 2 1 2 2 1
amputasi 2 amputasi
1 2 2 1 2 2
2 2 1
1 2 1 1 2 1 1
1 2 2 1 2 2 1
2 2 2
2 2 2
1 2 2 1 2 2 1
1 2 2 1 2 2 1
1 1 2 2 1
2 2 2
1 2 2 1 2 2 1
2 2 2
2 2 2
1 2 2 1 2 2 1
1 2 2 1 2 2 1
2 2 2
2 2 2
2 2 edema berat, tidak teraba
2 2 2

1 2 1 1 2 1 2
2 2 2
2 2 1
2 2 2
2 2 2
2 2 1
1 1 2 2
2 2 2
2 2 2
1 1 2 1 1 2 2
2 2 2
2 2 2
1 2 2 1 2 2 1
2 2 1
2 2 2
1 2 1 2 2
1 1 2 1 1 2 1
2 2 2
2 2 2
2 2 2
1 2 2 1 2 2 1
1 2 2 1 2 2 1
2 2 2
2 1 2 2 2
2 2 2
2 2 2
2 2 2
2 2 2
2 1 2 2
1 2 2 1 2 2 1
1 1 2 1 1 2 2
1 2 2 1 2 2 1
1 1 2 1 1 2 1
1 1 2 1 1 2 1
2 2 1
1 1 2 1 1 2 1
1 1 2 1 1 2 1
2 2 2
1 2 1 2 1
1 1 2 1 1 2 1
1 1 2 2
1 2 2 2 2
2 2 2
2 2 2
1 1 2 1 1 2 1
1 1 2 2 1
1 1 2 1 1 2 1

2 2 2

1 1 2 1 1 2 1
2 1 1 2 1
 2 2 2
amputasi 1 1 2 amputasi
amputasi 2 amputasi
1 1 2 amputasi 1
1 2 2 1 2 2 1
1 1 2 1 1 2 1
1 2 2 1 2 2 1
1 2 2 1 2 2 1
1 1 2 1 1 2 2
1 1 1 1 1 2 1
1 2 2 1 2 2 1

2 2 2
2 2 2
1 1 2 1 1 2 1
1 2 2 1 2 2 1
1 1 2 1 1 2 1
1 2 2 1 2 2 1
1 1 2 1 1 2 1
2 2 2
protese protese protese 1 1 2 protese
2 2 2
1 1 2 1 1 2 1
2 2 2
2 1 1 2 2
1 1 2 1 1 2 2
2 amputasi 2
1 1 2 1 1 2 1

2 1
1 1 2 1 1 2 1
1 1 2 1 1 2 1

2 2 2
2 2 2
2 2 2
1 1 2 1 1 2 1
2 2 2
amputasi 1 1 1 amputasi
1 1 2 1 1 2 1
1 1 2 1 1 2 1
2 2 2
1 2 2 1 2 2 1
2 2 2
1 2 amputasi 1
2 2 2
 1 1 2 1 1 2 1

2 2 2
2 1 1 2 2

2 2 2
1 2 2 1 2 2 1
2 2 2
2 2 2
2 1 1 2 1
2 2 2
2 1 1 2 1
1 1 2 1 1 2 2

1 1 2 1 1 2 1
1 1 2 1 1 2 2
1 1 2 tidak dinilai 2
1 1 2 1 1 2 1
1 2 2 1 2 2 1
2 1 1 2 2
2 2 2
1 1 2 1 1 1
2 2 2
1 1 2 1 1 2 1
2 2 2

2 2 2
1 2 2 amputasi amputasi amputasi 1
2 2 2
1 1 2 1 1 2
amputasi 1 2 2 amputasi

1 1 2 1 1 2 2
1 2
2 2 2
1 1 2 amputasi 1
2 2 1
1 1 2 1 1 2 1
1 1 2 1 1 2 edem
amputasi amputasi amputasi 2 amputasi
1 1 2 1 1 2 1

1 2 2 1 2 2 1
1 2 2 1 2 2 1
2 2 2
 1 1 1 1 1 1 1
1 1 2 1 1 2 1
1 1 2 1 1 2 1
1 1 2 1 1 2 1
1 1 2 1 1 2 1
2 2 2
2 2 2
1 1 2 2 2
1 1 2 1 1 2 2

2 2 2
1 2 2 1 2 2 1
2 2 2
2 2 1
1 2 2 1 2 2 1

2 2 2
amputasi 1 1 2 amputasi
1 2 2 1 1 2 1
amputasi 1 1 2 amputasi
2 2 2
alat bantu 1 1 2 alat bantu

2 2 1
2 2 edem
 1=lunak 1= ya 1= ya 1=lunak 1= ya 1=normal 1=normal
2= keras 2= tidak 2=tidak 2= keras 2= tidak 2=lemah 2=lemah
3= lumpuh 3= lumpuh

N. tibialis posterior N. radialis

dextra sinistra
dextra sinistra

konsistensi nyeri Ada/tidak konsistensi nyeri

2 1 1
2 1
 2 1 1
2 2 1
1 1
2 1
2 2 2 1 1
2 2 1 2 2 1 1
2 1 1
2 1
2 2 1 2 2 1 2
2 2 2 2 2
2 2 1 2 2 1 1
2 1 2
2 2 2
2 2 1 2 2 2 2
2 1 1
2 1 1
2 2 2
2 1 1
2 2 2 2 2 2
2 2 1 2 2 1 1

2 1 1 2 2 1 1
2 2 2
2 2
1 2 1 1 2 1 1
1 1
2 1 1
2 1 1
1 2 2 1 1
1 1 1 1 1 1 1
2

2 2 1 2 2 1 1
1 1 1 2 2
2 2 1 2 2 1 1

2 1 1
2 1 1
1 1 1 2
2 1 1
2 1 1
2 1 1
2 1 1
2 2 1 2 2 1 1
1 1 1 1 1 1 1
 2 1 1
1 2 amputasi 2 2
2 1
1 1 1
2 1 1
1 2 2 1 1
2 1 2
2 3 1
2 2 1 2 2 1 1
amputasi 2 2
1 2 2 1 1
1 2 2 2 2
fibrosis 1 1
2 2 1 2 2 1 1
2 1 1

2 1 1
1 1 2 2 2
2 2 1 2 2 1 2
2 2 2
2 2
1 2 1 1 2 1 1
2 2 1 2 2 1 1
2 2 1 2 2 1 1
2 1 1
2 1 2
2 2 1 2 2 1 1
2 2 1 2 2 1 1
1 2 1 1 2 2 2
2 1
1 2 1 1 2 1 1
2 1
2 2 2
2 2 1 2 2 1 1
1 2 1 1 2 1 1
2 1 1
2 1 1
erat, tidak teraba edema berat, tidak teraba 1 1
2 1

1 2 1 1 1
2 1 1
1 2 1 1 2 1 1
2 1 1
2 2 2
1 2 1 1 2 1 1
 2 2
2 1 1
1 1 1 1 1
2 1 1
2 1 1
2 2 1
1 2 1 1 2 1 1
1 2 1 1 2 1 1
2 2 1
2 2
1 2 1 1 2 1 1
2 1 1
2 1 1
2 1 1
2 2 1 2 2 1 1
2 2 1 2 2 1 1
2 1 1
1 1 2 1 1
2 1
2 2 2
2 1 1
2 1 1
1 1 2
2 2 1 2 2 1 1
2 1 1
2 2 1 2 2 1 1
1 2 2 1 1
1 2 edem edem edem 2 2
2 2 1 1 2 2 2
2 2 1 2 2 1 1
1 2 1 1 2 1 1
2 1 1
2 2 1 1
1 2 1 1 2 1 1
2 1 1
2 1
1 2 2 2 2
2 1 1
1 2 1 1 2 1 3
1 2 1 2 2 2 2
1 1 1 1 2 1 1
1 1
2 1 1
1 1
2 2 Scar scar scar 1
1 2 1 1 2 1 1
 1 1 2 1 2
1 1 2 1 1
2 1 1
2 2 amputasi 2 2
2 2 1 2 2 1 1
1 2 1 1 2 amputasi amputasi
2 2 1 2 2 1 1
2 2 1 2 2
2 1 1
1 2 1 1 2 1 1
2 2 1 2 2 1 1

2 1 1
2 1
1 2 1 1 2 sulit dinilai sulit dinilai
2 2 1 2 2 1 1
1 2 1 1 2 1 1
2 2 1 2 2 1 1
1 2 1 1 2 1 1
2 1 1
protese protese 1 1 2 1 1
2 1
1 2 1 1 2 1 1
2 1 1
1 1 2 1 1
2 1 1
amputasi 1 1
1 2 1 1 2 1 1
1 1
1 1 1 1 1 1 1
1 2 1 1 2 1 1
1 2 1 1 2 2

2 1 1
2 1 1
2 1 1
1 2 1 1 2 2 2
1 2 2 1 1
1 1 1 2 2
1 2 1 1 2 2 2
1 2 1 1 2 1 1
2 2 2
2 2 1 2 2 1 1
2 1 1
2 amputasi 1 3
2 1 1
 1 2 1 1 2 1 1
1 1
2 2 1
2 1 1
1 1
2 1 1 1 1
2 2 1 2 2 1 2
2 1 1
2 1 1
1 2 1 1 2 2 2
2 1 2
1 2 2 1 2
1 1 2 1 1

2 2 1 2 2 1 1
1 1 2 1 1
tidak dinilai 1 1
2 2 1 2 2 1 1
2 2 1 2 2 1 1
2 1 1
2 2 2
1 1 1 2 2
2 1 1
1 2 1 1 2 1 1
2 kontraktur kontraktur
3 kaki palsu
2 1 1
2 2 amputasi amputasi amputasi 1 1
2 1 1
amputasi, absorpsi
amputasi, absorpsi
1 2 2 1 1
1 1
2 1 2
1 2 1 1
2 1 1
1 2 amputasi 1 1
1 1 1 1 2 2 2
1 2 2 1 1
edem edem 1 2 1 2 2
amputasi amputasi 2 3 3
1 2 1 1 2 2 2
1 1
3 3
1 2 1 1 1 1 1
2 2 1 2 2 1 1
2 1 1
1 2 1 1 2 1 1
1 2 1 1 2 2 3
1 2 1 1 2 1 1
1 2 1 1 2 1 1
1 2 1 1 2 1 1
2 1 1
2 1
1 1 2 1 1
1 1 2 1 1

1 1
2 1 1
2 2 1 2 2 1 1
2 1 1
1 2 1 2 1 1 1
2 2 1 2 2 1 1
1 1
2 1 1
1 1 2 2 2
2 2 1 1 2 1 1
1 1 2 2 1
2 1 1
1 1 2 1 1
1 1
1 1
1 2 1 1 2 2 2
edem 2 2
1=normal 1=normal 1=normal 1=normal 1=normal 1=normal 1=normal
2=lemah 2=lemah 2=lemah 2=lemah 2=lemah 2=lemah 2=lemah
3= lumpuh 3= lumpuh 3= lumpuh 3= lumpuh 3= lumpuh 3= lumpuh 3= lumpuh

Fungsi motorik

N. ulnaris N. medianus N. peroneus komunis N. tibialis posterio

dextra sinistra dextra sinistra dextra sinistra dextra

1 1 1 1 1 1 1
1 1 1 1
 1 1 1 1 1 1 amputasi
2 2 1 2 1
1 1 1 1 2 2 2
1 1 2 1 1 1
1 1 1 1 1 1 1
2 2 2 2 1 1 1
1 1 1 1 1 1 1
1 1 1 1
2 2 2 2 2 2 2
1 1 1 1 1
2 2 1 1 1 1 1
2 3 2 3 3 2 3
2 2 2 2
2 2 2 2 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 2 3 2 3
1 1 1 1 1 1 1
2 2 2 2 2 3 2
2 2 1 1 1 1 1

2 2 3 3 1 1 1
2 2 2 2 amputasi 1 amputasi
2 3 2 2 2
3 3 2 2 1 1 1
2 2 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 3 1 2 1 1 1
mutilasi 3 2 2 1 1 1

2 2 1 1 1 1 1
2 2 2 2 amputasi 2 amputasi
1 1 1 1 1 1 1

1 1 1 1 2 2 2
1 1 1 1 1 1 1
1 2 1 2 1 1 1
1 1 1 1 1 1
1 1 1 1 2 2 2
1 1 1 1 2 2 2
1 1 1 1 1 1 1
2 1 2 1 1 1 1
3 3 2 2 1 1 1
1 1 1 1 amputasi 1 1
2 2 2 2 amputasi 2 2
1 1 1 1
1 1 1 1 2 2 2
1 1 1 1 1 1 1
2 2 1 1 1 1 1
1 2 1 2 2 2 2
3 3 2 1 1 1 1
1 1 1 1 1 1 1
1 1 2 2 amputasi amputasi amputasi
1 1 1 1 1 1 1
2 2 1 1 1 1 3
1 1 1 1 1 1 1
2 2 1 1 1 1 1
1 1 1 1 1 1 1

1 1 1 1 1 1 1
2 2 2 2 2 2 3
1 1 1 2 1
2 2 2 amputasi 2 amputasi
2 2 2 2 2 2 2
2 2 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 2 1 1 1
1 1 1 1 1 1 1
1 2 1 2 2 1 2
2 2 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 2 1 1 1
1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 amputasi 2 amputasi
2 1 2 2 2 1 2
2 2 1 1 1 1 1
2 2 2 2 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 2 2 2

1 1 1 1 1 1 1
1 1 1 1 1 1 1
3 3 3 3 1 1 1
1 1 1 1 1 1 1
2 2 2 2 3 3 3
2 2 2 2 1 1 1
2 2 2 2 2 amputasi 2
1 1 1 1 1 1 1
1 2 1 2 1 1 1
2 2 1 1 2 2 2
1 1 1 1 1 1 1
2 1 2 1 1 1 1
3 3 3 3 1 2 1
2 2 1 1 1 1 1
1 1 1 1 1 1 1
2 2 1 1 1
2 2 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
3 3 3 3 1 1 1
3 3 3 3 1 1 1
1 1 1 1 1 1 1
1 1 1 1 2 1 3
1 1 1 1
2 2 2 2 2 3 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 2 1 2 2
3 2 2 2 1 1 1
1 1 1 1 1 1 1
3 3 3 3 1 1 1
1 1 1 1 1 1
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 2 1 2 2 1 2
3 3 3 3
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2
2 2 2 2 1 2 1
1 1 1 1 1 1 1
3 3 2 3 3 3 3
2 2 2 2 2 2 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 2 1 2
1 1
1 1 1 1 1 1 2
 1 2 1 2 1 2 1
1 1 1 1 amputasi 1 amputasi
1 1 1 1 amputasi 1 amputasi
2 2 2 2 2 amputasi 2
2 2 1 1 2 2 2
amputasi amputasi amputasi amputasi amputasi amputasi amputasi
3 3 3 3 1 1 1
2 2 2 2 1 1 1
2 2 1 2 2 2 2
1 1 1 1 1 1 1
3 3 3 3 1 1 1

1 3 1 3 2 2 2
1 1 1 1
sulit dinilai sulit dinilai sulit dinilai sulit dinilai 1 1 sulit dinilai
2 2 2 2 1 1 1
1 1 1 1 1 1 1
1 2 1 2 1 1 1
1 1 1 1 1 1 1
1 2 1 1 1 1
2 2 2 2
1 1 1 1
1 1 1 1 1 1 1
1 2 1 2 1 1 1
1 1 1 1 1 1 1
1 1 1 1 2 2 2
1 1 1 1 1 1 1
1 1 1 1 2 2 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
3 3 3 3 1 1
2 2 1 1 sulit dinilai

3 3 1 1 1 1 1
1 1 1 1 1 1 1
1 2 1 1 1 1 1
2 2 2 2 2 2 2
1 1 1 1 1 1 1
2 2 2 2 amputasi 2 amputasi
2 2 2 2 2 2 2
1 1 1 1 2 2 2
2 2 1 2 1 2
2 3 2 2 1 1 1
1 3 1 2 1 1 2
3 3 2 2 3 amputasi 3
1 1 1 1 1 1 1
 1 1 1 1 2 2 2
1 3 1 2
2 2 2 1 amputasi 2 amputasi
1 1 1 1 1 1 1
1 1 1 1 2 1 2
1 1 1 1 1 1 1
2 3 2 3 2 1 2
1 1 1 1 1 amputasi 1
1 2 1 1 2 1 2
2 2 2 2 2 2 2
2 1 1 1 1 1 1
1 2 1 2 1 1 3
1 1 1 1 1 3 1
3 3 3
2 2 2 2 1 1 1
2 3 2 2 1 1 1
1 1 1 2 1 tidak dinilai 1
3 3 3 3 1 1
2 2 2 2 2 2 2
3 3 1 1 1 1 3
2 2 2 2 2 2 2
2 2 2 2 2 1 2
1 1 1 1 2 amputasi 2
2 2 2 2 2 2 amputasi
kontraktur kontraktur kontraktur kontraktur kontraktur kontraktur kontraktur
1 kaki palsu 1 kaki palsu 1 kaki palsu 1
1 1 1 1 1 2 1
3 3 1 1
1 1 1 1 2 2 2
amputasi, absorpsi
amputasi, absorpsi
amputasi, absorpsi
amputasi, absorpsi
amputasi, absorpsi
amputasi, absorpsi
amputasi, absorpsi
3 3 3 3 1 1 1
1 1 1 1 kaki palsu kaki palsu kaki palsu
1 2 1 2 2 2 2
1 1 1 1 kaki palsu 1 kaki palsu
1 1 1 1 amputasi 1 amputasi
1 1 1 1 1 amputasi 1
2 2 2 2 1 1 1
1 1 1 1 1 1 1
2 2 2 2 2 2 2
3 3 3 3 amputasi 1 amputasi
2 2 2 2 2 2 2
1 1 1 1 1 1 1
3 3 3 3 1 3
2 2 2 2 1 1 1
3 3 3 3 1 1 1
1 1 1 1 1 1 3
1 1 1 1 1 1 1
2 2 2 2 2 2 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 2 1 1
1 1 1 1 3 1 3
1 1 1 2 1
1 1 1 1 1 1 1
1 2 1 2 1 2 1

1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 2 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 2 amputasi 1 amputasi
1 1 1 1 1 1 1
2 1 2 1 amputasi 2 amputasi
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 3
1 1 1 1 1 2 3
2 2 2 2 2 2 2
1 2 1 1 1 1 1
 1=normal 1= normal 1= normal 1= normal 1= normal
2=lemah 2= tidak normal 2= tidak normal 2= tidak normal 2= tidak normal
3= lumpuh

Fungsi senso

N. tibialis posterior N. radialis N. ulnaris

sinistra dextra sinistra dextra sinistra

1 1 1 1 1
2 2 2 2
amputasi 2 2 2 2
2 2 2 2 2
2 1 1 1 1
1 1 1 1 2
1 1 1 1 1
1 2 2 2 2
1 1 1 1 2
1 1
2 2 2 2 2
1 1 1 1 1
1 1 1 1 1
2 1 2 1 2
2 2 2 2
1 2 2 2 2
2 1 2 2 2
1 1 1 1 1
2 1 1 1 1
1 1 1 1 1
2 2 2 2 2
1 1 1 2 1

1 2 2 2 2
1 2 2 2 2
2 1 2 2 2
1 2 2 2 2
1 2 2 2 2
1 2 2 2 2
1 1 2 2 2
1 2 2 2 2
1 1 1 1 1
2 2 2 2

1 2 2 2 2
2 2 2 2 2
1 1 1 2 1

2 1 1 1 1
1 1 1 1 1
1 2 2 2 2
2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 1 1 1 1
1 1 1 1 1
1 1 2 1 2
 1 1 1 1 1
2 2 2 2 2
1 1 2 1
2 2 2 2 2
1 1 1 1 1
1 1 1 1 1
2 2 2 2 2
1 2 2 2 2
1 1 1 1 1
amputasi 2 2 2 2
1 1 1 1 1
1 1 1 2 2
2 2 2 2 2
1 2 2 2 2
1 1 1 1 2

1 2 1 2 2
2 2 2 2 2
2 1 2 1 2
2 1 1 1 1
2 2 2 1 1
1 2 2
1 1 1 1 1
1 1 1 2 2
1 1 1 1 1
1 2 2 2 2
1 2 2 2 2
1 1 1 1 1
1 2 2 2 2
1 1 1 1
1 1 1 1 1
2 2 2 2 2
1 1 1 1 1
1 1 1 1 1
1 1 1 2 2
1 1 1 1 1
1 1 1 1 1
1 1 1 2 2
2 1 1 1 1

1 1 1 1 1
1 1 1 1 1
1 2 2 2 2
1 1 1 1 1
3 3 2 2 2
1 2 1 2 2
amputasi 2 2 2 2
1 2 2 2 2
1 2 2 2 2
2 1 1 2 2
1 1 1 1 1
1 2 1 2 1
2 2 2 2 2
1 1 2 1 2
1 2 1 2 1
1 1 2 1 2

1 2 2 2 2
1 2 2 2 2
1 1 1 1 1
1 2 2 2 2
1 2 2 2 2
1 1 1 1
1 1 1 1 1
1 1 1 1
3
1 1 1
1 2 1 2 1
2 1 2 1 2
1 2 2 2 2
1 1 1 2 1
1 2 2 2 2
1 1 1 2
2 2 2 2 2
2 2 1 2 2
1 2 2 2 2
2 2 2 2
1 1 1 2 2
1 1 1 2 2
1 2 2 2 2
1 2 2 2 2
2 2 2 2
2 2 2 2 2
1 1 1 2 2
3 1 2 1 2
2 2 2 2 2
1 1 1 1 1
1 2 2 2 2
1 2 2 2 2
1 1 2 1 2
1 1 1 1
2 1 1 2 2
 2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
amputasi 2 2 2 2
2 2 2 2 2
amputasi 2 2 2 2
1 2 2 2 2
1 1 1 1 1
2 2 2 2 2
1 1 1 1 1
1 2 2 2 2

2 1 2 1 2
1 1 2 2
sulit dinilai 2 2 2 2
1 2 2 2 2
1 1 1 1 1
1 2 2 2 2
1 2 2 2 2
1 1 1 2
2 2 2 2
1 1 1 1
1 1 1 2 2
1 1 1 1 2
1 2 2 2 2
2 1 1 1 1
1 1 1 1 1
2 1 1 1 1
3 1 1 1 1
1 1 1 1 1
2 2 2 2
sulit dinilai 2 2 2 2
2 2 2 2
1 2 2 2 2
1 1 1 1 1
1 1 1 2 2
2 2 2 2 2
1 2 1 2 1
3 2 2 2 2
2 2 2 2 2
2 2 2 2 2
1 2 2 2 2
1 2 2 2 2
2 1 1 1 2
amputasi 2 2 2 2
1 1 1 1 1
 2 2 2 2 2

2 2 2 2 2
1 2 2 2 2
1 1 1 1 1
1 1 1 1 1
1 2 2
amputasi 1 1 1 1
1 1 1 1 2
2 2 2 2 2
1 1 2 2
3 1 1 2 2
2 2 2 2 2
3 2 2 2 2
1 2 2 2 2
1 1 1 2 2
tidak dinilai 1 1 2 2
2 2 2 2
2 2 2 2 2
3 2 2 2 2
2 2 2 2 2
1 2 2 2 2
amputasi 2 2 2 2
2 2 2 2 2
kontraktur 2 2 2 2
kaki palsu 2 1 1 1
2 1 1 1 1
1 1 2 2
2 1 1 2 2
amputasi, absorpsi 2 2 2 2
1 2 2 2 2
kaki palsu 1 2 1 2
2 2 2 2 2
3 2 2 2 2
1 1 1 2 2
amputasi 1 2 2 2
1 1 1 2 2
2 2 2 2 2
1 1 2 2
1 2 2 2 2
2 2 2 2 2
1 1 1 1 1
2 2 2 2 2
1 1 1 2 2
1 1 1 2 2
3 1 1 1 1
1 2 2 2 2
2 2 2 2 2
1 1 1 1 1
1 2 2 2 2
1 1 2 2
1 2 1 2 1
2 2 2 2 2
1 2 2 2 2
2 1 2 1 2

1 2 2 2 2
1 2 2 2 2
1 1 1 1 1
1 1 1 1 2
2 1 1 2 2
1 1 1 1 1
1 1 1 1 1
1 1 1 1 1
1 2 2 2 2
1 1 1 1 1
2 2 2 2 2
1 1 1 2 2
1 2 2 2 2
3 2 2 2 2
3 2 2 2 2
2 2 2 2 2
1 2 2 2 2
 1= normal 1= normal 1= normal 1= normal 1= normal 1= normal
2= tidak 2= tidak
2= tidak normal 2= tidak normal 2= tidak normal 2= tidak normal normal normal

Fungsi sensorik

N. medianus N. peroneus komunis N. tibialis posterior

dextra sinistra dextra sinistra dextra sinistra

1 1 1 1 2 2
2 2 2 2 2 2
2 2 2 1 2 amputasi
2 2 2 2 2 2
1 1 2 2 2 2
1 2 1 1 1 1
1 1 1 1 1 1
2 2 2 2 2 2
1 1 1 1 1 1
1 2 2 2 2
2 2 2 2 2 2
1 1 2 2
1 1 2 2 2 2
2 2 1 2 1
2 2 2 1 1 1
2 2 2 2 2 2
1 2 1 1 2 2
1 1 1 1 1 1
1 1
1 1 1 1 1 1
2 2 2 2 2 2
1 1 2 2 2 2

2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 1 2 2 2 2
2 2 2 2 2 2

2 2 2 2 2 2
2 2 2 2 2 2
2 1 2 2 2 2

1 1 2 2 2 2
1 1 1 2 1 2
2 2 2 2 2 2
2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 1 2 1 2 1
1 1 1 1 1 1
1 2 1 1 1 1
1 1 amputasi 1 1 1
2 2 2 2 2 2
1 1 2 1 2 1
2 2 2 2 2 2
1 1 1 1 1 1
1 1 1 1 1 1
2 1 2 2 2 2
2 2 2 2 2 2
1 1 2 2 2 2
1 1 amputasi amputasi amputasi amputasi
1 1 1 1 2 2
2 1 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 1 1 1 1 1

2 1 1 1 2 2
2 2 2 2 2 2
1 2 1 2 1 2
1 1 amputasi 1 amputasi 1
2 2 2 2 2 2
2 2 2 2 2 2
1 1 1 1 1 1
2 2 2 2 2 2
1 1 1 1 1 1
2 2 2 2 2 2
2 2 2 2 2 2
1 1 1 1 2 2
2 2 2 2 2 2
1 1 1 1 1 1
1 1 2 2 2 2
amputasi 1 amputasi 1
1 1 1 1 1 1
1 1 2 2 2 2
2 2 2 2 2 2
1 1 1 1 1 1
1 1 1 1 1 2
2 2 2 2 2 2
1 1 2 2 2 2

1 1 1 1 1 1
1 1 1 1 1 1
2 2 2 2 2 2
1 1 1 1 1 1
2 2 2 2 2 2
2 1 1 1 1 1
2 2 2 amputasi 2 amputasi
2 2 2 2 2 2
2 2 2 2 2 2
1 1 2 2 2 2
1 1 1 1 1 1
2 1 2 1 2 1
2 2 2 2 2 2
1 2 1 1 1 2
2 1 1 1 1 1
1 2 1 1 1 1

2 2 1 1 1 2
1 1 1 1 2 2
1 1 1 1 1 1
2 2 2 2 2 2
2 2 2 2 2 2
2 1 1 1 1 1
2 1 2 1 2 2
1 1 1 1 1 2

1 1 1
2 1 2 1 1 1
1 2 1 2 1 2
2 2 2 2 2 2
1 1 2 2 2 2
2 2 2 2 2 2
1 1 1 2
2 2 2 2 2 2
2 1 2 2 2 2
1 1 2 2 2 2
2 2 2 2 2 2
1 1 2 2 2 2
1 1 1 1 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 1 2
2 2 2 2 2 2
1 1 1 1 2 2
1 2 2 2 2 2
2 2 2 2 2 2
1 1 1 1 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 1 1 2 1 2
1 1
2 2 1 2 2 2
2 2 1 2 1 2
2 2 amputasi 2 amputasi 2
2 2 amputasi 2 amputasi 2
2 2 2 amputasi 2 amputasi
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 1 1 1 1 1
1 2 2 2 2 2
1 1 1 1 2 2
2 2 2 2 2 2

1 2 2 2 2 2
1 1 2 2 1 1
2 2 2 2 2 2
2 2 2 2 2 2
1 1 1 1 1 2
2 2 1 1 1 1
2 2 2 2 2 2
1 1 2 2 2 2
2 2 2 2
1 1 1 1 1 1
2 2 2 2 2 2
1 2 2 2 1 2
2 2 2 2 2 2
1 1 2 2 2 2
1 1 1 amputasi 1 amputasi
1 1 2 2 2 2
1 1 1 1 2 2
1 1 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2
2 2 2 2 2 2
1 1 1 1 1 1
2 2 2 2 2 2
2 2 2 2 2 2
1 1 amputasi 1 amputasi 2
2 2 amputasi 2 amputasi 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 2 1 1 1 1
2 2 2 2 2 2
1 1 1 1 1 1
2 2 2 2 2 2

2 2 amputasi 2 amputasi 2
2 2 2 2 2 2
1 1 2 1 2 1
1 1 1 1 1 1
2 2 2 2 2 2
1 1 1 amputasi 1 amputasi
1 1 2 1 2 1
2 2 2 2 2 2
1 1 1 1 1 1
1 1 1 1 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 1 2 2 2 2
2 2 1 tidak dinilai 2 tidak dinilai
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 amputasi 2 amputasi
2 2 2 2 amputasi 2
2 2 2 2 2 2
1 kaki palsu 1 kaki palsu 2 kaki palsu
1 1 1 2 1 2
2 2 2 amputasi 2 amputasi
1 1 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 2 1 kaki palsu 1 kaki palsu
2 2 2 2 2 2
2 2 kaki palsu kaki palsu
2 2 amputasi 2 amputasi 1
2 2 2 amputasi 2 amputasi
1 1 1 1 2 2
2 2 2 1 2 1
1 1 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
1 1 1 1 1 1
2 2 2 2 2 2
2 2 2 2 2 2
2 2
1 1 1 1 1 1
2 2 2 2 2 2
2 2 2 2 2 2
1 1 1 1 1 1
2 2 2 2 2 2
2 2 2 2 2
2 1 2 2 2 2
1 1 2 2 2 2
2 2 2 2 2 2
1 2 2 2 2 2

2 2 2 2 2 2
2 2 2 2 2 2
1 1 2 2 2 2
1 1 1 1 1 1
1 1 1 2 1 1
1 1
1 1 1 1 1 2
1 2 1 1 1 1
2 2 2 2 2 2
1 1 1 1 2 2
2 2 amputasi 2 amputasi 2
1 1 1 1 1 1
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2 2
2 1 1 1 2 2
2 2 2 2 2 2
 1= pausi 1=0 1=0 1=0 1= tidak sama sekali
2=basiler
multi
3 =basiler
release 2= 1 2= 1 2= 1 2= kecil
from 3= 2 3= 2 3= 2 3=besar
4 = tidak
treatment 4 = sangat besar
diketahui 86=NA = pertanyaan tidak
sesuai untuk saya

Derajat kecacatan (WHO)

Selama seminggu terakhir,

seberapa parah rasa gatal,
Tipe kusta perih, nyeri, atau tersengat
pada kulit anda?

Mata Tangan Kaki

2,3 1 3 3 3
3 1 3 2 2
 3 1 3 3 1
2 1 3 3 4
3 1 3 3 3
3 1 3 1 1
2,3 1 1 1 3
2,3 1 3 3 2
3 1 2 3 2
3 1 3 3 4
2,3 1 3 3 1
3 1 3 3 1
3 1 1 2 3
3 1 3 3 4
3 1 2 3 4
2,3 1 3 3 2
3 1 3 3 1
3 1 3 1 1
3 3 3 3 1
3 1 3 2 4
3 1 3 3 1
3 1 3 2 1
3
2,3 3 3 3 2
2,3 1 3 3 1
3 3 3 3 2
2,3 3 3 3 2
3 3 3 3 3
3 3 3 3 1
3 3 3 3
2,3 3 3 2
3 1 3 3 3
3 1 3 3 1

2,3 3 3 3 4
2,3 3 3 3 3
3 1 3 3 2
1
2,3 1 1 3 2
1 1 3 3
3 1 3 2 3
3 3 3 1
3 1 3 3 1
3 3 3 3 4
3 3 3 3 1
3 1 2 2 2
3 1 3 1 1
 3 1 3 3 1
2,3 1 3 3 1
3 1 2 3 2
3 1 3 3 4
1
3 1 1 1 1
3 1 3 3 4
3 2 3 3 1
2,3 1 1 2 1
3 1 3 3 2
2,3 1 1 2 1
2,3 1 3 3 2
3 1 3 3 2
1 3 3 2
3 1 2 3 1

2 3 3 3 1
2,3 1 3 3 1
1,3 3 3 3 1
3 1 3 3 3
2,3 1 3 3 2
3 3 3 2 1
3 1 1 1 1
3 1 3 3 1
3 1 3 3 1
3 3 3 3 3
1,3 3 3 3 1
2,3 1 1 2
3 1 3 3 1
3 1 1 2 1
2,3 3 1 2 1
3 1 3 3 1
2 1 3 3 2
1,3 2 3 1
1,3 1 3 3 4
3 1 3 3 1
3 1 1 3 3
2,3 1 3 3 2
2,3 1 3 3 2

3 1 1 3 1
3 1 3 1
3 1 3 3 1
3 1 3 2 1
3 1 3 3 4
2,3 1 3 1 1
 3 1 3 3 3
3 1 3 3 3
1,3 1 3 3 3
2,3 1 3 3 1
3 1 1 1 1
3 1 3 2 3
1,3 3 3 3 1
3 1 3 3 1
3 1 3 3 1
3 1 3 3 1
3 3 3 3 1
3 1 3 2 1
3 3 3 2 2
3 1 1 3 1
2,3 1 3 3 1
3 1 3 3 3
3 3 3 3 1
1,3 1 2 3 4
3 1 1 3 1
3 1 3 3 1
4 1 1 1 1
3 1 3 1 4
3 1 3 3 4
2,3 1 3 2 3
3 1 3 3 1
3 3 3 3 2
2 3 3 3 1
2,3 3 3 3 2
2,3 3 3 3 1
3 3 1
3 3 3 3 4
3 2 2 1
3 1 1 1 2
3 3 3 3 4
2,3 3 3 3 2
3 1 3 2 1
2,3 1 3 3 2
3 1 2 2 2
3 1 3 3 1
2,3 1 3 3 1
2,3 1 1 3 2
3 1 3 3 3
3 1 3 3 1
3 1 3 3 4
3 1 2 3 2
1 3 3 3 1
 3 1 3 3 3
1,3 1 3 3 4
3 1 3 3 4
2,3 1 3 3 4
1 3 3 2
3 1 3 3 1
3 1 3 3 4
3 1 2 1 1
2,3 3 3 3 3
2,3 1 3 3 4
3 1 3 3 2
2
3 1 3 3 2
3 1 3 3 1
3 1 3 3 4
3 1 3 3 3
2,3 1 1 2 2
1 3 3 1
1,3 1 3 3 1
3 1 3 3 3
3 3 3 3 2
3 1 2 1 1
3 1 2 2 1
3 1 3 3 1
3 1 3 3 1
3 1 1 3 1
1,3 1 2 3 2
2,3 1 1 3 1
3 1 3 3 1
3 1 1 2 4
3 3 3 3 1
3 1 3 3 1
3 1 3 3 1
3 1 3 3 1
3 1 1 1 1
3 1 3 3 2
1,3 1 3 3 2
3 1 3 3 3
1,3 3 3 3 1
1,3 1 3 3 1
2,3 1 3 3 3
3 1 3 3 2
3 1 3 3 3
3 1 3 2 2
3 1 3 3 1
2,3 1 1 1 1
1,3 1 3 3 3
3 1 3 3
3 1 3 3 2
3 1 3 3 4
1,3 3 3 3 3
3 1 3 1 2
3 1 3 3 1
2,3 1 1 3 2
3 1 2 3 4
2,3 3 3 3 4
3 1 2 1 2
3 1 3 3 2
3 1 3 3 1
3 1 3 3 3
3 1 3 3 1
3 1 3 3 2
3 1 3 3 1
3 1 3 1
3 3 3 3 2
3 1 3 3 2
3 1 3 3 4
2,3 3 3 3 1
3 1 3 3 3
1,3 1 3 3 1
3 3 3 3 1
1 3 3 3
3 1 1 3 3
3 1 3 3 1
3 1 3 3 1
3 3 3 3 1
3 1 3 3 2
3 1 3 3 1
3 1 2 2 3
3 1 3 3 1
3 3 3 3 1
1,3 1 3 3 3
2,3 1 3 2 2
2,3 1 3 3 1
2,3 1 3 3 1
3 1 3 3 3
2,3 3 2 3 2
3 1 1 2 3
3 1 3 3 1
3 1 3 3 3
1 3 3 2
1 1 3 1
 3
2,3 1 3 3 2
2,3 1 3 2 1
3 1 1 1 1
1,3 1 3 3 1
3 3 3 3 3
3 1 3 3 3
3 1 3 3 2
3 1 3 3 2
2,3 1 3 3 1

3 1 3 3 3
3 1 2 2 2
3 1 1 3 1
3 1 2 1 3
3 1 3 3 2
3 1 3 3 1
3 1 3 3 2
3 1 3 3 1
1,3 3 3 3 1
2,3 1 1 3 2
1,3 1 3 3 2
1 3 3 1
1,3 1 3 3 2
3 1 3 3 3
3 1 3 3 3
2,3 1 2 2 1
3 1 3 3 1
1= tidak sama sekali 1= tidak sama sekali 1= tidak sama sekali 1= tidak sama sekali
2= kecil 2= kecil 2= kecil 2= kecil
3=besar 3=besar 3=besar 3=besar
4 = sangat
86=NA besar
= pertanyaan 4 = sangat besar 4 = sangat besar 4 = sangat besar
86=NA = pertanyaan 86=NA = pertanyaan 86=NA = pertanyaan
tidak sesuai untuk tidak tidak sesuai untuk tidak sesuai untuk
sesuai untuk saya
saya saya saya

INDEKS KUALITAS HIDUP DERMATOLOGI

Selama seminggu terakhir, Selama seminggu terakhir,

Selama seminggu Selama seminggu
terakhir, seberapa malu seberapa besar kelainan seberapa besar kelainan
terakhir, seberapa besar kulit
kulit anda mengganggu anda mempengaruhi
atau tidak nyamankah kelainan kulit anda
kegiatan berbelanja, kegiatan social atai
anda karena keliainan memperngaruhi cara
mengurus rumah atau kegiatan di waktu santai
kulit anda? anda berpakaian?
pekarangan? anda?

1 1 1 1
1 1 1 2
4 3 3 1
1 1 4 1
3 3 2 3
2 1 1 1
2 1 1 3
2 1 1 2
4 2 1 4
3 1 1 1
1 1 1 1
4 3 1 3
3 2 3 2
4 2 2 3
3 1 2 1
1 1 1 1
1 1 1 1
1 1 1 1
4 3 1
2 1 2 2
1 1 1 1
1 1 1 1
4 3 1 3
4 1 2 1
1 1 1 1
3 1 1 1
2 1 1 1
3 1 1 1
3 3 3 3
4 2 2 2
2 1 1 1
4 1 1 2
3 1 1 2

1 1 1 3
2 2 2 2
1 1 1 1
2 1 1 1
1 1 1 1
3 2 1 2
2 2 2 2
3 2 3 2
1 1 2 1
3 2 1 2
1 1 1 1
1 1 1 1
2 1 1 1
1 1 1 1
1 1 1 1
2 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
4 2 1 1
1 1 1 1
1 1 1 1
1 2 1 1
1 1 1 1
3 2 1 2
1 1 3 1
1 1 1 1
1 1 1 1

4 1 1 1
4 4 4 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
2 1 1 1
1 1 1 1
2 1 1 1
1 1 1 1
1 2 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 2
1 1 1
1 3 1 1
1 1 1 1
3 1 3 3
1 1 1 1
1 1 1 1

2 1 1 1

4 1 1 1
1 1 2 2
1 1 1 2
2 2 2 2
3 2 3 2
3 2 1 2
3 3 3 3
1 1 1 1
1 1 1 1
3 1 1 1
1 1 1 1
1 1 1 1
1 1 1
2 2 1 1
1 1 1 1
1 1 1 1
1 2 1 1
1 1 1 2
3 1 1 1
3 2 4 2
1 1 1 1
1 3 1 1
1 1 1 1
1 1 1 3
1 1 1 1
4 1 1 1
3 1 3 1
1 1 1 1
2 1 1 1
1 1 1 2
3 1 2 2
3 2 2 2
1 1 1 1
1 1 1 1
1 1 3 1
1 1 1 1
3 1 1 1
1 2 4 3
1 1 1 1
2 1 2 1
2 1 2 2
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
3 4 2 1
3 1 1 1
2 1 1 1
2 1 2 1
1 1 1 1
1 2 1 1
2 1 4 1
4 1 4 1
1 1 1 1
1 1 1 1
1 1 1 1
1 3 3 2
1 1 1 1
1 1 1 1
2 1 1 1
2 2 2 1
2 2 2 1
2 2 2 1
1 1 1 2
2 1 4 1
1 1 3 1
3 1 1 1
1 1 1 1
1 1 1 1
3 2 3 2
2 2 1 2
1 1 1 1
1 1 1 1
1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 2 1
3 1 1 1
1 1 1 1
2 1 3 3
1 1 2 1
1 1 1 1
1 1 1 1
1 1 1 1
4 1 4 1
1 2 1 3
2 1 1 1
2 2 2 2
1 1 3 1
2 1 2 2
2 1 2 2
1 1 1 1
1 1 1 1
1 1 1 3
3 2 4 2
2 1 1 1
2 2 2 2
1 1 1 1
1 1 2 1
1 1 1 1
1 1 4 1
3 3 1 3
1 1 1 1
2 2 1 2
1 1 1 1
1 1 1 3
1 1 1 1
1 1 1 1
1 1 1 1
2 1 1 1
1 1 1 1
2 1 1 1
1 1 3 1
1 1 1 1
3 1 1 1
1 1 1 1
4 1 3 3
1 1 1 2
1 2 1 2
1 1 1 1
1 1 2 1
1 1 1 1
1 2 2 2
1 1 1 1
2 3 2 3
1 1 1 1
1 1 1 1
4 3 3 3
1 1 1 1
1 1 1 1
1 1 1 1
1 3 1 3
3 3 3 3
1 1 1 1
1 1 3 3
3 3 1 3
1 1 1 1
1 1 1 1
1 2 1 2
1 1 1 1
1 1 1 1
1 1 1 1
4 1 1 3
1 1 1 1
2 3 2 3
1 1 1 1
1 1 1 1
1 1 1 1

1 2 1 2
1 1 1 1
1 1 1 2
2 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
1 1 1 1
2 1 2 1
1 1 1 1
2 1 2 2
1 1 1 1
1 3 3 3
3 2 1 1
3 2 2 1
1 1 1 1
3 1 1 1
 0 = tidak, jika
"tidak",
selama
seminggu
terakhir,
1 = ya
seberapa
besar
1= tidak sama sekali kelainan
1= tidak sama kulit
sekali 1= tidak sama sekali 1= tidak sama sekali
anda menjadi
2= kecil 2= kecil
masalah 2= kecil 2= kecil
3=besar 3=besar
ketika anda 3=besar 3=besar
4 =
bekerjasangat
86=NA atau
=
4 = sangat
86=NA besar
= pertanyaan 4 = sangat
86=NA besar
= pertanyaan 4 = sangat
86=NA besar
= pertanyaan
besar
belajar
pertanyaan
tidak sesuai untuk tidak sesuai tidak sesuai untuk tidak sesuai untuk
saya saya saya
untuk saya

UALITAS HIDUP DERMATOLOGI

Selama seminggu
Selama seminggu Selama seminggu terakhir, apakah terakhir, seberapa besar
kelainan kulit anda Selama
kelainan kulit anda seminggu terakhir,
terakhir, seberapa besar
menyebabkan masalah kulit andabesar
mengakibatkan anda tidak dapat seberapa kelainan
kelainan kulit anda
bekerja atau belajar? menyebabkan
menyulitkan anda untuk dengan pasangan, masalah seksual?
berolahraga? teman dekat, atau
keluarga anda?

Ya / Tidak Jika Tidak

1 Ya 1 1
2 Tidak 2 2 1
 1 Tidak 2 1 1
4 Ya 1 1
98 Tidak 3 1 98
1 Ya 1 1 1
88 Tidak 2 1 1
2 Tidak 1 88 88
4 Tidak 1 2 1
1 Tidak 1 1 1
1 Tidak 1 1 1
4 Tidak 1 1 1
2 Tidak 2 1 1
2 Tidak 1 1 1
1 Tidak 1 1 1
1 Ya 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 88
4 Tidak 1 1 1
1 Tidak 2 1 1
1 Tidak 1 1 1
1 Ya 1 1
88 Tidak 3 1 88
2 Ya 1 2 88
1 Tidak 1 1 1
1 Tidak 2 3 1
1 Ya 1 1 1
1 Tidak 1 2 1
1 Tidak 1 1 1
88 Tidak 1 88 1
88 Tidak 1 4 1
88 Tidak 1 1 1
2 Tidak 1 1 88

1 Ya 1 88
1 Tidak 2 1 2
88 Tidak 1 88 88
1 Tidak 1 1 1
1 Tidak 1 1 1
88 Tidak 2 1 2
2 Tidak 3 1 1
2 Tidak 1 1 1
88 Tidak 1 1 88
3 Ya 1 1
1 Tidak 2 1 1
88 Tidak 1 1 88
1 Ya 1 1 2
 1 Tidak 1 1 1
1 Tidak 1 1 1
88 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 2 88 88
1 Tidak 1 1 88
88 Tidak 1 1 1
88 Tidak 1 1 1
1 Tidak 1 1 1
2 Tidak 2 1 88
3 Ya 3 1 1
88 Tidak 1 1 1
1 Tidak 1 1 88

1 Ya 2 1 1
4 Ya 1 1
1 Tidak 1 1 1
1 Tidak 1 3 88
1 Tidak 1 1 88
1 Tidak 1 1 1
88 Tidak 1 1 1
1 Tidak 1 1 88
1 Tidak 1 1 1
2 Tidak 2 1 1
1 Tidak 1 1 1
88 Tidak 1 1 88
88 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
88 Tidak 1 1 1
1 Tidak 1 4 88
88 Tidak 3 88 88
1 Ya 1 1 1
3 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1

1 Tidak 1 1 1

1 Tidak 2 1 1
1 Tidak 2 1 1
88 Tidak 1 1 88
88 Tidak 1 2 2
88 Tidak 2 1 88
1 Tidak 2 1 1
88 Ya 3 1 88
1 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
88 Ya 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
1 Ya 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
2 Tidak 2 2 88
1 Tidak 1 1 88
2 Tidak 2 1 88
88 Tidak 1 1 1
88 Tidak 1 1 1
1 Ya 1 1 1
88 Tidak 2 88 88
1 Tidak 1 1 1
1 Tidak 1 1 1
3 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 88
1 Tidak 1 1 1
1 Tidak 1 1
2 Tidak 2 3 88
1 Tidak 1 1 1
1 Tidak 1 1 1
88 Tidak 1 1
1 Tidak 1 1
2 Tidak 1 1 1
2 Ya 2 1 2
88 Tidak 1 1
1 Tidak 1 1 1
1 Ya 3 1 1
88 Tidak 1 2
4 Tidak 1 1
1 Ya 1 1 1
1 Tidak 2 1 1
88 Ya 3 1 1
1 Tidak 1 2 88
1 Tidak 1 1 1
3 Tidak 1 88
4 Tidak 1 1
 1 Tidak 1 1
1 Tidak 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
2 Tidak 1 1
88 Tidak 1 1
1 Tidak 1 1 1
3 Tidak 1 1
1 Tidak 1 1
88 Tidak 1 88 88
88 Tidak 1 1
4 Ya 2 1 1
1 Tidak 2 1 1
88 Tidak 1 1
2 Tidak 1 2
1 Tidak 1 1
1 Tidak 1 1 1
1 Tidak 88 1 1
88 Tidak 2 1 1
4 Tidak 1 1
1 Tidak 1 1 88
1 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 88 88
1 Tidak 1 1 88
1 Tidak 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
88 Tidak 1 1
88 Tidak 1 1
1 Tidak 1 1 1
88 Tidak 1 1 1
88 Tidak 2 1
88 Tidak 1 1 1
88 Tidak 1 1
1 Tidak 1 1
1 Tidak 1 1 1
2 Tidak 1 1 1
1 Ya 3 1
1 Tidak 1 88
88 Tidak 2 2 88
3 Ya 1 1 1
2 Tidak 1 1
1 Tidak 2 1
1 Tidak 1 1
88 Tidak 4 1 1
88 Tidak 2 2 1
1 Tidak 1 1 1
88 Tidak 88 1 1
88 Tidak 2 2 88
1 Tidak 1 1 88
3 Tidak 1 1
88 Tidak 2 1 88
3 Tidak 1 1 1
3 Tidak 2 3 1
1 Ya 1 1 1
4 Ya 2 1 1
1 Tidak 1 1 1
3 Tidak 88 3 88
1 Tidak 1 1 88
1 Tidak 1 1
1 Tidak 1 88
1 Tidak 2 1 1
2 Tidak 1 1 1
1 Tidak 1 1 1
88 Ya 2 1 1
3 Ya 4 1 1
1 Tidak 1 1 2
1 Tidak 1 1 1
88 Tidak 1 1
88 Tidak 1 1 1
88 Tidak 1 1 1
2 Tidak 1 1
88 Tidak 1 1
88 Tidak 1 1 1
2 Tidak 2 1 88
1 Tidak 1 1 1
88 Tidak 1 1
1 Tidak 1 1 1
1 Tidak 1 1 88
4 Ya 3 1
1 Ya 1 88
1 Tidak 1 1 1
1 Tidak 1 1 88
88 Tidak 3 1 88
3 Ya 4 3 1
88 Tidak 1 1 88
1 Tidak 1 1 1
88 Ya 2 1
1 Tidak 1 1 88
88 Tidak 1 1
88 Tidak 1 2 1
88 Tidak 1 1 1
88 Tidak 1 1 1
1 Tidak 1 1 1
88 Tidak 88 2 88
1 Tidak 1 1 1
88 Tidak 3 1 1
88 Tidak 1 1
1 Tidak 1 1 88
1 Tidak 1 1 1

88 Tidak 2 1 1
1 Tidak 1 1 1
1 Tidak 1 1 1
88 Tidak 1 1 1
1 Tidak 1 1 1
1 Tidak 1 1 88
88 Tidak 1 1 1
1 Tidak 1 1 1
2 Tidak 1 1 1
88 Tidak 1 1 88
1 tidak 1 1 1
1 Tidak 1 1
3 Ya 2 1 1
1 Tidak 1 1 1
88 Tidak 3 1 88
1 Tidak 1 1 1
88 Tidak 1 1
1= tidak sama sekali 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
2= kecil 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada
3=besar
4 = sangat
86=NA besar
= pertanyaan
tidak sesuai untuk
saya

Selama seminggu
terakhir, seberapa Do you walk
Can you see
mengganggukah Do you walk longer
(enough to Do you sit or Do you walk
pengobatan kulit anda, barefoot? e.g. distances?
misalnya mengotori carry out squat on the on uneven
most of the i.e. longer
rumah atau your daily ground? ground?
time than 30
menghabisakn waktu activities)?
minutes
anda?

1 1 1 4 1 1
1 1 2 2 1 1
1 2 3 1 2 1
1 1 4 4 2 2
98 1 2 1 2 2
1 1 1 3 3
1 1 1 1 2 1
1 4 1 4 4 4
1 1 4 4 4 2
1 2 1 4 4 1
1 1 1 0 2 0
2 2 4 4 4 2
2 1 2 4 4 4
1 1 1 2 2 2
1 1 3 2 3 1
1 1 4 4 4 1
1 1 1 1 1 1
1 2 2 1 1 1
2 1 4 4 2
2 2 1 4 1 1
1 1 1 1 1 1
88 1 1 1 1 1
88 2 4 4 4 4
1 2 1 1 1 1
1 1 2 1 1 4
2 2 3 4 1 1
1 1 1 4 1 1
1 1 1 2 3 3
1 3 2 2 2 3
1 1 1 1 1 0
1 1 1 4 1 1
1 1 1 1 2 2
1 1 1 1 1 1

2 1 1 3 2 2
2 2 2 1 3 2
88 1 1 1 1 1
1 2 3 2 2 2
1 1 1 4 4 1
1 1 2 1 2 1
2 2 1 1 1 1
1 1 3 2 2 2
1 3 1 1 2 2
2 3 2 3 3 3
1 1 1 4 1 1
88 2 1 1 1 1
1 1 1 4 1 1
1 1 2 1 2 2
1 2 2 1 3 2
1 1 1 1 1 2
1 1 1 2 2 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 3 2
3 1 1 4 1 3
1 1 1 1 1 1
2 1 3 2 3 3
1 1 1 1 1 1
1 2 2 2 2 2
1 1 1 4 3
88 1 3 1 1 1
1 1 2 1 2 2

1 1 1 2 2 1
2 1 4 4 4 4
1 2 1 4 1 2
2 1 2 3 3 3
1 2 2 3 3 2
1 4 1 4 4 4
1 1 2 3 3 1
1 2 1 2 4 2
1 1 1 1 1 1
1 2 1 1 2 3
1 4 1 1 1 1
1 1 1 1 1 1
2 1 3 4 1 1
1 1 1 1 1 1
1 2 1 1 1 1
1 1 3 4 1 3
1 2 1 1 2 4
1 2 1 2 2 1
1 2 1 4 1 1
1 1 1 4 4 1
1 1 1 4 3 4
1 1 2 3 3 1
1 1 1 4 4 2

1 1 1 1 1 1
2 2 2 2 2
2 1 1 4 4 2
1 1 1 4 4 1
88 1 4 4 1 4
1 2 2 4 1 1
1 3 3 3 3 3
1 1 1 1 2 2
3 1 3 4 3 4
1 1 1 1 2 1
1 1 1 1 1 1
1 2 1 2 1 1
1 1 1 4 1 4
1 1 1 4 1 1
1 2 4 2 2 2
1 2 1 3 3 3
2 2 1 4 1 1
1 1 1 1 1 1
1 2 2 3 2 3
1 1 1 4 4 2
1 2 1 1 1 1
1 2 1 4 4 2
1 4 1 4 4 1
3 1 2 4 1 1
1 1 2 3 3 4
2 1 1 4 4 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 4 2 3
3 2 2 1 0 2
1 1 1 4 1 1
1 2 1 4 2 1
2 2 3 4 4 4
1 3 2 4 4 4
1 1 1 3 1 1
2 1 1 1 1
1 2 2 4 4 2
1 2 1 1 1 1
1 1 2 4 4 0
1 2 3 4 4 2
1 3 1 4 4 4
1 2 1 4 4 1
1 1 2 4 4 4
1 1 1 4 1 1
1 3 1 4 4 2
1 2 1 4 1 1
1 2 2 4 4 2
1 2 4 4 4 4
1 3 1 1 1 1
1 2 1 1 2 1
1 2 4 4 4 3
1 2 1 4 3 4
1 2 1 4 4 1
1 2 1 4 4 1
1 2 1 4 4 1
1 1 1 4 1 3
1 2 4 4 4 2
1 1 1 1 4 2
1 2 1 4 4 2
1 1 1 1 1 1
1 2 3 4 4 3
1 1 2 2 2 1
2 1 3 3 4 4
2 2 1 4 4 3
1 2 4 4 4 4
1 2 1 1 1 1
1 2 1 4 4 4
1 1 1 4 4 4
1 1 1 4 4 1
1 2 1 1 1 1
1 2 1 4 1 2
1 1 1 4 4 4
1 2 4 1 2 2
1 3 2 4 2 2
1 2 2 4 2 1
1 1 1 4 1 0
88 1 1 1 1 1
88 2 1 3 3 3
1 2 1 1 1 1
1 4 1 1 1 3
88 1 2 1 2 1
1 2 2 2 2 4
1 1 3 2 2 2
1 1 1 4 1 1
88 1 1 4 1 1
1 3 1 4 4 4
1 2 3 4 3 4
1 2 1 2 2 3
1 2 4 4 4 4
1 1 2 4 3 3
1 1 4 1 4 4
1 2 1 4 4 4
1 2 1 4 4 1
1 2 1 4 4 2
1 1 2 1 4 4
1 2 1 1 1 1
1 2 4 4 4 3
1 1 1 1 1 1
1 1 2 4 3 3
2 2 4 4 1 3
1 3 4 3 4 4
1 2 2 4 4 2
1 1 2 4 2 3
1 1 1 4 4 1
1 1 1 4 2 4
3 1 1 4 4 4
1 2 1 4 2 3
3 2 1 4 1 4
1 2 1 4 1 3
2 2 2 4 4 4
1 1 1 4 1 3
88 2 2 4 4 2
1 1 1 4 4 1
1 2 1 4 4 2
1 1 2 1 1 1
1 1 1 4 1 1
1 2 1 4 1 1
1 1 1 1 1 2
1 2 2 4 4 3
1 1 1 4 4 4
1 2 2 4 3 4
88 1 1 1 1 1
1 2 2 2 4 1
2 1 4 2 2 2
1 1 1 4 2 2
1 1 4 4 4 4
2 1 1 4 4 4
88 1 1 4 2 0
1 3 1 1 1 1
1 2 1 1 2 1
1 2 3 4 4 4
1 1 3 4 4 2
1 1 1 1 1 1
1 3 4 4 4 4
1 1 2 4 4 1
3 1 4 4 1
1 1 4 4 4 4
2 2 4 3 4 4
3 2 2 4 4 3
1 1 4 4 2 4
1 3 1 4 1 2
3 2 1 4 3 3
1 2 2 4 1 1
1 1 2 4 4
3 3 1 4 1 1
1 2 1 1 1 1
1 1 3 4 1 4
1 1 1 1 1 1
1 2 1 1 2 4
1 3 1 1 1 1
88 1 2 4 2 3
1 2 2 4 4 2
1 3 1 4 3 3
1 2 2 4 4 1

1 1 1 1 1 1
1 2 1 1 2 3
1 2 1 4 2 2
1 3 1 1 2 1
1 3 1 4 1 1
1 3 1 1 1 1
1 3 1 1 1 2
1 1 1 4 4 1
1 1 4 4 2 4
1 1 4 1 1 2
1 1 1 4 2
1 1 1 1 1 1
1 2 4 4 4 2
1 1 2 4 1 1
1 2 2 2 2 2
1 1 1 4 4 4
1 1 1 4 3 3
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada

SALSA SCALE

Do you lift
Do you wash Do you work Do you carry objects
Do you cut Do you hold a
your whole with tools? heavy above your
your finger or cup or basin Do you cook?
body? (using i.e. tools objects or head? e.g. to
toenails? e.g. with hot i.e. prepare
soap, which you bags? e.g. place on a
using contents? food both hot
sponge, jug; hold in your shopping, shelf, on your
scissors or e.g. drinks, and cold
standing or hands to help food, water, head, to hang
clippers... food…
sitting....) you work ... wood ... clothes to dry
...

1 4 1 1 1 1 1
1 1 1 1 1 1 1
1 1 2 2 2 0 2
1 4 4 1 2 1 1
2 1 2 1 1 1 1
1 1 1 1 1 1 1
2 1 1 1 1 1 1
2 4 1 2 2 2 1
1 1 2 1 1 1
1 1 1 1 1 1 1
1 1 2 1 1 3 1
2 4 3 4 4 4 2
1 1 1 1 1 1 1
1 1 4 1 1 1 1
2 1 1 1 1 1 1
1 1 1 1 1 1
1 4 2 2 2 0 1
1 1 1 0 1 1 1
3 4 3 3 3 1 1
1 1 1 1 1 1 1
1 0 3 1 1 1 1
1 1 1 1 1 1 1
1 4 4 2 4 4 4
4 4 1 1 4 1 1
2 4 2 2 2 1 1
1 1 1 1 1 1 1
1 4 4 1 1 1 1
1 1 2 1 1 2 1
3 2 2 3 3 1 2
1 3 2 2 1 1 1
1 1 1 1 1 1 1
1 2 2 1 3 3 1
1 1 1 0 1 1 1

1 3 2 1 3 1 1
2 3 3 1 2 3 0
1 1 1 1 1 1 1
1 2 1 1 2 2 1
1 1 1 0 1 1 1
1 1 1 1 1 1 1
1 2 1 1 1 1 1
2 4 4 2 2 1 2
1 3 2 2 1 2 0
1 1 1 2 1 1 3
1 1 1 1 1 2 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 3 2 1 1 1 1
1 3 1 1 1 2 0
1 1 1 1 1 2 0
1 1 1 1 1 1 1
1 1 1 0 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 0
1 1 1 1 1 1 1
1 1 2 1 3 3 1
1 1 1 1 1 1 1
1 1 2 1 1 1 1
1 1 2 2 1 1 1
1 1 1 1 3 2 0
1 1 1 1 1 2 1

1 1 1 1 1 1 1
1 1 4 4 4 4 4
1 1 4 2 2 2 1
1 2 2 1 3 2 0
1 1 1 1 3 3 1
1 4 3 1 1 1 4
1 1 1 1 1 2 1
2 4 4 0 0 1 0
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 4 1 4 1 1 4
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 0
1 1 1 1 1 1 1
1 4 1 1 1 1 2
1 1 1 1 2 2 1
1 1 1 1 1 1 1
1 4 2 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 0
1 1 1 0 1 1 1

1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 3 2 2 1 1 1
1 1 1 0 1 1 1
1 5 5 3 1 4 4
1 1 1 1 1 1 1
2 0 3 2 3 3 0
1 2 2 2 1 1 1
1 2 2 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 4 1 1 1 1 1
1 1 1 1 1 1 1
1 2 1 1 2 4 0
1 1 1 1 1 2 1
1 1 1 1 1 1 1
1 2 2 2 2 1 1
1 1 2 1 1 2 0
1 1 1 0 1 1 1
1 2 2 1 1 1 0
1 2 4 1 1 1 4
1 4 4 4 1 1 4
1 1 1 1 1 1 1
1 1 1 2 2 3 1
1 1 1 0 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 2 2 3 3 2
1 1 4 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 2 4 1
1 4 4 2 3 3 0
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 4 4 0 2 2 0
1 1 1 1 1 1 1
1 1 1 1 2 0 1
1 3 1 3 2 2 4
1 4 4 4 4 4 4
2 1 1 1 1 1 1
1 1 4 1 2 4 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 2 1 1 1 1
2 2 1 1 1 1 1
1 1 1 1 4 4 4
1 0 1 1 1 1 0
1 1 1 1 1 1 1
1 1 1 1 4 4 1
1 1 1 1 1 1 1
1 4 1 1 1 1
1 4 4 2 1 2 0
1 1 1 1 1 1 1
1 2 2 1 1 1 1
1 1 1 1 4 1 1
1 2 4 1 1 1 4
1 4 4 2 4 4 2
1 1 1 1 1 1 1
1 4 2 4 4 4 2
1 1 1 1 1 1 1
2 4 2 0 3 4 1
1 4 4 2 2 2 4
2 1 2 2 3 2 0
1 3 2 2 1 1
1 4 4 3 1 4 2
1 1 4 1 2 1 4
1 1 1 1 1 0 1
1 4 1 1 1 1 1
1 4 2 1 1 1 4
1 1 1 1 2 3 1
1 2 1 2 1 1 1
1 4 1 1 3 3 0
1 1 1 2 2 1 0
1 1 1 1 4 1 0
1 4 4 3 1 1 1
1 1 1 1 1 4 1
1 1 4 1 2 1 0
4 4 4 4 4 4 4
1 1 1 1 1 1 0
1 1 1 1 1 1 1
1 4 2 2 2 3 2
1 4 1 1 1 1 0
1 4 1 1 1 1 1
1 3 3 2 2 1
1 1 1 3 3 4 1
1 1 1 1 2 3 2
1 4 4 4 4 4 4
1 1 1 1 1 1 1
1 4 4 4 1 1 0
1 3 4 4 4 1 1
1 1 1 1 2 1 0
2 4 4 1 1 4 1
2 1 1 1 1 1 4
1 1 2 1 1 1 1
1 3 4 1 2 1 4
1 1 1 1 1 1 1
2 4 4 1 4 2 0
1 2 1 1 1 1 1
2 3 2 2 4 3 1
1 4 2 2 3 3 2
1 1 1 1 1 1 1
1 1 2 2 2 1 0
1 1 1 1 1 1 1
1 1 1 0 4 2 1
1 1 1 1 1 1 1
1 4 4 1 1 1 0
1 2 1 2 1 1 1
1 1 1 4 4 4 4
1 2 1 1 1 1 1
2 4 4 2 4 4 2
1 1 1 1 1 1 1
1 1 1 1 1 0 1
1 1 1 1 1 1 1
1 3 4 1 1 1 0
1 4 1 1 2 1 1
1 1 1 1 1 2 0
1 4 4 2 2 4 2
1 4 4 4 1 1 1
1 2 4 1 1 2 0
1 1 1 1 1 1 1
2 3 2 4 4 1 1
1 1 1 1 1 2 1
1 1 1 1 1 1 1
1 4 3 4 4 4 4
1 1 1 1 2 1 1
1 4 4 1 1 1 0
1 2 2 1 1 2 0
1 1 1 1 1 4 0
2 1 2 0 4 4 0
1 2 4 1 2 2 1
1 1 1 1 1 1 1
1 1 1 1 1 1 0
1 1 1 1 2 1 1
1 2 3 2 2 2 1
1 2 1 1 3 4 0
1 4 3 3 3 4 4
1 1 1 1 1 1 1
1 1 1 1 4 0
2 0 4 4 2 1 0
3 4 4 2 1 1 0
1 4 1 1 1 1 1
1 1 1 1 1 1 1
1 2 4 1 1 1 0
1 3 4 1 1 1 1
3 4 4 2 4 4 1
1 1 1 1 1 1 1
2 4 1 1 2 1 1
1 1 2 1 1 1 1
1 2 3 1 1 1 1
1 1 2 1 1 2 1
1 1 1 1 1 3 0
1 1 1 1 1 1 1

1 1 1 1 1 1 0
1 1 1 1 1 1 1
1 1 4 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 0
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 4 4 1 2 1 0
1 1 1 1 1 1 1
2 1 4 1 4 1 3
1 1 1 1 1 1 1
1 2 2 2 1 3 2
1 4 4 4 1 1 0
2 3 3 2 2 2 3
1 1 1 1 3 1 1
2 4 1 1 3 3 1
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada

Do you
handle or Do you
Do you
Do you open manipulate Do you use thread Do you pick
open/close
jars with small buttons? e.g. needles? i.e. up pieces of
Do you pour screw
screw-on objects? e.g. buttons on pass thread paper, handle
hot liquids? capped
lids? e.g. coins, nails, clothing, through the paper or put
bottles? e.g.
jam... small screws, bags... eye of a it in order?
oil, water ..
grains and needle
seeds ...

1 1 1 3 1 1 1
1 1 1 1 1 2 1
2 4 4 2 0 4 3
1 2 2 4 3 2 2
1 1 1 4 4 4 1
1 1 1 1 1 2 2
1 1 1 1 1 2 1
2 2 2 4 4 4 2
2 1 1 1 1 4 1
1 1 1 1 1 3 1
1 2 2 2 2 2 1
2 3 3 2 2 4 4
1 1 1 1 1 4 1
1 3 3 4 2 2 3
2 3 3 3 2 3 1
1 2 2 2 2 2 1
1 1 1 1 1 2 1
1 1 1 1 1 1 1
2 2 2 2 2 4 2
1 4 4 3 1 2 1
1 1 1 3 3 4 1
1 1 1 1 1 1 1
0 3 3 4 4 4 2
1 4 4 4 4 4 1
1 2 2 4 4 2 1
1 2 2 2 2 1 1
4 1 1 4 4 4 1
2 2 2 1 1 2 1
2 3 3 3 3 3 3
1 2 0 1 1 1 1
1 1 1 1 1 1 1
1 4 4 3 3 1 1
1 1 1 1 1 1 1

1 1 1 1 2 3 1
1 2 2 3 2 3 2
1 1 1 1 1 1 1
1 2 2 2 2 3 2
1 1 1 1 1 1 1
1 1 1 1 1 2 1
1 1 1 2 1 2 1
2 2 2 3 3 3 3
2 2 2 3 2 3 2
3 4 4 4 4 4 4
2 2 2 2 3 3 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 3 3 2 3 1 3
1 1 1 3 3 3 2
1 1 1 1 1 2 1
1 1 1 3 1 2 1
1 1 1 1 1 3 1
1 1 1 1 1 1 1
1 1 1 3 2 4 3
1 2 2 1 1 1 1
1 1 1 1 1 2 1
0 1 1 1 1 2 1
1 1 1 1 1 2 2
1 1 1 1 1 3 1
1 1 1 2 2 2 1
1 1 1 2 1 1 1
1 1 1 1 1 2 1

1 1 1 1 1 1 1
4 4 4 4 4 4
1 1 1 1 1 4 1
1 1 1 1 2 3 1
1 1 1 1 1 2 2
4 1 1 4 4 4 4
1 1 1 1 1 2 1
1 2 2 4 3 4 2
1 1 1 1 1 3 1
1 1 1 3 1 2 1
4 4 4 4 4 4 4
1 1 1 1 1 2 1
1 3 3 4 3 3 2
1 1 1 1 1 1 1
1 1 1 1 1 3 1
1 1 1 1 1 2 1
1 1 1 4 4 4 1
1 1 1 1 1 2 1
1 1 1 1 1 3 1
1 1 1 3 4 4 2
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 2 2 1 3 1

1 1 1 1 1 0 1
1 1 1 1 1 4 1
1 4 4 3 4 4 2
1 1 1 1 1 0 1
4 4 4 4 4 4 3
1 2 2 4 3 4 1
3 3 3 3 3 3 2
1 1 1 2 1 2 2
1 1 1 2 2 3 2
1 1 1 1 1 2 1
1 1 1 1 1 4 4
1 1 1 1 1 1 1
1 2 1 4 4 4 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 2 1 2 1
1 1 1 2 2 4 2
2 2 2 3 2 2 1
1 2 2 2 2 3 1
1 1 1 1 3 1
1 1 1 3 3 3 1
4 1 1 2 2 4 2
4 1 1 4 2 4 2
1 1 1 1 1 1 1
1 1 1 2 2 3 3
1 1 1 1 3 4 1
1 1 1 1 1 2 1
1 1 4 4 1 1 1
1 1 1 1 1 4 1
1 3 1 3 3 4 1
1 1 1 1 1 2 1
1 2 2 2 2 3 2
1 1 1 2 2 4 1
1 3 3 4 2 2 1
1 1 1 1 2 3 1
1 1 1 1 1 1 1
4 2 2 4 4 4 4
1 1 1 1 1 2 1
1 1 1 1 1 4 1
2 3 3 4 4 4 1
4 4 4 4 4 4 4
1 1 4 2 2 3 3
1 1 1 1 1 4 1
1 1 1 2 1 4 1
1 1 1 1 1 4 1
1 1 1 2 3 2 1
1 1 1 1 1 3 1
4 2 3 2 1 3 1
1 1 1 4 4 4 2
1 1 1 1 1 2 1
1 3 3 1 2 4 1
1 3 3 2 2 3 1
1 1 1 3 3 3 1
2 4 4 2 3 2 1
1 2 4 3 1 1 2
1 2 2 4 3 3 1
1 4 4 3 1 4 1
4 2 2 4 4 3 2
4 4 4 4 2 4 2
1 1 1 1 1 1 1
1 1 1 1 3 4 1
1 1 1 1 1 1 1
1 2 3 4 4 4 4
4 2 2 3 2 4 1
1 1 1 1 3 1
1 1 1 1 1 1 1
2 4 4 3 4 4 2
2 1 1 2 3 4 1
1 1 1 1 1 3 1
1 1 1 4 1 3 1
2 4 4 3 4 4 2
1 1 1 1 1 2 1
1 2 2 2 1 1 1
1 1 1 2 4 4 2
1 1 1 2 1 4 1
1 1 1 1 1 3 1
1 1 1 3 3 3 3
1 3 3 3 1 4 1
2 1 1 1 1 2 1
4 4 1 4 1 4 4
1 1 1 1 1 1 1
1 1 1 1 1 2 1
2 3 3 2 2 2 1
1 1 1 4 2 4 1
1 1 1 3 4 4 1
1 2 2 3 3 4 2
4 2 2 2 2 3 1
1 1 1 1 1 4 1
4 4 4 4 4 4 4
1 1 1 1 1 3 1
4 4 4 4 4 4 4
2 3 4 4 4 4 3
1 1 1 1 1 3 1
1 1 1 3 4 4 1
1 1 1 1 1 3 1
1 1 1 1 1 3 1
1 3 3 2 4 4 1
1 1 1 1 1 1 1
0 0 4 1 0 4 1
1 1 1 1 1 1 1
1 2 2 2 3 4 2
2 4 4 2 2 2 2
1 1 1 1 1 3 1
0 4 4 2 1 4 1
1 1 1 1 1 4 1
1 1 1 4 4 0 4
1 1 1 1 1 1 1
1 4 4 4 4 4 4
1 1 1 1 1 4 1
1 2 3 2 4 4 1
1 2 2 1 1 4 1
4 4 4 3 4 4 1
1 1 1 1 1 2 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
4 1 1 3 1 2 3
1 2 1 3 3 0 1
1 1 1 2 3 3 1
4 3 3 3 4 4 1
1 1 4 4 4 4 1
1 1 1 3 4 3 1
1 1 1 3 3 2 1
1 2 2 3 3 3 3
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 4 4 4 4 4 2
1 1 1 1 1 1 1
4 1 1 1 3 4 1
1 1 1 3 1 4 2
1 1 1 1 1 2 1
4 1 1 1 1 1 4
4 4 4 4 2 4 4
1 1 1 1 1 1 1
1 1 1 3 3 3 1
1 1 1 1 1 4 1
1 4 4 2 2 4 1
1 2 2 1 1 2 1
3 3 3 4 4 4 3
1 1 1 1 1 1 1
2 1 1 1 1 2 2
1 2 2 3 3 4 3
2 4 4 4 3 4 1
1 1 1 3 2 3 1
1 1 1 1 1 1 1
1 4 1 4 3 3 1
1 1 2 2 1 4 1
1 4 4 4 4 4 1
1 1 1 1 1 1 1
1 2 2 3 3 3 2
1 1 1 2 2 4 1
1 2 2 2 1 4 1
1 2 2 2 2 4
1 1 1 1 1 3 1
1 1 1 1 1 4 1

1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 3 1
1 1 1 1 1 4 1
1 1 1 1 1 3 1
1 1 1 1 1 3 1
1 1 1 1 1 3 1
1 1 1 1 1 4 1
4 4 4 4 4 4 4
1 1 1 1 1 2 1
3 4 1 4 4 2 4
1 1 1 1 1 1 1
4 2 2 3 3 4 1
4 2 2 2 2 3 3
3 3 3 3 3 3 3
1 1 1 2 1 4 1
1 1 1 1 2 1
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada

DEFORMITAS

Do you pick
up things Total SALSA
from the Score CLAW HAND ULNAR CLAW HAND MEDIOULNAR APE HAND
floor?

Dekstra Sinistra Dekstra Sinistra Dekstra

1 28 0 0 1 1 0
1 23 1 1 0 0 0
4 42 1 1 0 0 0
2 45 0 0 1 1 0
1 34 0 0 1 1 0
1 25 1 1 0 0 0
1 23 0 0 0 0 0
2 53 0 0 1 1 0
4 37 0 0 0 0 0
1 25 1 0 0 0 0
1 27 0 0 1 1 0
2 61 0 0 0 0 0
1 33 0 0 0 0 0
2 38 1 0 0 1 0
1 36 0 0 0 0 0
1 33 0 0 1 1 0
1 26 1 1 0 0 0
1 21 0 0 1 0 0
2 47 0 0 1 1 0
1 33 0 0 1 1 0
1 28 0 0 1 1 0
1 20 0 0 0 0 0
2 63
4 48 0 0 1 1 0
1 40 0 0 1 1 0
1 30 1 0 0 1 0
1 41 0 0 1 1 0
1 31 1 1 0 0 0
3 51 0 0 1 1 0
1 23 0 0 1 0 0
1 23 1 1 0 0 0
3 40 1 0 0 0 0
1 19 1 1 0 0 0

1 28 0 0 1 1 0
1 40 0 0 1 1 0
1 20 0 0 0 0 0
2 37 1 1 0 0 0
1 25 0 0 0 0 0
1 23 0 0 0 0 0
1 24 0 0 1 1 0
3 48 0 0 1 1 0
2 38 0 0 1 1 0
3 54 0 0 1 1 0
2 35 0 0 1 1 0
1 21 0 0 0 0 0
1 23 0 0 0 1 0
2 36 0 0 1 1 0
2 35 0 0 1 1 0
1 22 0 0 0 0 0
1 27 0 0 1 1 0
1 21 1 0 0 0 0
1 20 0 0 0 0 0
2 32 0 1 1 0 0
1 26
1 21 0 0 0 0 0
1 34 0 0 1 1 0
1 22 0 0 0 0 0
1 28 0 0 0 0 0
1 29 0 1 1 0 0
1 25 1 0 0 0 0
1 25 0 0 0 1 0

1 22 0 0 1 0 0
4 67 0 0 1 1 0
1 34 0 0 0 0 0
1 34 0 0 1 1 0
2 34 1 0 0 0 0
4 58 1 1 0 0 0
1 27 0 0 0 0 0
4 41 1 1 0 0 0
1 22 0 0 1 1 0
1 27 0 0 1 1 0
4 56 0 0 1 1 0
1 21 0 0 0 0 0
3 39 0 0 1 1 0
1 20 0 0 0 0 0
1 22 0 0 0 0 0
1 28 0 0 0 0 0
2 39 0 0 1 1 0
1 26 0 0 0 0 0
1 26 0 0 0 0 0
1 39 0 1 0 0 0
1 28 0 0 0 0 0
1 24 0 0 0 0 0
1 30 1 1 0 0 0

1 19 0 0 0 0 0
1 28 0 1 0 0 0
1 46 0 0 1 1 0
1 24 0 0 1 1 0
4 62 0 0 0 0 0
1 35 0 0 1 0 0
2 50 0 0 0 0 0
1 28 0 0 1 0 0
2 38 0 0 0 0 0
1 22 0 0 0 0 0
1 26 0 0 0 0 0
1 22 1 0 0 0 0
1 39 0 0 1 1 0
1 23 0 0 0 1 0
2 35 0 0 1 0 0
1 30 0 0 0 1 0
2 42 0 0 1 1 0
1 31 0 0 1 1 0
1 34 0 0 0 1 0
1 27 0 0 0 0 0
1 28 0 0 1 1 0
4 47 1 1 0 0 0
2 53 0 0 0 1 0
1 24 0 0 0 0 0
3 40 0 0 0 0 0
1 30 0 0 1 1 0
1 21 1 0 0 0 0
1 26 0 0 1 0 0
1 29 0 0 1 1 0
3 36 0 0 0 0 0
1 28 1 0 0 0 0
1 32 0 0 0 0 0
1 40 0 0 0 1 0
2 52 0 0 0 0 0
1 25 0 0 0 0 0
1 19 0 0 1 1 0
2 53 0 0 1 1 0
1 22 0 0 0 0 0
1 25 0 0 0 0 0
2 54 0 0 0 0 0
4 73
3 39 0 0 1 1 0
1 41 0 0 0 0 0
1 47 0 0 0 0 0
1 32 0 0 1 1 0
1 29 0 0 0 0 0
1 33 0 0 0 0 0
1 51 0 0 0 0 0
1 30 0 0 1 1 0
1 23 0 0 0 0 0
1 46 0 0 0 0 0
1 37 0 0 1 1 0
2 37 0 0 1 1 0
1 45 0 0 1 1 0
1 34 0 0 0 0 0
1 32 0 0 1 1 0
1 49 0 0 0 0 0
2 42 0 0 0 0 0
2 60 0 0 1 1 0
1 20 0 0 0 0 0
1 50 1 0 0 1 0
1 23 0 0 0 0 0
3 56 0 0 0 0 0
2 32 0 0 1 1 0
1 39 0 1 0 0 0
1 24 0 0 1 1 0
2 59 0 0 1 1 0
1 43 0 0 1 1 0
1 27 0 0 0 0 0
1 29 0 0 0 1 0
2 49 0 0 1 1 0
1 33 0 0 0 0 0
1 31 0 0 0 1 0
2 49 0 0 0 0 0
1 31 0 0 0 0 0
1 26 0 0 0 0 0
2 37 0 0 1 1 0
1 39 0 0 0 0 0
1 26 0 0 0 0 0
4 64 0 0 0 0 0
1 21 0 0 0 0 0
1 28 0 0 0 0 0
1 42 0 0 1 1 0
1 32 0 0 1 1 0
3 36 0 0 1 1 0
3 48 0 0 1 1 0
1 47 0 0 0 0 0
1 26 0 1 0 0 0
4 75 0 0 1 1 0
1 27 0 0 0 0 0
4 61 0 0 0 0 0
3 60 0 0 1 1 0
1 29 0 0 0 1 0
2 47 0 0 1 1 0
1 33 1 0 0 1 0
1 24 0 0 0 1 0
2 53 0 0 1 1 0
1 20 0 0 0 0 0
2 42 0 0 1 1 0
1 30 0 0 0 1 0
2 53 0 0 1 0 0
2 35 0 0 1 1 0
1 29 0 0 0 0 0
1 37 0 0 1 1 0
1 29 0 0 1 1 0
4 43 0 0 0 0 0
1 27 0 0 0 0 0
3 52 0 0 1 1 0
1 31 1 0 0 0 0
1 53 0 0 0 0 0
1 41 0 0 1 1 0
3 63 0 0 0 1 0
1 27 0 0 1 1 0
1 27 0 1 0 0 0
1 21 0 0 0 0 0
3 37 0 0 1 1 0
1 30 0 0 1 1 0
1 26 0 0 1 1 0
3 59 0 0 0 1 0
1 50 0 0 1 1 0
1 41 0 0 0 0 0
2 26 0 0 1 1 0
3 48 0 0 0 1 0
1 27 0 0 1 0 0
1 25 0 0 0 0 0
4 69 0 0 1 1 0
1 30 0 0 1 1 0
2 37 0 0 1 1 0
1 30 0 0 1 1 0
1 25 0 0 0 0 0
1 44 0 0 0 0 0
1 52 0 0 1 1 0
1 20 0 0 1 1 0
1 35 0 0 1 1 0
1 31 0 0 1 1 0
1 43 1 0 0 1 0
1 40 1 1 0 0 0
3 66 0 0 0 0 0
1 40 0 0 0 0 0
1 34 0 0 0 0 0
3 45 0 0 0 1 0
4 53 0 0 1 1 0
2 34 0 0 1 1 0
1 26 0 0 0 0 0
1 34 0 0 1 1 0
1 31 0 0 1 1 0
2 59 0 0 1 1 0
1 20 0 0 0 0 0
2 40 0 0 1 1 0
1 28 0 0 0 0 0
2 37 0 0 1 0 0
1 35 0 0 1 1 0
1 32 0 0 0 0 0
1 31 0 0 0 0 0
0 0 0 0 0
1 19 0 0 1 1 0
1 24 0 0 0 0 0
1 27 1 0 0 0 0
1 26 0 0 0 0 0
1 27 0 0 1 1 0
1 23 0 0 0 0 0
1 23 0 0 0 0 0
1 28 0 0 1 1 0
2 58 0 0 1 1 0
1 25 0 0 0 0 0
4 50 0 0 1 0 0
1 20 1 1 0 0 0
1 49 0 0 1 1 0
3 43 0 0 1 1 0
3 51 0 0 0 1 0
1 35 0 0 0 0 0
1 35
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada

TAS AMPUTA

APE HAND DROP HAND DIGITI I DIGITI II

Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 1 0 0 0
0 0 0 1 0 1 1
0 0 0 0 1 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 1 1 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 1 1
0 0 0 0 0 1 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 1 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 1 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 1
0 0 0 1 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 1 1 1 1
0 0 0 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 1 0
0 0 0 0 0 1 0
0 0 0 0 0 0 1
0 0 0 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 1 0
0 0 0 0 0 0 0
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 2 - tidak ada

AMPUTASI DIGITI

DIGITI III DIGITI IV DIGITI V WRIST FLEXI

Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra

0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 80
0 0 0 0 0 0 90
0 0 0 0 0 0 70
0 0 0 0 0 0 70
0 0 0 0 0 0 75
0 0 0 0 0 0 80
0 0 0 0 0 0 85
0 0 0 0 0 0 80
0 0 0 0 0 0 65
0 0 0 0 0 0 50
0 0 0 0 0 0 70
0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 80
0 0 0 0 0 0 75
0 0 0 0 1 0 85
0 1 0 1 1 1 70
0 0 0 0 0 0 65
1 1 0 0 0 0 75
0 0 0 0 0 0 80

0 0 0 0 0 0 65
1 0 1 0 0 0 80
0 0 1 0 0 0 60
0 O 0 0 0 0 85
0 0 0 0 0 0 90
0 0 0 0 0 0 60
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 1 0 0 0 75
0 0 0 0 0 0 80

0 0 0 0 0 0 85
0 0 0 0 0 0 75
1 0 0 0 0 0 70
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 75
0 0 0 0 0 0 90
1 0 1 0 0 0 90
0 0 0 0 1 0 65
0 0 0 0 0 0 70
0 0 0 0 0 0 70
0 0 0 0 0 0 85
0 0 0 0 0 0 85
0 0 0 0 0 0 70
0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 0 0 0 70
0 0 0 0 0 0 70
0 0 0 0 0 0 80

0 0 0 0 0 0 85
0 0 0 0 0 0 70
0 0 0 0 0 0 85
0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 0 0 0 70
0 0 0 0 0 0 75

0 0 0 0 0 0 80
0 0 0 0 0 0 75
0 1 0 1 0 1 70
0 0 1 1 0 1 65
0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 0 0 0 75
0 0 0 0 0 0 80
0 0 0 1 1 1 65
0 0 0 0 0 0 90
0 0 0 0 0 0 55
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 85
0 0 0 0 0 0 75
0 0 0 0 0 0 85
0 0 0 0 0 0 60
0 0 0 0 0 0 80
0 0 0 0 0 0 85
0 0 0 0 0 0 70
0 0 0 0 0 0 90
0 0 0 0 0 1 90
0 0 0 0 0 0 80

0 0 0 0 0 0 70
0 0 0 0 0 0 60
0 0 0 0 0 0 70
0 0 0 0 0 0 75
1 0 1 1 1 0 80
0 0 0 0 1 0 70
1 1 1 1 1 1 60
0 1 0 1 0 1 70
0 0 0 1 0 0 80
0 0 0 0 1 1 65
0 0 0 0 0 0 70
0 0 0 0 0 0 70
0 0 0 0 0 0 85
0 0 0 0 0 0 80
0 0 0 0 0 0 75
0 0 0 0 0 0 75
0 0 0 0 0 0 80
0 0 0 0 0 0 60
0 0 0 0 0 0 70
0 0 0 0 0 0 70
1 1 0 0 0 0 70
0 0 0 0 0 1 75
1 0 1 0 0 1 80
0 0 0 0 0 0 80
0 0 0 0 0 0 85
1 0 0 0 0 0 NA
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 0 0 0 80
1 1 1 1 1 1 60
0 0 0 0 0 0 75
0 0 1 0 0 0 50
1 0 1 0 1 0 70
0 0 0 0 0 0 60
0 0 0 0 0 0 60
0 0 0 0 0 0 60
0 0 0 0 0 0 55
1 1 1 1 1 1 80

0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 0 0 0 60
0 0 0 1 0 1 75
1 1 1 1 1 1 80
0 0 0 0 0 0 80
0 0 0 0 0 0 80
1 1 1 1 1 1 65
0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 1 0 0 70
0 0 0 0 0 0 80
1 1 1 1 1 1 75
0 0 0 0 0 0 100
0 0 0 0 0 0 70
0 0 0 0 0 0 80
1 1 1 1 1 1 60
0 0 0 0 0 0 60
0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 0 0 0 80
1 1 1 1 1 1 80
1 1 1 1 1 1 80
0 0 0 0 0 0 80
0 0 0 0 0 0 60
1 0 1 0 1 0 65
0 0 0 0 1 1 80
0 0 0 0 0 0 80
0 0 0 0 0 0 90
1 0 0 0 0 0 45
0 0 0 0 0 0 80
1 1 1 1 1 1 70
0 0 0 0 0 0
0 0 0 0 0 0 70
0 0 0 0 0 0 100
0 0 0 0 0 0 70
0 0 0 0 0 0 55
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 70
1 0 0 1 0 1 70
0 0 0 0 0 0 80
1 0 0 0 0 0 35
0 0 0 0 0 0 70
0 0 0 0 0 0 45
0 0 0 0 0 0 55
1 1 1 1 1 1 90
0 0 0 0 0 0 80
0 1 1 1 1 1 60
1 0 1 0 1 1 60
0 0 0 0 0 0 80
1 0 1 0 0 0 80
0 0 0 0 1 1 90
0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 0 0 0 90
0 0 0 0 0 0 60
0 0 0 0 0 0 90
0 0 0 0 0 0 50
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 1 0 70
0 0 0 0 0 0 90
0 0 0 0 0 0 80
0 0 0 0 0 0 90
0 1 1 0 0 0 70
0 0 0 0 0 0 60
0 0 0 0 0 0 70
0 0 0 0 0 0 70
0 0 0 0 0 1 90
0 0 0 0 0 0 75
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 60
0 0 1 0 0 0 60
1 1 1 1 1 1 70
0 0 1 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 80
0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 80
1 1 1 1 1 1 80
0 0 0 0 0 0 90
1 1 1 1 0 1 60
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 90
0 0 0 0 0 0 90
1 1 0 1 0 0 90
1 0 0 0 0 0 90
0 0 0 0 0 1 90
0 0 0 0 0 0 90
0 0 0 0 0 0 75
1 1 1 1 1 1 70
0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 1 0 0 45
0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 80
0 0 0 0 0 0 80
0 1 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 1 90
0 0 0 0 0 0 80
0 0 0 0 1 1 90
0 0 0 0 0 0 40
0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 70
0 0 0 0 1 0 80
0 0 0 0 0 0 80
0 0 0 0 0 0 70
0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 90
0 0 0 0 0 0 70
0 1 1 0 0 0 90
0 0 0 0 0 0 65
0 0 0 0 0 0 70
0 0 0 1 0 1 80
0 0 0 0 0 0 70
0 0 0 0 0 0 80
0 0 0 0 0 0 80
1 0 1 0 1 0 40
0 0 0 0 0 0 90
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada

ROM (ISI DENGAN ANGKA YANG TERTERA DLM

WRIST FLEXI WRIST EXTENSI FINGER TO PALM OPPONENT TIP TO TIP DIGITI II

Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra

85 85 85 0 0 0
90 85 80 0 0 0
60 85 60 0 0 0
80 75 80 0 0 0
70 60 70 0 0 0
90 90 70 0,5 0,5 0
70 70 80 0 0 0
80 70 75 0 0 0
85 75 90 0 0 0
70 80 80 0 0 0
55 60 85 1 0 0
70 50 80 0 0 0
70 70 75 0 0 0
60 90 90 0 1 0
85 80 80 1 1 0
50 70 80 0 0 0
60 90 75 0 0 0
80 85 70 0 0 0
90 75 80 2 3 0
65 70 70 0 0 0
75 85 90 2 3 1
85 85 75 0 0 0

60 50 90 2 0 0
90 90 90 2 0 2
85 60 80 0 NA 0
40 70 65 3 0 1
85 50 60 0 0 0
75 70 80 3 2 3
70 75 75 0,5 1 0
70 65 70 0 0 0
80 80 85 1 8 0
85 75 75 0 0 0

80 70 85 0 2 0
80 85 75 2 0 0
65 80 75 0 0 0
90 60 75 0 0 0
90 70 80 0 0 0
90 80 80 0 0 0
70 65 60 0 0 0
90 75 90 0 1 0
80 80 90 2 1 0
60 60 45 4 3 4
75 70 70 0,5 0 0
85 70 80 0 0 0
80 70 90 0 0 0
75 85 80 2 2 0
80 65 65 1 0 0
90 75 65 0 0 0
85 70 80 0 0 0
80 50 70 0 0 0
65 75 85 0 0 0
80 70 90 0 0 0

85 80 70 0 0 0
75 75 80 0 0 0
80 70 85 0 0 0
90 65 50 0 0 0
70 70 70 0 0 0
60 75 55 0 0 0
60 70 65 0 0 0

80 70 70 0 0 0
70 80 70 0 0 0
60 55 50 0 3 0
75 70 70 NA NA 0
50 80 50 2 0 0
55 50 70 0 0 0
80 70 70 0 0 0
80 75 85 0 0 0
80 70 60 0 0,5 0
90 85 70 0 0 0
65 75 70 2 5 3
90 85 90 0 0 0
70 40 50 2 3 0
90 85 65 0 0 0
80 65 80 0 0 0
70 40 70 0 0 0
65 75 80 0 0 0
85 90 80 0 0 0
70 70 85 0 0 0
70 70 60 0 0 0
75 85 80 0 0 0
45 60 30 0 0 0
70 75 90 0 0 0

70 80 75 0 0 0
60 55 55 0 0 0
30 70 60 0 2 0
70 40 40 0 0 0
60 90 75 3 5 NA
70 65 65 0 0 0
50 65 65 NA NA NA
70 40 75 0 2 0
70 70 50 0 0 0
50 70 50 0 0 0
60 65 70 0 0 0
70 80 80 0 0 0
75 75 80 2,5 0 0
85 70 70 0 0 0
80 75 80 0 0 2,5
65 80 70 0 0 0
70 80 70 0 0 0
60 80 70 0 0 0
60 60 60 0 0 0
65 80 80 0 0 0
70 90 80 2 1,5 0
70 70 65 0 0 0
60 70 50 0 0 0
80 85 90 0 0 0
85 80 85 0 0 0
80 70 90 4 3 0
80 80 90 0 0 0
80 90 85 0,5 0 0
90 75 75 0 4 0
70 80 80 0 0 0
75 55 70 0 0 0
55 50 40 1,5 3 0
80 60 70 0 0 0
50 40 35 3 0 3
60 50 70 0 0 0
70 40 50 0,5 0 0
60 45 55 0,5 0,5 0
60 60 60 0 0 0
60 50 50 0 0 0
85 70 70 2 2 2

75 60 65 0 0 0
90 60 60 0 0 0
60 55 55 0 0 0
30 65 75 0 0 0
80 70 65 2 1 0
90 55 80 0 0 0
85 90 70 0 0 0
70 65 70 3 2 2
75 55 55 0 0 0
70 50 70 0 0 0
70 80 70 0 0 0
75 90 60 1 0,5 0
70 90 70 3 2 2
90 80 90 0 0 0
60 90 90 2 1 2,5
70 80 80 0 3 0
65 50 60 2 2 0
70 55 70 0 0 1,5
80 45 55 0 0 0
70 40 60 0 0 0
90 70 80 0 0 0
90 80 90 4 3 3
90 70 70 2 3 0
90 40 70 0 0 0
80 55 55 0 2 0
70 70 70 0 0 0
80 80 80 2 1 0
90 80 70 0 0 0
80 55 65 0 0 0
60 40 60 3 2 NA
80 40 70 0 0 0
90 50 70 3 2 0

60 70 70 0 0 0
90 80 80 0 0 0
70 70 65 0 0 0
80 60 70 0 0 0
80 60 70 0 0 0
80 55 80 0 0 0
75 65 60 0 0 0
70 70 75 0 0 0
60 60 70 0,5 0 0
90 45 80 1 3 0
80 45 60 1 0 0
85 45 45 0 1 0
70 80 70 0 0 0
70 80 80 0 0 0
90 60 80 NA NA NA
80 60 55 0 0 0
70 50 60 NA NA NA
50 70 50 3 5 1,5
80 80 80 0 0 0
90 90 80 3 1 1
90 25 80 0 2 0
70 60 70 0 0 0
45 60 30 2,5 1 0
90 70 60 0 0 0
80 45 60 0,5 0 0
90 80 70 0 0 0
55 70 60 1 0 0
85 70 70 1 1,5 2
90 75 70 0 0 0
80 70 70 3 2 2
70 90 70 0 0 0
70 80 65 0 0 0
80 90 70 0 0 0
60 80 40 1 1,5 0
80 60 70 0 0 0
80 70 60 0 0 0
75 70 65 0 0 0
90 50 90 0 0 0
80 70 90 0 0 NA
80 75 80 0 0 0
90 60 90 0 0 0
60 75 60 0 0 NA
70 35 40 1,5 0 3,5
90 70 80 3 2 2
45 70 60 NA NA 4
90 90 80 2 0,5 1
90 60 70 0 0 0
80 70 60 3 2 0
35 50 45 0 0,5 0
90 70 75 0,5 0 0
90 55 75 1,5 0 0
90 80 50 0 0 0
90 80 80 0 0 0
60 70 80 2 3,5 1
90 70 70 0 0 2
90 80 80 1,5 0 0
90 60 90 0 0 0
80 80 70 0 0 0
90 80 80 2 2 NA
90 75 70 1 0 0
90 90 60 0 0,5 0
90 80 75 2 1 0
90 50 60 0 0 0
80 35 55 NA NA NA
90 80 80 0 0 0
90 75 80 0 0 0
35 55 40 NA 0,5 NA
80 50 55 1,5 0 0
90 80 80 1,5 1 0
80 75 70 0 0 0
90 70 80 1 0 0
90 90 90 0 0 0
10 90 80 1,5 0 0
90 80 70 0 0 0
80 70 80 3 0,5 0
90 60 60 0,5 1 0
90 70 80 0 0 0
60 90 90 1 0 0
90 70 80 0 0 0
90 40 45 0 0 0
80 60 55 1 0,5 0
90 70 80 3 2 0
90 80 70 0 0 0
70 80 80 0 0 0
90 80 80 0 0 0
90 70 80 0 0 0
90 60 80 0 0 0
80 70 80 0 0 0
90 80 90 0 0 0
70 90 90 1 0 0
60 80 80 0 0 0
80 40 70 0 2 NA
80 70 80 0 0 0
90 70 70 0 1 0
70 70 60 0,5 0 0
50 80 60 4 0 2
90 80 80 0 0 0
 1 - ada
2 - tidak ada

PEMERIKS

SI DENGAN ANGKA YANG TERTERA DLM FORM)

PPONENT TIP TO TIP DIGITI II OPPONENT TIP TO TIP DIGITI III OPPONENT TIP TO TIP DIGITI IV OPPONENT TIP TO TIP DIG

Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra

0 0 0 0 2 2
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 0 3
0 0 0 0 5 4
4 0 0 0 3 0
3 3 4 4 6 6
0 0 0 0 0 0

0 0 0 0 0 0
0 4 0 5 2 6
0 0 3 0 4 0
2 2 3 3 4 5
0 0 0 0 0 1
0,5 2 0 3 3 0
0 0 0 1 0 4
0 0 0 0 0 0
1 0 3 0 5 0
0 0 0 0 0 0

0 0 0 0 0 2
0 2 0 3 0 5
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 0 0 0
0 5 0 4 5 5
0 0 0 0 0 1
0 0 0 0 0 0
0 0 3 0 4 0
0 1 0 3 0 6
3 0 2 3 4 4
0 0 0 0 0 0
0 0 0 3 0 6
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 3

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 3
0 0 0 0 3 0
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 5 0 6 0
0 0 4 5 6 6
0 0 0 0 0 0
0 0 0 0 0 3
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0,5
0 0 0 0 0 0,5
4 5 5 6 6 7
0 0 0 0 0 0
0 0 0 0 2 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 2
0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 2 0
0 0 0 3 0 0
NA NA NA NA NA NA
0 0 0 4 0 6
NA NA NA NA NA NA
1 0 2 0 4 0
0 0 0 0 3 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0,5
0 0 0 3 0 5
0 0 0 0 0 0
0,5 5 2 3 3,5 1
0 0 0 0 0 0
0 0 0 3 4 5
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 0 0 0
0 0 0 2 1,5 2
0 0 0 0 0 2
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 4 0 4 0 7
0 0 0 0 0 0
0 0 0 0,5 0 3
0 0 0 0 2 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 2
0 0 0 0 0 0
0 5 0 6 4 8
0 0 0 1 0 5
0 0 0 0 0 0
0 0 0 3 0 4
0 0 0 0 0 0
0 0 0 0 0 0
1 3 1,5 3 3 5

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 2 0,5
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 2 0 1 0 2,5
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
 0 0 0,5 0 2,5 1,5
0 3 2 4 4 5
0 0 0 0 0 0
1,5 2 2,5 1 4 4
0 0 0 0 0 0
0 0 0 0 0 3
0 1 1 1 3 4
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
2 NA 3 NA 4 NA
0 1 2 2 3 0,5
0 0 0 0 0 0
0 0 0 0 0 0
0 0.5 0 2 0 3,5
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 2 0 3
0 0 0 0 0 0
0 5 0 NA 0 NA

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 0 3
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 3 0
4 0 1,5 0 3 2
NA 0 2 9 1,5 3
0 0 0 0 3 2
1 1 2 0,5 2 1,5
0 0 0 0 0 0
NA NA NA NA NA NA
0 0 0 0 0 0
NA NA NA NA NA NA
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 1 0 2
0 0 0 0 0 0
0 0 0 0 0 0
0 0 1 0 4 2
0 0 0 0 0 0
 2 0 3 0 6 4
0 0 0 0 1,5 0
0 0,5 0 2 0 3,5
0 0 0 0 0 2
0 0 0 0 0 0
0 1 0 3 2 5
NA 0 NA 0 NA 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 3 1 4
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 2,5
0 0 0 0 1,5 0
0 0 0 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
2 3 1 2 3 3
0 0 0 1,5 0 4
2 3 3 3 2,5 4
4 3 5 5 3 6
0 2 0 3 0 3,5
0 0 0 0 0 2
0 0 0 0 0 2
2 0 3 0 5 1,5
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 NA
0 0 0 0 0 0
0 3 0 5 NA 6
1 2 0 2 0 2
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 1
0 NA 0 0 0 0
0 1 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 2
NA NA NA NA NA NA
0 0 0 0 0 0
0 0 0 0 0 0
0 Na 2 NA 3 NA
0 1 0 2 0,5 1,5
0 0 0 0 0 2
0 0 0 0 0 0
 0 0 0 0 0 0
0 0 0 0 0 2
NA 0 0 1 0 2
0 0 0 0 0 0
0 0 0 0 0 1
0 0 0 0 0 1
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
2 0 2 1 4 3
0 0 0 0 0 0
NA NA NA NA NA NA
0 0 0 0 0 0,5
0 0 0 0 0 0
1 0 4 1,5 5 4
0 2 0 NA 1 NA
0 0 0 0 0 0
 0- tidak ada 0- tidak ada 0- tidak ada 0- tidak ada 0- tidak ada 0- tidak ada
1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang
2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 2 - ada

PEMERIKSAAN FISIK EKSTREMITAS ATAS

SENSIBILITAS LIGHT TOUCH

PONENT TIP TO TIP DIGITI V NERVUS ULNARIS NERVUS MEDIANUS NERVUS RADIALIS

Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra

5 0 0 0 0 0 0
0 2 0 2 0 2 2
0,5 0 0 0 0 0 0
0 0 0 0 0 0 0
0,5 0 0 0 0 0 0
0 2 2 2 2 2 2
0 2 2 2 2 1 1
0 0 2 1 2 0 2
0 1 1 2 2 2 2
0 2 2 2 2 2 2
1 0 0 0 0 0 0
0 0 0 2 2 1 1
0 0 0 0 1 0 0
3 2 0 1 0 2 0
0 1 1 0 1 0 0
0 2 2 2 2 2 2
0 1 2 1 2 0 2
0 1 NA 1 NA 0 1
7 2 2 2 2 2 2
5 1 0 1 0 0 0
5 0 0 0 0 0 0
0 1 1 2 2 2 2

2 1 0 1 0 0 0
3 1 1 1 1 1 1
6 0 0 1 0 0 0
7 0 0 0 0 0 0
1 0 0 0 0 2 0
4 0 0 0 0 0 0
0 0 0 0 0 1 2
0 2 0 2 0 2 0
4 1 1 1 1 1 1
0 0 0 0 1 1 1

0 0 0 0 0 0 0
0.5 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 2 1 2 2 2
0 2 2 2 2 2 2
0 2 2 2 2 2 2
0 0 0 0 0 0 2
0 0 0 0 0 0 0
0 0 0 0 0 0 0
6 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 2 1 2 1 2
4 2 0 2 0 2 0
2 0 0 0 0 0 0
5 0 0 0 0 0 0
0 0 2 1 1 1 1
2 0 0 0 0 0 0
0 2 2 2 2 2 2
0 1 1 1 1 2 1
0 0 0 0 0 2 2

0 2 2 2 2 2 2
0 0 0 0 0 0 0
0 2 2 2 2 2 2
0 0 0 0 0 0 0
0 0 0 0 2 0 2
4 0 0 0 0 2 2
1 1 1 1 1 1 1

0 0 0 0 0 0 0
0
7 0 0 0 0 0 0
6 0 0 0 0 0 0
0 1 1 1 1 0 1
2 0 0 0 0 2 2
0 0 2 0 0 2 0
1 0 0 0 0 0 0
0,5 2 2 2 2 2 2
0 0 0 0 0 0 0
7 0 0 0 0 0 0
0 2 2 2 2 2 2
1 0 0 0 0 0 0
0 2 2 2 2 2 2
0 2 2 2 2 2 2
0 0 2 0 2 2 2
2 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 2 0 0 2
1 0 0 0 0 0 0
0 2 2 2 2 2 2
0 2 2 2 1 1 0
1 0 0 0 0 2 2

0 1 1 1 1 0 0
0 0 0 1 1 1 1
4 0 0 0 0 0 0
0
NA 0 0 0 0 0 0
0 0 1 0 0 0 0
 0 0 0 0 0 0 0
6 0 0 0 0 0 0
4 0 0 0 0 0 0
0 2 2 2 2 2 2
0 2 2 2 2 2 2
0 0 1 0 1 1 1
1 0 0 0 0 0 0
1,5 2 0 0 0 2 0
4,5 0 2 0 2 0 2
1 0 0 0 0 0 0
5 0 0 0 0 0 0
0
0 0 0 0 0 0 0
0 2 2 2 2 2 2
2 0 0 0 0 0 0
4 0 0 0 0 0 0
0 0 0 0 0 0 0
0 2 2 2 2 2 2
0 0 0 0 0 0 0
2 0 0 0 0 0 0
0 2 2 2 2 2 2
0 2 2 2 2 2 2
3 0 0 1 0 0 0
0,5 0 1 0 1 1 1
0 0 0 0 0 2 0
2 0 0 0 0 0 0
0 1 1 1 0 1 1
5 0 0 0 0 0 0
0 0 1 1 0 1 2
2 0 0 0 0 0 0
2 0 0 0 0 0 0
0 1 2 1 2 1 2
0 0 2 2 2 2 2
5 0 0 0 0 0 0

0 0 0 0 0 1 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
3 0 0 0 0 0 0
0 0 0 0 0 0 0
0 2 2 2 2 1 1
0 2 2 2 2 2 2
3 0 0 1 1 0 0
0 2 2 2 2 2 0
0 0 0 0 0 0 0
0 1 0 0 2 0 0
 4 0 0 0 0 0 0
5 0 0 0 0 0 0
0 0 0 0 0 0 0
5 0 0 0 0 0 0
0 1 1 1 1 0 0
2 0 0 0 0 0 0
5 0 0 0 0 0 0
0 2 2 2 2 2 2
0 0 0 0 1 0 0
0 0 0 0 0 0 0
NA 1 1 1 1 1 0
3,5 0 0 0 0 0 0
0 1 0 1 1 0 1
0 3 0 2 2 2 2
2 0 0 0 0 0 0
0,5 0 0 0 0 0 0
0 0 0 0 0 2 2
2 2 0 2 0 2 0
0 0 0 0 0 0 0
0 0 0 0 1 1 1
2 2 0 0 0 0 0
2 2 0 2 2 2
0 0 2 2 0 2 0
0 0 1 1 1 0 0
0,5 0 0 0 0 0 1
0 1 0 0 0 0 0
0 2 2 2 0 2 2
0 1 1 1 0 0 0
0 2 2 2 2 2 1
0 2 1 0 1 0 0
5 2 0 0 0 0 0
5 0 0 0 0 0 0
3 0 0 0 0 0 0
4 0 0 0 0 0 0
2 0 0 0 0 0 0
NA 0 2 0 2 0 0
NA 0 0 0 0 0 0
0 1 2 1 2 1 1
NA 0 0 0 0 0 0
NA 0 0 0 0 0 0
0 0 0 0 0 0 0
0.5 0 0 0 0 0 0
0 0 0 0 0 0 0
0,5 2 1 2 1 2 2
4 0 0 0 0 0 0
0 2 2 2 2 2 2
 8 0 0 0 0 0 0
1 1 0 1 0 2 0
0,5 0 1 0 0 0 0
2 0 0 0 0 0 0
0 1 1 2 2 2 0
3 2 1 2 0 0 0
NA 0 0 1 1 2 0
0 1 1 1 1 1 1
0 2 0 2 2 2 2
0,5 0 0 0 0 0 0
0 0 1 1 0 0 2
0 0 0 0 0 0 0
2 0 0 0 2 0 2
2 0 0 0 0 0 0
0,5 0 0 0 0 0 0
0 0 0 2 2 0 2
0 0 0 0 1 0 0
4 0 0 0 0 0 0
0,5 0 0 0 0 0 0
5 0 0 0 0 0 0
5 0 0 1 1 0 0
0,5 0 0 0 0 0 0
1 0 0 0 0 0 0
2 0 0 0 0 1 0
6 0 0 0 0 0 0
0 0 1 0 2 0 2
0 2 1 2 2 2 1
NA 0 0 0 0 0 0
0 0 0 0 2 0 2
NA 0 0 0 0 0 0
3 0 0 0 0 0 0
1 0 0 2 0 2 0
0 2 2 2 2 0 0
2 0 0 0 0 0 0
2 0 0 0 2 0 0
0 0 0 0 0 0 0
1 0 1 2 1 0 0
0 2 0 2 2 2 0
2 2 2 2 2 0 0
NA 0 0 0 0 0 0
0 0 2 0 0 1 0
0 2 2 2 2 2 1
4 0 0 0 0 0 0
1 0 0 0 0 0 0
2 0 0 0 0 0 0
0 2 2 2 2 2 2
 0 0 0 0 0 0 0
1,5 0 0 0 0 0 0
0 0 0 0 0 0 0
NA 2 2 2 2 2 2
1,5 0 0 0 0 0 0
0 2 2 1 1 0 2
0 0 1 0 1 0 1
0 0 0 0 0 0 0
0 2 2 2 2 0 0
3 2 0 0 0 0 0
0 0 0 0 2 1 1
2 0 0 2 0 0 0
0 2 2 2 2 2 2
0 2 2 2 2 2 2
0 2 2 2 2 2 0
0 0 0 2 2 2 2
0 2 2 2 2 2 0
0 0 2 2 2 0 0
0 1 1 1 1 0 0
5 0 0 0 0 0 0
0 2 2 1 2 0 0
NA 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
5 0 0 0 0 0 0
2 0 0 0 0 0 0
0 2 2 1 0 0 0
0- tidak ada 0- tidak ada 0- tidak ada 0- tidak ada 0- tidak ada 0- tidak ada
1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - ada
2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 2 - tidak ada

SENSILIBILTAS PIN PRICK

NERVUS ULNARIS NERVUS MEDIANUS NERVUS RADIALIS LATERAL PINCH

Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra

2 0 2 0 2 2 1
2 2 2 2 2 2 1
2 1 2 1 1 1 1
2 1 1 1 2 1 2
2 2 2 2 2 2 2
2 2 2 2 2 2 1
1 1 1 1 2 2 1
1 1 2 1 0 1 1
1 0 1 1 1 1 1
2 2 2 2 2 2 1
2 1 1 0 1 1 2
2 1 2 1 1 2 1
2 2 1 2 2 2 1
0 0 0 0 2 0 1
1 1 1 1 1 1 1
2 2 2 2 2 2 1
2 2 2 2 2 2 1
1 1 0 1 0 1 1
2 2 2 2 2 2 2
2 1 2 1 2 0 1
0 0 0 0 0 0
1 1 1 1 1 1 1

2 1 2 1 2 2 1
1 1 1 1 1 1 1
0 0 1 0 0 0 1
0 0 0 0 0 0 2
1 2 2 2 2 2 1
0 0 0 0 0 0 2
0 0 0 0 1 1 1
0 0 0 1 0 0 1
1 1 1 1 1 1 1
0 0 1 1 2 2 1

1 0 1 0 2 1 1
0 0 0 0 0 0 1
2 2 2 2 2 2 1
2 2 2 2 2 2 1
2 2 2 2 2 2 1
2 2 2 2 2 2 1
2 2 2 2 0 0 1
0 0 2 0 0 0 1
1 2 1 2 1 2 1
2 0 0 0 0 0 2
0 1 0 1 0 2 1
2 2 2 2 2 2 1
2 1 2 1 2 1 1
2 2 2 2 2 2 2
0 0 0 0 0 0 1
0 2 1 2 1 2
0 0 0 0 0 0 2
2 2 2 2 2 2 1
1 1 1 1 1 1 1
0 0 0 2 0 2 1

1 2 1 2 1 1 1
2 2 2 2 2 2 1
2 2 2 2 2 2 2
2 2 2 2 2 2 1
0 0 1 1 0 2 1
1 1 1 1 1 1 1
2 2 2 2 2 2 1

1 1 1 1 1 1 1

2 0 0 0 2 0 1
0 1 1 1 0 1 1
0 1 1 1 0 1 1
1 1 1 1 1 1 1
2 2 2 2 2 2 1
2 0 0 0 1 0 1
1 1 1 1 1 1 1
0 0 0 1 0 0 1
1 1 1 1 1 1 2
2 2 2 2 2 2 1
0 0 0 0 0 0 1
2 2 2 2 2 2 1
2 2 2 2 2 2 1
1 1 1 1 1 1 1
0 0 0 0 0 0 1
1 1 1 1 2 1 1
2 1 2 1 2 2 1
0 0 0 0 0 0 2
2 2 2 2 2 2 1
1 1 2 2 1 1 1
1 1 1 1 1 1 1

2 2 2 2 2 2 1
1 1 1 1 1 1 1
0 0 0 0 0 0 2

0 0 0 0 0 0 2
0 1 0 1 0 1 3
0 0 0 1 1 2 2
2 0 2 0 2 0 2
0 0 0 0 0 0 1
1 1 1 1 1 1 1
2 2 2 2 2 2 1
1 1 1 1 1 1 1
0 1 0 0 0 0 2
2 0 0 0 2 0 1
0 2 0 2 0 2 2
1 1 1 1 1 1 1
0 0 0 0 0 0 1

1 0 1 0 1 0 1
2 2 2 2 2 2 1
0 0 0 1 0 0 1
2 0 2 0 2 2 1
1 1 1 1 1 1 1
1 2 1 2 1 2 1
0 1 0 1 1 1 1
2 0 2 0 2 0 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 2 2 2 1
1 1 1 1 1 1 1
2 1 2 1 2 1 1
0 0 0 0 0 0 2
0 1 0 1 0 0 1
0 0 0 1 0 0 1
0 0 0 0 0 1 1
1 2 1 2 1 2 1
1 2 2 2 2 2 1
0 0 0 0 0 0 2

1 1 1 1 1 1 1
0 0 0 1 0 0 1
1 1 0 1 1 1 1
1 1 1 1 0 0 2
1 1 1 1 0 0 1
1 1 2 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 0 0 1
1 1 1 1 2 2 1
1 2 1 1 0 0 1
1 0 1 2 0 0 1
0 0 0 0 0 0 1
0 0 0 0 0 0 2
0 0 0 0 0 0 1
1 1 1 0
1 1 1 1 1 1 1
0 0 0 0 0 0 1
1 1 1 1 0 0 2
1 1 1 1 2 2 1
0 1 1 1 0 0 1
1 1 1 1 1 1 1
1 1 1 0 1 1 2
0 0 0 0 0 0 2
2 1 1 1 1 1 1
2 2 2 2 2 2 2
0 0 0 0 0 0 1
1 1 1 1 0 0 1
1 1 2 1 1 1 1
2 0 2 0 2 0 1
0 0 0 0 0 0 1
1 1 0 1 1 1 1
0 0 0 1 0 0 2
2 2 2 1 1 1 1
2 1 2 0 1 0 1
1 1 1 1 0 0 1
0 0 0 0 1 0 1
1 1 1 2 0 0 1
1 1 1 0 1 1 1
0 1 2 1 2 0 1
2 2 2 2 1 1 1
1 1 1 1 1 1 1
0 0 2 0 0 0 1
0 0 0 0 0 0 2
0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 2 0 0 2 1
2 2 1 2 1 1 1
0 0 0 0 0 0 2
1 1 1 1 2 2 1
0 0 0 0 0 0 2
0 0 0 0 0 0 2
1 1 1 1 1 1 1
0 0 0 0 0 0 2
0 1 1 0 0 0 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
0 0 1 0 1 1 2
1 0 1 0 1 0 1
1 1 0 1 0 0 2
0 0 0 0 0 0 1
1 1 1 2 1 1 1
1 1 1 1 1 1 2
0 0 1 0 1 0 1
1 1 1 1 1 1 2
2 0 2 2 2 2 1
0 0 0 0 0 0 1
0 1 2 0 0 2 1
1 1 1 1 1 0 1
0 0 0 1 0 0 2
0 0 0 0 0 0 1
0 0 0 0 0 0 2
1 1 1 1 1 1 1
0 0 1 0 1 0 1
0 0 0 0 0 0 2
1 1 1 1 0 1 2
0 0 0 0 0 0 1
2 1 1 2 0 0 1
1 1 2 1 1 1 2
0 0 0 0 0 0 1
0 0 0 0 2 0 2
0 0 0 0 0 0 1
0 2 0 2 0 2 1
1 1 1 1 1 0 1
0 0 0 0 0 0 2
0 1 0 2 0 1 2
1 1 1 1 1 1 1
1 1 1 1 1 1 2
2 1 1 2 1 1 1
1 1 1 1 0 0 1
0 0 1 0 0 0 1
0 1 1 1 0 0 2
0 0 0 0 0 0 1
1 0 1 2 1 0 1
1 0 1 1 1 0 1
1 1 1 1 1 1 2
0 0 0 0 0 0 2
1 2 1 0 1 0 1
1 1 1 1 1 1 1
0 0 1 0 1 0 2
0 0 0 0 0 0 1
0 1 0 1 0 0 1
1 1 1 1 1 1 1
1 0 1 1 1 1 2
0 0 0 0 0 0 2
0 0 0 0 0 0 1
1 1 1 1 2 1 1
0 0 0 0 0 0 1
1 1 1 1 1 2 1
0 2 0 2 0 2 1
0 0 0 0 0 0 1
1 1 1 1 1 1 1
1 1 1 1 1 1 1
2 2 2 2 0 1 1
0 0 1 2 1 0 2
2 2 2 2 1 2 1
1 1 1 1 1 1 1
2 1 2 2 2 0 1
2 2 2 2 2 2 1
2 2 2 1 2 0 1
1 1 1 1 0 0 1
1 1 1 1 0 0 1
0 0 0 0 0 0 2
1 2 1 1 2 2 1
0 0 0 0 0 0 2
0 1 2 2 0 0 1
0 0 0 2 0 0 2
0 0 1 1 2 2 2
0 0 0 0 0 0 1
2 2 2 2 2 2 1
 SENSIBILITAS MONIFI

1 - ada 1 - ada 1 - ada 1 - ada 1 - ada

2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada

PINCH

LATERAL PINCH TIP TO TIP THREE JAW CHUCK POWER (IN KG)

Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra

2 1 2 1 2 4.5 4.25
1 1 1 1 1 10.5 7.5
2 1 2 1 2 5.5 3.75
1 2 1 1 1 3.5 3.5
2 2 2 1 2 3.75 1.5
1 2 2 1 1 3,35 3,75
1 1 1 1 1 6,5 7
1 1 2 2 2 3,25 5,25
1 1 1 1 1 6 4,5
1 1 1 1 1 6,5 6,5
2 2 2 2 2 3 1,5
1 1 1 1 1 3,5 4
1 1 1 1 1 7 6,25
1 1 1 1 1 3,25 2,5
1 1 1 1 1 7 6,5
1 1 1 1 1 5 4,5
1 2 1 1 1 6 5
1 2 1 1 1 2,5 5,5
2 2 2 2 2 4,25 4,5
1 1 2 1 1 4,5 2
5,5 3,75
1 1 1 1 1 6 7,5

2 1 2 1 2 5 4,5
1 2 2 1 1 NA 4
2 1 2 1 2 5,75 5
2 2 2 1 1 1,5 0,5
1 1 1 1 1 5 5
2 2 2 1 1 NA 3,5
1 2 1 1 1 4,25 5
1 1 1 1 1 6,75 5
1 1 2 1 1 6,5 6
1 1 1 1 1 4,5 6

1 1 2 1 1 6 4
1 1 2 1 2 6 3
1 1 1 1 1 5.5 6.5
1 1 1 1 6 3,75
1 1 1 1 1 6,25 5,5
1 1 1 1 1 7 6,5
1 1 1 1 1 5,5 5
1 2 1 1 1 2,75 1,5
1 2 1 2 1 5 4,5
1 2 2 2 2 NA NA
1 2 2 1 1 6 6,75
1 1 1 1 1 3,5 6,75
1 1 1 1 1 4,5 4,25
2 2 2 1 1 2,5 2,5
1 2 2 2 2 3,25 4,5
7,5 6
1 2 1 1 1 5 4,5
1 1 1 1 1 4,5 6,5
1 1 1 1 1 6,75 6,25
1 2 1 1 1 2,5 2,5

1 1 1 1 1 6,75 4,75
1 1 1 1 1 3 3
2 2 2 1 1 6,5 5,5
1 1 1 1 1 6,25 5
1 2 1 1 1 4,5 4,75
1 1 2 1 1 4,5 4,5
1 1 1 1 1 5,5 3,75

1 1 1 1 1 7 5,25
3,75 2,5
2 1 2 1 2 3 NA
1 2 2 1 1 3,75 2,5
1 1 1 1 5,5 3,5
1 1 1 1 1 6,5 4
1 1 1 1 1 4,75 6,5
1 1 1 1 1 5,75 2,75
2 1 1 1 1 3,75 4
1 1 1 1 1 4,25 4,5
2 2 2 2 1 1,5 3
1 1 1 1 1 7,5 7
2 1 2 1 2 2,5 1,5
1 1 1 1 1 5,75 6,5
1 1 1 1 1 5,75 5,25
1 1 1 1 1 5 12
2 2 2 2 1 2,5 3,5
1 1 1 1 1 6,5 5
1 1 1 1 1 3 1,5
2 1 1 2 2 7 3,5
1 1 1 1 1 4,5 6,5
1 1 1 1 1 7 5
1 1 1 1 1 7 6

1 1 1 1 1 4,5 3
1 1 1 1 1 5 6,25
2 2 2 1 1 5 NA
5,5 6,5
2 2 2 2 2 NA NA
1 3 1 2 1 NA 7
2 2 2 2 2 NA NA
2 1 2 1 2 7,5 NA
2 1 2 1 2 6 3,5
1 1 1 1 1 4 6,5
1 1 1 1 1 6,5 6
1 1 1 1 1 2,5 6
1 2 2 1 1 NA 3
1 1 2 1 2 5,5 4
1 2 1 2 1 4 5,5
1 1 1 1 1 4 1,5
1 1 2 1 2 4,5 3,5
4,5 3
1 1 1 1 1 2,5 2,5
1 1 1 1 1 6,5 4,25
1 2 2 1 1 5,25 4,75
1 1 1 1 1 7,5 5,5
1 2 2 1 1 7,5 8,5
1 1 1 1 1 4.25 5
1 1 1 1 1 3,5 3
1 2 2 1 1 5 3,5
1 1 1 1 1 6,25 6,5
1 1 1 2 1 3 4
2 1 2 1 2 3,5 3
1 1 1 1 1 2,5 6
1 1 1 1 1 3,5 4
1 1 1 1 2 8,5 5
1 1 1 1 1 7 3
1 2 1 2 1 0,5 4,5
1 1 1 1 1 3 5,5
1 1 1 1 1 3,5 3,25
1 1 2 1 2 4,5 4,5
1 1 1 1 1 5 8,5
1 1 1 1 1 3 6
1 2 2 2 2 NA NA

1 1 2 1 1 5 3
1 1 1 5 4
1 1 1 1 1 4,5 5
1 1 1 1 1 3 2,5
1 2 1 1 1 6 8,5
1 1 1 1 1 5 4
1 1 1 5,5 6
1 2 1 1 NA NA
1 1 1 1 1 7,5 5,5
1 1 1 1 1 5 4
1 2 1 1 1 3,5 3,5
2 2 2 1 2
2 2 1 2 1 3,5 2,5
1 1 1 2 1 7,5 8
2 2 2 2 1 1 NA
1 1 1 1 1 3,5 3,5
1 2 2 2 2 5,5 6
1 2 2 1 1 2,5 2
1 1 1 1 1 8,5 7
1 1 1 1 1 5,25 3
1 1 1 1 1 4,5 3,5
2 2 2 2 2 NA NA
2 2 2 2 2 3 3
2 1 1 1 2 7 3
2 5 4
1 2 2 1 1 2 2,5
1 1 1 1 1 5 4,5
1 1 1 1 1 6,5 6
2 1 1 1 1 5,5 3
2 2 2 2 2 NA 5
1 1 1 6 5
1 2 1 2 2 NA 3,5
1 1 1 1 1
1 1 1 1 1 6,5 2,5
1 1 1 1 1 7,5 4,25
1 2 2 1 1 3,5 3,5
1 1 1 1 1 1,5 2,5
1 1 1 1 1 7,5 3,5
1 1 1 1 1 6 6,5
1 1 1 1 1 8,5 7,5
1 1 1 1 1 8,5 6
1 1 2 1 2 7,5 NA
2 1 2 1 1 4,5 2
NA 3,5
1 1 1 1 1 3 3
1 1 1 1 1 5,5 3,5
1 1 1 1 1 4,5 2
2 2 2 2 2 NA NA
1 1 1 1 1 7,5 9
2 2 2 2 2 NA NA
1 2 2 2 2 4 1,5
1 1 1 1 1 3,5 3,25
1 2 2 1 1 2,5 2,5
1 1 1 1 1 6 5
1 1 1 1 1 5,5 2,5
1 2 2 1 1 4,5 7,5
1 1 1 1 1 4,25 4,25
2 2 2 1 1 2 NA
2 1 2 1 2 4 NA
1 2 2 1 1 NA 2,5
1 2 2 2 1 3 4
1 1 1 1 1 3 3
2 1 1 1 1 3,5 3,5
2 1 2 1 2 3,5 NA
2 1 1 1 1 5,5 5,5
1 1 1 1 1 5 3,5
2 2 2 2 2 NA NA
1 1 1 1 1 4 3,5
1 1 1 1 1 6 6,5
2 1 1 1 1 4 3
2 2 2 2 2 1,5 NA
1 2 1 2 1 2 5
1 1 1 1 1 6 5,5
1 2 1 1 1 4 2,75
1 2 2 2 1 2 NA
2 2 2 2 1 NA 4
1 2 2 1 1 2 0,5
1 2 2 2 2 2,5 2,5
2 2 2 2 2 1,5 2,5
1 2 2 2 2 3,5 4
2 2 2 2 2 5 3,5
1 2 2 2 2 4 NA
1 1 1 1 1 6 8,25
1 1 1 1 1 6 5,5
1 2 2 2 2 NA NA
2 1 1 1 1 3 3,5
1 2 2 2 2 2 1,5
2 2 2 2 2 NA NA
1 1 2 1 1 2,5 NA
1 1 1 1 1 3,25 2,5
1 2 2 2 2 3,25 3,5
1 2 1 2 1 2 2,5
1 2 1 1 1 5 6
1 1 1 1 1 2,5 2,5
1 1 2 1 1 4 2
2 1 1 1 1 3,5 2,5
2 2 2 2 2 NA NA
1 1 1 1 1 8 7
1 1 1 1 1 4 4,5
2 2 2 2 2 NA NA
1 2 2 2 2 7,5 4
1 2 2 1 1 4,5 4,5
1 1 1 1 1 9.5 10
2 1 1 2 1 5 4
2 2 2 2 2 NA 1
2 1 2 1 2 4 NA
1 1 1 1 1 7 6,5
1 2 2 2 2 5,5 5
1 2 2 1 1 8,5 6
1 1 1 1 1 4,5 8,5
1 1 1 1 1 3 3
1 1 1 1 1 7,5 7
1 1 2 1 2 7,5 NA
1 1 1 1 1
2 1 1 1 2 5,5 3,5
1 1 1 1 1 8,5 8,5
1 1 1 1 1 8 8,5
1 1 1 1 1 8 5
1 1 1 1 1 4,5 3,5
1 1 1 1 1 7,5 3,25
1 1 1 1 1 8,5 7,5
1 2 1 1 1 5,75 3,5
2 2 2 2 2 NA NA
1 1 1 1 1 20 18
2 2 2 2 2 NA NA
1 1 1 1 1 4,5 4,25
2 2 1 1 1 5 6
2 1 2 2 2 7,5 4,5
1 2 1 2 2 NA 3,5
1 1 1 1 1 4,5 45,
SENSIBILITAS MONIFILAMEN
ISI DENGAN :

1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada

2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada 2 - tidak ada

GRASP

SILINDER HOOK SPHERIC POWER (IN KG)

Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra

1 2 1 1 1 2 16
1 1 1 1 1 1 28
 1 1 1 1 1 1 19
1 1 1 1 1 1 14
2 1 1 1 2 2 10
1 1 1 1 1 1 14
1 1 1 1 1 1 22
1 1 1 1 1 1 1
1 1 1 1 1 1 22
1 1 1 1 1 1 20
2 2 2 1 2 2 16
1 1 1 1 1 1 13
1 1 1 1 1 1 13
1 2 1 1 1 2 20
1 1 1 1 1 1 14
1 1 1 1 1 1 18
1 1 1 1 1 1 25
2 2 2 2 2 2 10
2 2 2 2 2 2 12
1 1 1 1 1 1 16
NA NA NA NA NA NA NA
1 1 1 1 1 1 32

1 2 1 1 1 2 18
2 2 2 2 2 2 NA
1 2 1 1 1 2 24
1 2 1 1 2 2 4
1 1 1 1 1 1 18
2 2 1 1 2 2 NA
1 1 1 1 2 1 14
1 1 1 1 1 1 26
1 2 1 1 1 2 10
1 1 1 1 1 1 22

1 1 1 1 1 1 18
2 1 1 1 2 1 13
1 1 1 1 1 1 22
1 1 1 1 1 1 14
1 1 1 1 1 1 28
1 1 1 1 1 1 20
1 1 1 1 1 1 18
1 1 1 1 1 1 11
1 1 1 20
2 2 2 2 2 2 NA
1 1 1 1 1 1 18
1 1 1 1 1 1 15
1 1 1 1 1 1 26
2 2 1 1 2 2 6
1 1 1 1 2 2 20
30
2 2 1 1 2 1 18
1 1 1 1 1 1 17
1 1 1 1 1 1 22
1 1 1 1 1 1 8

1 1 1 1 1 1 16
1 1 1 1 1 1 12
1 1 1 1 1 1 14
1 1 1 1 1 1 20
1 1 1 1 1 1 19
1 1 1 1 1 1 15
1 1 1 1 1 1 17

1 1 1 1 1 1 24
6
1 2 1 1 1 2 11
2 2 1 1 2 2 NA
1 1 1 1 1 1 10
1 1 1 1 1 1 18
1 1 1 1 1 1 10
1 2 1 1 1 2 26
1 1 1 1 1 1 9
1 1 1 1 1 1 28
2 2 1 1 2 2 NA
1 1 1 1 1 1 22
1 2 1 2 1 2 10
1 1 1 1 1 1 19
1 1 1 1 1 1 23
1 1 1 1 1 1 18
1 2 1 1 2 2 7
1 1 1 1 1 1 26
1 1 1 1 1 1 10
1 1 1 1 1 1 24
1 1 1 1 1 1 21
1 1 1 1 1 1 20
1 1 1 1 1 1 26

1 1 1 1 1 1 18
1 1 1 1 1 1 24
1 2 1 1 1 2 9
30
2 2 2 2 2 2 NA
2 1 1 1 2 1 NA
2 2 2 2 2 2 NA
1 2 1 2 1 2 32
1 2 1 1 1 2 20
1 1 1 1 1 1 18
1 1 1 1 1 1 14
1 1 1 1 1 1 7
1 1 1 1 2 1 12
1 1 1 1 1 2 19
1 1 1 1 1 1 10
1 1 1 1 1 1 16
1 2 1 1 1 2 22
16
1 1 1 1 1 1 28
1 1 1 1 1 1 20
2 2 1 1 2 2 17
1 1 1 1 1 1 28
1 1 1 1 1 1 30
1 1 1 1 1 1 22
1 1 1 1 1 1 12
2 2 1 1 2 2 NA
1 1 1 1 1 1 22
2 1 1 1 2 1 NA
1 2 1 1 1 2 10
1 1 1 1 1 1 7
1 1 1 1 1 1 18
1 1 1 1 1 1 20
1 1 1 1 1 1 22
2 1 1 1 2 1 8
1 1 1 1 1 1 12
1 2 1 1 1 2 22
18
1 1 1 1 1 1 34
1 1 1 1 1 1 24
NA

1 1 1 1 1 1 14
1 1 1 1 1 1 28
1 1 1 1 1 1 12
1 1 1 1 1 1 30
2 1 1 1 1 1 18
1 1 1 1 1 1 16
1 1 1 1 1 1 16
2 1 1 1 2 1 NA
1 1 1 1 1 1 22
1 1 1 1 1 1 14
1 1 1 1 1 1 12
1 2 1 1 2 2
2 2 1 1 2 2 8
1 1 1 1 1 1 22
2 2 1 1 2 2 NA
1 1 1 1 1 1 14
2 2 1 1 2 2 NA
2 2 1 1 2 2 4
1 1 1 1 1 1 36
1 1 1 1 1 1 16
1 1 1 1 1 1 14
2 2 2 2 2 2 NA
2 2 1 2 2 2 4
1 1 1 1 1 1 31
12
2 2 2 1 2 2 NA
1 1 1 1 1 1 14
1 1 1 1 1 1 22
1 1 1 1 1 2 26
2 1 1 1 2 1 NA
1 1 1 1 1 1 14
2 1 2 1 2 2 NA
1 1 1 1 1 1
1 1 1 1 1 1 30
1 1 1 1 26
1 1 1 1 1 1 18
1 1 1 1 1 1 4
1 1 1 1 1 1 19
1 1 1 1 1 1 22
1 1 1 1 1 1 26
1 1 1 1 1 1 19
1 2 1 1 1 2 27
1 2 1 1 2 2 4
NA
1 1 1 1 1 1 14
1 1 1 1 1 1 4
1 1 1 1 1 1 20
2 2 2 2 2 2 NA
1 1 1 1 38
2 2 1 1 2 2 NA
2 1 1 1 2 2 10
1 1 1 1 1 1 12
2 2 1 1 2 2 1
1 1 1 1 1 1 22
1 1 1 1 1 1 30
1 2 1 1 1 2 20
1 1 1 1 1 1 13
1 2 1 1 1 2 9
1 1 1 1 1 1 22
2 1 1 1 2 1 14
2 2 1 1 2 2 4
1 1 1 1 1 1 16
1 1 1 1 1 1 9
1 1 2 2 2 12
1 1 1 1 1 1 8
1 1 1 1 1 1 20
2 2 1 1 1 2 4
1 1 1 1 1 1 14
1 1 1 1 1 1 16
1 1 1 1 1 1 24
1 1 1 1 1 1 16
1 1 1 1 2 1 14
1 1 1 1 1 1 16
1 1 1 1 1 1 15
1 1 1 1 1 1 14
2 1 1 1 2 2 14
1 2 1 1 2 1 8
2 2 2 2 2 2 NA
2 2 1 1 2 2 2
1 1 1 1 1 1 23
2 2 1 1 2 2 22
1 2 1 1 1 2 14
1 1 1 1 1 1 13
1 1 1 1 1 1 13
2 2 1 1 2 2 2
1 1 1 1 1 1 14
2 2 1 1 2 2 8
2 1 1 1 2 1 9
1 1 1 1 1 1 8
1 1 1 1 1 1 10
2 1 1 1 2 2 1
1 1 1 1 2 2 NA
2 1 1 1 1 1 13
1 1 1 1 1 1 12
1 2 1 1 1 2 8
1 1 1 1 1 1 12
3 3 3 3 3 3 NA
1 1 1 1 1 1 28
1 1 1 1 1 1 10
2 2 2 2 2 2 NA
2 2 1 1 2 2 22
1 1 1 1 1 1 10
1 1 1 1 1 42
2 1 1 1 1 1 23
2 2 1 1 2 2 8
1 2 1 2 1 2 13
1 1 1 1 1 1 20
1 2 1 1 1 2 12
2 1 1 1 2 1 24
1 1 1 1 1 1 22
1 1 1 1 1 1 12
1 1 1 1 1 1 22
1 1 1 1 1 2 16
1 1 1 1 1 1 14
1 1 1 1 1 1 12
1 1 1 1 1 1 18
1 1 1 1 1 1 33
1 1 1 1 1 1 18
1 1 1 1 1 1 23
1 1 1 1 1 1 20
1 1 1 1 1 1 29
1 1 1 1 1 1 18
2 2 1 1 2 2 6
1 1 1 1 1 1 5
2 2 1 1 2 2 NA
1 1 1 1 1 1 16
1 1 1 1 1 1 20
2 2 1 1 2 2 34
2 2 2 1 2 2 NA
1 1 1 1 1 1 9
 USG NERVUS ULNARIS

POWER (IN KG) KETERANGAN

CIRCUMFERENCE AREA

Sinistra

Dekstra Sinistra Dekstra

10 1,38 0,97 0,12
24 night splint 1,12 1,05 0,08
12 night splint bilateral 1,21 1,06 0,09
8 night splint bilateral 1,07 1,26 0,08
8 night splint 1,09 1,39 0,08
14 night splint bilateral 1,09 1,22 0,09
26 1,58 1,45 0,16
1 knuckle bender dextra 1,25 1,36 0,09
22 1,38 1,53 0,13
20 night splint dextra 1,98 1,28 0,07
10 9,41 10,33 0,07
20 kontraktur DIP/PIP V sinistra 13,71 14,91 0,12
17 1,64 1,03 0,17
10 night splint 1,40 1,03 0,07
14 10,48 12,2 0,07
16 14,57 13,21 0,14
27 night splint NA 1,53 NA
11 night splint 1,39 1,22 0,12
NA 1,08 1,08 1,80 0,06
10 night splint bilateral 12,57 15,74 0,1
NA 12,17 11,14 0,1
36 night splint dextra 17,09 15,53 0,2

13 knuckle bender 1,24 0,85 0,11

12 knuckle bender dextra - sinistra 1,11 0,90 0,09
11 knuckle bender sinistra 10,69 10,26 0,07
2 11,37 14,93 0,08
18 night splint 12,77 11,37 0,11
NA 11,38 11,44 0,06
13 night splint 1,09 1,27 0,06
22 15,48 15,14 0,17
NA
24 14,55 14,61 0,11

7 night splint dekstra 1.60 1.91 0.13

18 0.11 0.1 13.5
22 0.12 0.13 14.39
16 night splint
21 12,79 12,24 0,11
26 13,75 12,84 0,13
14 10,76 12,53 0,07
10 1,20 1,22 0,09
18 pasien buta 16,35 16,34 0,14
NA 14,96 14,65 0,11
28 knuckle bender 17,12 15,46 0,2
18 13,82 12,27 0,13
22 night splint bilateral 17,2 14,22 0,2
7 1,68 0,93 0,17
18 night splint 12,71 11,10 0,11
30 12,01 11,74 0,09
18 10,95 10,48 0,08
17 11,28 11,77 0,08
22 1,65 1,62 0,13
3 night splint sin 10,36 10,74 0,07
15,37 14,39 0,17
16 10,25 12,00 0,06
6 2,13 1,71 0,17
20 11,87 13,01 0,08
18 12,91 14,66 0,11
19 night splint sinistra 2,07 2,05 0,17
20 hand splint sinistra 10,51 11,77 0,07
14 hand splint sinistra 19,74 16,9 0,21

26 1,93 1,99 0,17

11 hand splint bilateral 1,58 0,06 0,1
NA 16,35 12,44 0,16
NA 1,44 1,98 0,13
16 1,36 1,68 0,10
23 hand splint bilateral 13,37 13,84 0,11
20 13,9 11,9 0,14
21 night splint bilateral 14,83 14,63 0,14
12 15,00 15,11 0,17
16 night splint bilateral 14,19 13,96 0,13
NA 15,03 14,97 0,14
24 1,42 1,52 0,12
9 3,97 2,63 0,63
18 15,6 15,83 0,18
22 1,94 1,61 0,15
42 hand splint dextra 18,22 15,21 0,19
6 hand splint bilateral 1,36 1,52 0,09
19 1,74 2,17 0,19
12 10,79 10,37 0,07
12 hand plint sinistra 13,23 11,91 0,08
20 2,21 1,46 0,23
2 1,75 1,63 0,17
22 hand plint bilateral 1,91 1,9 0,16

20 1,5 1,19 0,14

26 14,5 16,46 0,04
NA 11,58 12,53 0,08
23 10,84 12,81 0,07
NA 1,63 1,79 0,13
16 10,94 13,18 0,7
 NA 15,34 13,11 0,14
NA hand splint dextra 14,69 12,08 0,13
22 13,29 12,00 0,09
18 14,95 12,3 0,15
20 2,38 1,68 0,25
20 hand splint dextra 1,90 1,56 0,15
12 11,12 14,28 0,07
12 1,56 1,13 0,12
22 hand splint dextra 13,27 13,48 0,11
10 hand splint sinistra 1,31 1,05 0,07
24 night splint dextra 12,8 13,67 0,09
10 1,56 1,48 0,14
18 hand splint bilateral 12,85 11,57 0,1
16 18,9 14,58 0,17
16 11,07 12,12 0,9
28 hand splint bilateral 17,31 14,4 0,19
26 14,47 13,25 0,13
18 12,48 14,20 0,08
17 1,8 2,48 0,15
NA NA 13,55 NA
24 15,74 12,13 0,13
14 1,28 1,22 0,06
10 8,91 9,9 0,14
20 hand splint dextra post op 1,90 1,56 0,15
12 1,69 1,59 0,12
8 1,61 1,47 0,18
6 1,59 1,55 0,12
atrofi otot,
12dextra : kontraktur fleksi 3 & 5,sinistra: kontraktur digiti
1,57 1,2,3&5 1,38 0,11
dextra
16 : kontraktur 4&5, sinistra: deformitas fleksi, kontraktur
1,461 5 1,018 0,10
dextra:
18 kontraktur digiti 1-4, sinistra: kontraktur digiti 1.12
1-5 1.052 0,07
10 1,,72 1,16 0,13
32 1,552 1,368 0,17
31 1,4 1,17 0,14
NA 1,95 1,95 0,16

26 1,39 1,10 0,11

26 1,438 1,314 0,12
10 1,27 1,67 0,1
22 1,51 1,33 0,12
22 1,527 0,959 0,12
14 1,45 1,54 0,11
12 1,54 1,52 0,13
10 1,82 1,61 0,20
24 2,00 1,87 0,20
16 0,883 1,47 0,05
10 1,85 1,13 0,19
 onset usia 9 tahun 1,4 1,3 0,13
NA 1,53 1,61 0,14
28 onset kelas 4 SD 1,269 1,446 0,06
NA 1,07 0,90 0,06
10 1,50 1,49 0,10
NA 1,619 1,324 0,09
2 1,65 1,33 0,11
32 1,29 1,65 0,08
13 1,75 1,5 0,12
18 1,94 1,81 0,19
NA 1,49 1,33 0,16
NA 1,35 1,05 0,09
4 1,43 1,72 0,15
4 1,07 1,282 0,07
4 1,52 1,47 0,10
12 12,32 14,13 0,10
16 2,32 1,837 0,28
12 1,74 1,63 0,19
22 1,67 1,33 0,16
10 1,068 0,929 0,08
7,5 1,88 1,68 0,07
15,69 13,48 0,17
20 16,76 16,21 0,18
18 1,198 1,362 0,11
15 1,37 1,37 0,08
0,5 0,99 1,07 0,06
14 9,98 13,99 0,06
19 0,986 12,12 0,08
19 10,59 15,85 0,08
20 1,71 1,47 0,2
12 10,6 10,85 0,08
2
8 1,171 1,238 0,08
8 1,318 1,109 0,09
2 11,71 13,27 0,09
14 1,1 1,356 0,07
NA 1,86 1,71 0,16
36 1,87 1,95 0,17
NA 0,91 1,45 0,05
10 1,061 1,017 0,07
10 2,14 2,49 0,28
2 0,696 0,826 0,03
18 onset sd kelas 3 12,56 18,37 0,11
16 resting hand splint sinistra onset 1975 1,041 1,234 0,10
12 onset 1989 1,328 0,957 0,10
12 1,151 0,982 0,08
10 onset 1950 1,12 1,13 0,08
14 1,81 1,55 0,14
12 1,219 0,913 0,09
2 onset 1981 10,68 11,15 0,06
18 10,42 13,98 0,07
6 onset kelas 2 SD 3,08 2,27 0,62
NA onset 9161 12,64 12,38 0,07
6 1,597 1,295 0,10
12 9,74 11,56 0,07
8 onset 1985 14,98 10,93 0,12
14 onset 1985, resting hand splint dextra 1,05 1,36 0,07
10 1,50 1,54 0,14
24 onset 1989 1,12 1,12 0,08
2 onset SD kelas 3 13,65 12,16 0,12
8 onset 1982, resting splint bilateral 12,39 12,27 0,11
12 onset 1965 15,15 15,22 0,15
2 1,26 0,70 0,09
14 onset 2 SD, pernah splint operasi thn 87 1,87 1,58 0,17
20 onset 1985 14,09 10,14 0,14
18 onset SD kelas 1 13,08 12,34 0,09
NA onset 1990 12,88 NA 0,10
8 0,911 1,567 0,06
20 2,275 1,017 0,17
12 1,48 1,15 0,14
NA onset SD kelas 1 10,86 11,91 0,07
27 onset thn 1988 2,74 1,63 0,41
21 1,259 0,98 0,07
3 15,28 9,81 0,14
12 11,95 11,58 0,10
NA onset 30 thn yll 1,07 1,41 0,06
12 1,47 1,07 0,14
10 1,35 1,88 0,11
2 1,55 1,3 0,17
2 onset usia 10 thn, resting hand splint bilateral 0,73 1,227 0,03
14 1,718 1,281 0,13
14 1,164 20,02 0,08
14 resting hand splint 1,36 1,53 0,11
4 16,29 1,025 0,16
12 0,896 12,05 0,05
NA onset 1950 1,26 1,00 0,08
29 1,261 1,371 0,11
4 0,921 0,108 0,06
NA onset 6 SD, 1,232 1,738 0,06
16 1,669 1,199 0,21
12 1,34 1,07 0,12
38 1,40 1,28 0,09
26 1,279 1,079 0,10
2 1,84 1,89 0,13
NA 0,16 1,485 1,664
16 1,55 1,11 0,15
16 1,066 1,751 0,06
18 1,54 1,50 0,14
42 0,895 1,42 0,05
10 1,38 0,93 0,07
30 1,7 1,55 0,20
8 2,494 1,278 0,32
8
10 1,35 1,19 0,12
22 1,487 1,4 0,12
30 1,64 1,48 0,17
15 1,294 1,571 0,09
22 resting hand splint bilateral 17,00 22,16 0,16
17 0,995 1,303 0,06
26 0,87 1,28 0,05
9 1,042 1,287 0,08
10 1,655 1,285 0,12
5
NA 1,23 1,3 0,10
18
18 2,162 1,998 0,24
10 modifikasi alat makan
2
10 1,26 1,64 0,12
 MMT

2- lainnya
1 - steppage gait 1 - ada 1 - ada
0 - normal 0 - tidak ada 0 - tidak ada
tidak diisi - sulit dinilai
tidak diisi - sulit dinilai

ULNARIS

POLA JALAN POLA JALAN LAINNYA CLAW TOE

AREA

Kanan Kiri

Sinistra
0,06 1 0 0
0,06 0 0 0
0,07 1 protesa 0 NA
0,09 2 antalgic gait 0 0
0,12 1 0 1
0,10 0 1 0
0,13 0 0 0
0,08 0 0 0
0,13 0 0 0
0,08 0 0 0
0,07 2 antalgic gait 0 0
0,16 2 protesa dextra below knee NA 0
0,11 0 0 0
0,08 1 0 0
0,1 2 antalgic gait 0 0
0,13 2 NA NA
0,12 1 0 0
0,09 0 0 0
0,15 1 NA NA
0,13 0 0 0
0,08 1 1 0
0,17 0 0 0

0,05 0 1 0
0,06 0 protesa dextra below knee NA 0
0,06 1 NA 1
0,09 0 1 0
0,09 2 antalgic gait 0 0
0,09 2 antalgic gait 0 1
0,05 0 0 0
0,15 0 0 0
1 0 0
0,14 1 0 0

0.20 1 0 0
12.14 1 0 1
14.25 0 0 0

0,09 2 antalgic gait 1 1

0,12 0 0 0
0,08 0 1 1
0,06 2 protesa sinistra below knee 1 NA
0,19 1 1 1
0,12 1 1 1
0,16 1 protesa destra below knee 0
0,09 0 1 1
0,15 0 0 1
0,05 1 0 0
0,09 1 0 0
0,10 0 0 0
0,1 1
0,09 1 1 1
0,09 0 0 0
0,08 0 1 0
0,14 1 0 0
0,08 0 0 0
0,13 1 NA NA
0,09 0 0 0
0,15 0 1 1
0,17 1 0 0
0,10 2 antalgic gait (luka di plantar kaki kanan) NA 0
0,17 1 0 0

0,25 1 1 1
0,04 1 1 0
0,11 1 antalgic gait 0 0
0,25 1 NA 0
0,12 0
0,13 0 0 0
0,1 0 0 0
0,12 0 0 0
0,14 0 0 0
0,11 0 0 0
0,15 1 0 0
0,15 0 0 0
0,29 1 antalgic gait ec nyeri post TKR genu sinistra 0 1
0,18 0 0 0
0,14 0 0 0
0,16 2 protesa below knee dextra NA 0
0,12 1 0 0
0,23 0 0 0
0,07 1 0 0
0,09 0 0 0
0,11 1 antalgic gait 0 1
0,17 2 NT (pain) 0 0
0,13 1 0 0

0,1 1 0 0
0,15 0 0 0
0,09 2 antalgic gait 0 0
0,09 0 0 0
0,19 2 protesa dectra sinistra below knee NA NA
0,11 0 0 0
0,12 NA NA
0,10 0 0 0
0,10 2 antalgic gait 0 0
0,11 1 0 0
0,18 0 0 0
0,16 0 0
0,09 2 antalgic gait 1 1
0,07 0 0 1
0,11 0
0,06 1 antalgic gait 0 0
0,09 2 imbalance karena valgus ankle 0 0
0,13 0 0 0
0,9 1 1 1
0,14 0 1 1
0,10 0 0 0
0,16 1 0 0
0,11 0 0 1
0,11 1 1 0
0,22 1 0 0
0,11 0 protesa below knee 0 0
0,10 0 0 0
0,08 0 0 1
0,05 1 0 0
0,16 0 0 0
0,14 0 0 0
0,14 0 0 0
0,13 1 NA 0
0,09 1 0 0
0,06 2 antalgic gait 0 0
0,06 1 0 0
0,09 1 0 0
0,13 0 0 0
0,06 2 antalgic gait 0 0
0,14 2 NT (nyeri) 0 0

0,07 2 NT 0 0
0,11 0 0 0
0,13 0 0 0
0,10 1 0 0
0,07 0 0 0
0,13 0 0 0
0,14 0 0 0
0,17 NT 0 0
0,2 0 0 0
0,11 0 0 0
0,08 1 0 0
0,07 0 0 1
0,17 2 hiperabduksi NA NA
0,12 1 NA 0
0,07 1 0 NA
0,11 0 0 0
0,10 2 0 0
0,09 0 0 0
0,13 0 0 0
0,17 0 0 0
0,21 0 0 0
0,13 1 0 0
0,07 0 0 0
0,21 2 NT (pasien nyeri) 0 0
0,13 0 0 0
0,11 2 antalgic gait 1 1
0,12 0 0 0
0,2 0 0 0
0,16 0 1 1
0,08 0 0 0
0,06 2 NT (nyeri) 0 0
0,13 1 NA 0
0,12 1 0 0
0,17 0 0 0
0,13 0 0 0
0,10 0 0 0
0,09 0 0 0
0,09 0 NA
0,11 0 0 0
0,16 0 0 0
0,14 0 0
0,08 1 0 0
1 1 1
0,10 2 limping gait NA 0
0,06 0 0 0
0,10 1 0 0
0,13 1 0 0
0,17 2 antalgic gait 0 0
0,23 2 lateral trunk bending NA 0
0,09 2 protesa below knee dextra 0 0
0,07 0 1 1
0,44 0 0 0
0,05 2 antalgic gait 0 0
0,19 0 0 0
0,08 0 0 0
0,06 1 0 NA
0,06 0 1 0
0,07 2whole base, bradikinesia, geriatri long crane 0 0
0,15 0 NA NA
0,05 1 NA 0
0,07 2 antalgic gait 0 0
0,12 2 antalgic gait 0 0
0,35 0 1 1
0,08 1 0 0
0,12 2 hiper abd 0
0,09 2 antagic gait 0 0
0,09 0 0 0
0,10 0 0 0
0,13 2 NA NA NA
0,08 0 AFO dengan dorsoflexor asist NA NA
0,10 1 1 1
0,11 0 0 0
0,14 1 0 0
0,03 2 protesa below knee sinistra 1 NA
0,12 pasien menolak
0,06 0 0 0
0,08 1 0 1
NA 2 0 0
0,12 2 antalgic gait 1 1
0,08 2 abduction gait 0 NA
0,05 0 0 1
0,10 0 0 0
0,17 2 abdiction gait 1 NA
0,07 0 0 0
0,07 kursi roda 0 NA
0,09 2 antalgic gait 0 0
0,08 1
0,07 0 1 NA
0,22 2 protesa below knee sinistra 0 NA
0,11 2 wide base imbalance, slow step 0 0
0,08 0 NA 1
0,09 2 protesa below knee dextra NA 0
0,22 0 1 NA
0,15 0 0 0
0,07 2 NT 0
0,09 2 antalgic gait 0 1
0,07 2 crunches bilateral NA 0
0,12 2 antagic gait 1 0
0,06 2 protesa below knee dextra NA 0
0,12 2 asymmetrical gait 1 1
0,11 2 antalgic gait 0 0
0,07 0 0 0
0,10 1 dengan dorso flexor assist 0 0
0,08 0 1 0
0,13 2 antagic gait 1 1
0,09 0 0 0
0,09 0 0 0
0,12 1 1 1
0,14 0 1 1
0,10 0 pakai sandal 1 0
0,05 2 antalgic gait 0 1
0,14 0 1 1
0,11 0 0 0
2 antagic gait 1 1
0,07 0 1 1
0,14 0 0 0
0,14 0 0 0
0,13 0 0 0
0,23 0 1 1
0,10 0 0 0
0,10 0 0 0
0,10 1 1
0,06 2protesa dextra below knee, drop foot sinistra NA 0
1 1 0
0,11 1 protesa dextra NA 1
0 0 0
0,19 2 hemiplegic gait (post stroke 2013) 1 1
0 dengan sendal 1 1
2 antalgic gait 1 1
0,18 0 0 0
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada
tidak diisi - sulit dinilai
tidak diisi - sulit dinilai
tidak diisi - sulit dinilai
tidak diisi - sulit dinilai
tidak diisi - sulit dinilai

DEFO

EQUINUS VALGUS ANKLE VARUS ANKLE

Kanan Kiri Kanan Kiri Kanan

0 0 0 1 0
0 0 0 0 0
 0 NA 0 NA 0
0 0 0 0 0
0 0 0 0 1
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
NA 0 NA 0 NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
NA NA NA NA NA
0 0 0 0 1
0 0 0 0 0
NA NA NA NA NA
0 0 0 0 0
0 0 0 0 1
0 0 0 0 0

0 0 0 0 0
NA 0 NA 0 NA
NA 0 NA 0 NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 1 0 0

0 0 0 0 0
0 0 0 1 0
0 0 0 0 0

0 0 1 1 0
0 0 1 1 0
0 0 0 0 0
0 NA 0 NA 0
0 0 0 0 0
0 0 0 1 0
0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 1 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
NA NA NA NA NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
NA 0 NA 0 NA
0 0 0 0 0

0 0 0 0 0
0 0 1 0 0
0 0 1 0 0
NA 0 NA 0 NA

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 1 0 0
0 0 0 0 0
0 0 0 0 0
NA 0 NA 0 NA
0 0 1 0 0
0 0 0 0 0
0 0 1 0 0
0 0 1 1 0
0 0 0 0 0
0 0 1 1 0
0 0 0 0 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
NA NA NA NA NA
0 0 0 0 0
NA NA NA NA NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 1 0
0 0 0 0
0 0
0 0 0 0 1
0 0 1 1 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 1 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 1 0 0
0 0 0 0 0
NA 0 NA 0 NA
0 0 1 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 1 1 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 1 1 0
0 0 1 1 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 1 1 0
0 0 1 1 0
 0 0 0 0 0
NA NA NA NA NA
NA 0 NA 1 NA
0 NA 0 NA 0
0 0 1 1 0
0 0 0 0 0
0 0 1 1 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 1 1 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 1
NA 0 NA 1 NA
0 0 0 0 0
0 0 0 0 1
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 NA 1 NA 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 1
0 0 1 1 0
0 0 0 0 0
NA 0 NA 0 NA
0 0 0 0 0
0 0 0 0 0
0 0 1 1 0
0 0 0 0 0
NA 0 NA 0 NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 1 0 0
0 0 1 1 0
0 0 0 0 0
0 NA 0 NA 1
0 0 0 0 0
 0 0 0 0 0
NA NA NA NA NA
NA 0 NA 0 NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
NA NA NA NA NA
NA NA NA NA NA
0 0 1 1 0
0 0 0 0 0
0 0 0 0 0
0 NA 0 NA 0

0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 NA 0 NA 0
0 0 0 0 0
0 0 0 0 0
0 NA 0 NA 0
0 0 0 0 0
0 NA 0 NA 0
0 0 0 0 0

0 NA 0 NA 0
0 NA 0 NA 0
0 0 0 0 1
NA 0 NA 1 NA
NA 0 NA 0 NA
0 NA 0 NA 0
0 0 0 0 0
0 0
0 0 0 0 0
NA 0 NA 0 NA
0 0 0 0 0
NA 0 NA 0 NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
 0 0 1 1 0
0 0 0 0 1
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 1
0 0 1 0 0
0 0 0 0 0
0 0 1 1 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
NA 0 NA 0 NA
0 0 0 0 0
NA 0 NA 0 NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada
tidak diisi - sulit dinilaitidak diisi - sulit dinilai
tidak diisi - sulit dinilai
tidak diisi - sulit dinilai

DEFORMITAS

VARUS ANKLE EQUINOVARUS EQUINOVALGUS

Kiri Kanan Kiri Kanan

0 1 0 0
0 0 0 0
NA 0 NA 0
0 0 0 1
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 1
0 0 0 0
0 NA 0 NA
0 0 1 0
0 0 0 0
0 1 1 0
NA NA NA NA
1 0 0 0
1 0 0 0
NA NA NA NA
0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 NA 0 NA
0 NA 0 NA
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 1 0 0
0 0 0 0
0 0 0 0

0 1 0 1
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 1
0 0 0 0
NA 0 NA 0
0 0 0 0
0 0 0 0
0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
NA NA NA NA
0 0 0 0
0 0 0 0
0 0 0 0
0 NA 0 NA
1 0 0 0

0 0 0 0
1 0 0 0
0 0 0 0
0 NA 0 NA

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 1
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 NA 0 NA
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0

0 1 0 0
0 0 0 0
0 0 0 1
0 0 0 0
NA NA NA NA
0 0 0 0
NA NA NA NA
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 1 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
1 0 0 0
0 0 0 0
0 0 0 0
0 1 1 0
0 0 0 0
0 0 0 0
0 0 0 0
0 NA 0 NA
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
 0 0 0 0
NA NA NA NA
0 NA 0 NA
NA 0 NA 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
1 0 0 0
0 NA 0 NA
0 0 0 0
1 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
NA 0 NA 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 NA 0 NA
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 NA 0 NA
0 0 1 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
NA 0 NA 0
0 0 0 0
 0 0 0 0
NA NA NA NA
1 NA 0 NA
0 0 0 0
0 1 0 0
0 0 0 0
0 0 0 0
0 0
0 0 0 0
0 0 0 0
0 0 0 0
NA NA NA NA
NA NA NA NA
0 0 0 0
0 0 0 0
0 0 0 0
NA 0 NA 0

0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
NA 0 NA 0
0 0 0 0
0 0 0 0
Na 0 NA 0
0 0 0 0
NA 0 NA 0
0 1 0 0

NA 0 NA 0
NA 0 NA 0
1 0 0 0
0 NA 0 NA
0 NA 0 NA
NA 0 NA 0
0 0 0 0
0 0
0 0 0 0
0 NA 0 NA
0 0 0 0
0 NA 0 NA
0 1 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
1 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 NA 0 NA
0 0 0 0
0 NA 0 NA
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada
tidak diisi - sulit dinilai

PEMERIKSAAN F

EQUINOVALGUS lainnya DIGITI I

Kiri Kanan Kiri Kanan

0 1 0
0 0 0
NA 0 protesa 1
1 1 0
0 1 0
0 0
0 0
0 Halux valgus Pemendekan digiti 4-5 0
1 0
1 1
0 pemendekan metatarsal pemendekan metatarsal 1
0 NA
0 pemendekan metatarsal pemendekan metatarsal 0
0 0
0 0
NA amputasi metatarsal amputasi metatarsal NA
0 pemendekan digiti 1-5pemendekan digiti 1-5 0
0 pemendekan digiti 1 0
NA below knee amputation amputation digiti 1-5 NA
0 0
0 0
0 0

0 0
0 NA
0 amputasi 1
0 1
0 0
0 0 0 0
0 0
0 0
0 pemendekan jari 2-5 pemendekan jari 2-5 0
0 halux valgus 0

0 hallux valgus, talipes varus, equinovalgus

halluxphalang
valgus, pemendekan
proximal 2-4 metatarsal 2-5
0
0 claw toe 2,4,5 1
0 0

0 pemendekan digiti 1-5 dan

pemendekan
metatarsal 1-5
digiti 1-5 dan metatarsal 1-5
0
0 0
0 0
NA amputasi 0
0 0
0 0
0 amputasi below knee halux valgus 1
0 0
0 claw toe digiti 5 0
0 1
0 1
0 0
sullit dinilai (ditutup kaos sullit
kaki) dinilai (ditutup kaos kaki) 1
0 pemendekan phalang2-5 0
0 0
0 0
0 0
0 0
NA transtibial amputee dextra
transtibial amputee sinistra 1
0 0
0 0
0 amputasi phalang proximal 2-5 1
0 luka di plantar kaki 0
0 1

0 amputee metatarsal digiti 1-5 0

0 0
0 halux valgus, pemendekanhalux
digitivalgus,
2-5 pemendekan digiti 2-5 0
0 amputasi below knee flat foot NA

0 0
0 0
0 0
0 1
0 pemendekan metatarsal 0
0 halux valgus, pemendekan jarihalux
1-5, flat
valgus,
feet pemendekan jari 1-5 0
0 0
0 0
0 0
0 0
0 protesa below knee pemendekan digiti 5 NA
0 1
0 0
0 pemendekan metatarsal 1-5 0
0 pemendekan metatarsal pemendekan metatarsal 0
0 pemendakan metatarsal digiti 2-5 0
0 PTB PTB 0
0 pemendekan digiti 1-4 pemendekan digiti 1-3 1

0 1
0 0
0 pemendekan metatarsal 1-5 0
0 0
NA amptasi transtibial dextraamputasi transtibial sinistra 1
0 0
NA amputasi chopart amputasi below knee 1
0 pemendekan digiti 2-4 0
0 pemendekan metatarsal pemendekan metatarsal 1
0 pemendekan digiti 1,2,4,amputee metatarsal 5 1
0 0
0 0
0 luka di plantar 0
0 0
0 sulit dinilai pasien memakai kaos kaki
0 0
0 pemendekan metatarsal 1
0 0
0 pemendekan phalang proximal
pemendekan
digiti 2-5
phalang proximal digiti 2-50
0 0
0 0
0 flat feet flat feet 0
0 0
0 pemendekan jari 4-5 halux valgus 0
0 luka telapak kaki 0
0 0
0 0
0 claw toe jari ke 5 0
0 0
0
0 0
0 1
0 transtibial amputasi NA
0 rocker bottom shoes + custom
rockerinsole
bottom shoes + custom insole 0
0 hallucx valgus, PTB 1
0 1
1 high quarter shoes + rocker
high
bottom
quarter
dengan
shoesmedial
+ rocker
strap
bottom dengan medial
0 strap
0 0
0 custom insole custom insole 0
0 PTB 0

0 luka plantar pedis 0

0 hallux valgus calw finger, hallux valgus 0
0 hallux valgus 0
0 0
0 1
0 0
0 0
0 hallux valgus hallux valgus 0
0 0
0 0
0 0
 0 atrofi digiti 1 0
NA protesa dextra tertutup verban 0
0 amputasi transtibial NA
NA PTB dextra amputasi transtibial 0
0 hallux valgus hallux valgus 0
0 1
0 0
0 0
0 genu varum genu varum 0
0 0
0 atrofi setinggi chopart lineatrofi setinggi chopart line 1
0 PTB 1
0 1
0 genu valgus genu valgus 0
0 atrofi atrofi, luka di plantar sinistra 0
0 halux valgus halux valgus 0
0 0
0 0
0 oposisi hallux ke MTP 2 oposisi hallux ke MTP 2 0
0 0
0 amputasi transtibial NA
0 0
0 0
0 0
0 0
0 0
NA protesa sinistra 0
0 0
0 0
0 0
0 1
0 0
0 amputasi below knee NA
0 claw finger claw finger 0
0 0
0 0
0 atrofi metatarsal atrofi metatarsal 1
0 prosthesis dextra hallux valgus NA
0 prosthesis dextra 1
0 1
0 0
0 hallux valgus 1
0 1
0 0
NA amputasi transtibial 0
0 0
 0 atrofi digiti 1 atrofi digiti 1-5 0
NA amputasi transtibial amputasi transtibial NA
0 amputasi transtibial NA
0 0
0 0
0 0
0 atrofi tarsal, atrofi digiti 2-5 0
pemendekan metatarsal 1
0 claw finger 0
0 claw finger, hallux valgus hallux valgus 0
0 0
NA pasien memiliki li¥uka di kaki
pasien
tidak
memiliki
mau membuka
li¥uka di kaki
kaostidak
kaki mau membukaNAkaos kaki
NA AFO dengan dorsoflexor asist AFO dengan dorsoflexor asist NA
0 0
0 claw finger 0
0 0
NA protesa below knee 0
pasien menolak pasien menolak
0 0
0 0
0 0
0 PTB 0
NA ptotesa sinisra 0
0 1
0 hallux valus claw finger, hallux valgus 0
NA protesa 0
0 0
NA amputasi transtibial 1
0 0
pasien tidak mau membukapasien kaos kaki
tidakkanan
mau membuka kaos kaki kiri
NA protesa sinistra 0
NA atrofi metatarsal amputasi below knee 1
0 atrofi digiti 4-5 atrofi digiti 4-5 0
0 amputasi transtibial NA
0 NA
NA PTB amputasi transtibial 0
0 0
0 sulit dinilai tertutup perban
0 1
0 amputasi below knee NA
0 chsrco foot 0
0 amputasi below knee NA
0 0
0 0
0 atrofi metatarsal 1-5, luka di plantar 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 PTB PTB 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 atrofi digiti 4 0
0 0
0 0
0 amputasi below knee drop foot 1
0 0
0 amputasi NA
0 0
0 drop foot drop foot, post op 0
0 pro PTD dextra 0
0 luka 0
0 0
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada

PEMERIKSAAN FISIK EKSTREMITAS BAWAH

AMPUTASI DIGITI

DIGITI I DIGITI II DIGITI III DIGITI IV

Kiri Kanan Kiri Kanan Kiri Kanan Kiri

0 0 0 0 0 0 0
0 0 0 0 0 0 0
NA 0 NA 0 NA 0 NA
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 1
1 0 0 0 0 0 0
0 0 1 1 1 1 1
0 0 0 0 0 0 0
1 NA 1 NA 1 NA 1
0 0 0 0 0 0 0
0 1 0 1 0 1 0
0 0 0 0 0 0 0
NA NA NA NA NA NA NA
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 NA 1 NA 1 NA 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0

0 0 0 0 0 0 0
1 NA 0 NA 0 NA 01
0 1 0 1 0 1 0
0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 1 0 0 0
0 0 0 0 0 0 0
0 0 1 0 1 1 1

0 0 0 0 0 0 0
0 1 0 1 1 1 0
0 0 0 0 0 0 0

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 1 1 1 1
1 0 1 0 1 0 1
0 1 1 1 1 1 1
0 0 0 0 0 1 0
0 1 0 1 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
 1 1 1
1 1 1 1 1 1 1
0 0 0 0 1 0 1
1 1 1 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 1 0 1 1 1
1 1 1 1 1 1 1
0 0 0 0 0 0 0
1 1 1 1 1 1 1
0 0 0 0 0 0 0
0 1 0 1 0 1 0
1 1 0 1 0 0 0
0 1 0 0 0 1 0
0 1 0 1 0 1 0

1 0 1 0 0 0 0
1 0 1 0 1 0 1
0 0 0 0 0 0 0
0 NA 0 NA 1 NA 1

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 0 0 0 0
0 1 1 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 NA 0 NA 0 NA 0
0 1 0 1 0 1 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1 1 1 1 0

1 1 1 1 1 1 1
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1 1 1 1 1
0 0 0 0 0 0 0
1 1 1 1 1 1 1
0 1 0 1 0 1 0
1 0 0 0 0 0 0
0 1 1 1 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0
1 1 1 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 1 1 1 1
0 1 0 1 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1 0 0 1 0

0 0 0 0 0 0 0
1 1 1 1 1 1 1
1 NA 0 NA 0 NA 0
1 1 1 0 1 0 1
0 1 0 1 0 1 0
0 0 0 0 0 0 0
1 0 1 0 1 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 1 0 1

0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 0 0 0 1 0 1
0 0 0 0 0 0 0
0 1 0 1 0 1 0
0 0 0 0 0 0 0
0 1 0 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 0 1 0 1 0
 0 0 0 0 0 0 0
0 0 1 0 0 0 0
0 NA 0 NA 0 NA 0
NA 0 NA 0 NA 0 NA
0 0 0 0 0 0 0
1 1 1 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1 1 1 1 1
0 0 0 0 0 0 0
1 1 1 1 1 1 1
0 0 1 9 1 0 1
0 0 0 0 0 0 0
0 1 1 1 1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 NA 1 NA 0 NA 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
NA 0 NA 0 NA 0 NA
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 1 0 1 0
1 1 1 0 0 0 0
0 0 0 0 0 0 0
0 NA 0 NA 0 NA 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 1 1 1 1 1
0 1 0 1 0 1 0
0 na 0 NA 0 NA 0
0 1 0 1 0 1 0
1 1 0 1 0 1 0
0 0 0 0 0 0 0
0 1 1 1 1 0 1
1 0 1 0 1 0 1
0 0 0 0 0 0 0
NA 1 NA 1 NA 1 NA
0 0 0 0 0 0 0
 0 0 0 0 0 0 0
NA NA NA NA NA NA NA
0 NA 0 NA 0 NA 0
0 1 0 0 0 0 0
0 1 0 1 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 1
0 0 0 0 0 0 0
NA NA NA NA NA NA NA
NA NA NA NA NA NA NA
0 1 0 0 1 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
NA 0 NA 0 NA 0 NA

0 0 0 0 0 0 0
0 0 0 0 0 0 0
1 1 1 1 1 1 1
0 0 0 0 0 1 0
NA 0 NA 0 NA 0 NA
0 1 0 1 0 1 0
0 0 1 0 1 1 1
NA 0 NA 1 NA 0 NA
0 0 0 0 0 0 0
NA 1 NA 1 NA 1 NA
0 0 0 0 0 0 0

NA 0 NA 0 NA 0 NA
NA 0 NA 0 NA 0 NA
0 0 0 0 0 0 0
0 NA 0 NA 0 NA 0
0 NA 0 NA 0 NA 0
NA 0 NA 0 NA 0 NA
0 0 0 0 0 0 0
0 0 0 0
0 1 0 1 0 1 0
0 NA 1 NA 1 NA 1
0 0 0 0 0 0 0
0 NA 0 NA 0 NA 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 1 0 1 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 0 0 0 0 0 0
1 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 1 0 0 1 1
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 1 0 1 0
0 0 0 0 0 0 0
0 NA 0 NA 0 NA 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 1 0 1 0 1 0
0 0 0 0 0 0 0
 0- tidak ada
1 - ada 1 - ada 1 - kurang
0 - tidak ada 0 - tidak ada 2 - ada

REHAB MEDIK

ROM (DALAM DERAJAT) S

DIGITI V DORSOFLEXI PLANTAR FLEXI N. SAPHENUS MEDIAL

Kanan Kiri Kanan Kiri Kanan Kiri Kanan

0 0 20 20 50 50 0
0 0 20 20 50 50 2
 0 NA full protesa full protesa 1
1 0 20 0 50 40 0
0 0 20 20 50 20 0
0 0 10 10 40 full 2
0 0 full full full full 2
0 1 full full full full 1
0 0 0
1 1 20 10 0 0 0
0 0 20 NA 0 NA 0
NA 1 NA 20 NA 0 NA
0 0 20 10 10 20 0
1 0 full 10 full 40 2
0 0 NA NA NA NA NA
NA NA NA NA NA NA 0
0 0 NA 0 NA 10 0
0 0 full 0 full 0 2
NA 1 NA NA NA NA NA
0 0 full full full full 0
0 1 30 20 0 0 0
0 0 20 20 50 50 2

0 0 full full full full 0

NA 0 NA 20 NA 30 0
1 0 protesa 10 protesa 10 NA
0 0 NA NA NA NA
0 0 10 20 10 40 0
0 0 full full full full 0
0 0
0 0 20 0 50 0 0
0 0 full full full full 1
0 0 0 full 0 full 0

0 0 full full full full 0

1 0 protesa full protesa full NA
0 0 20 20 40 40 0

0 0 20 10 0 0 0
0 0 full full full full 1
1 1
0 1 20 NA 20 NA 0
1 1
1 0 10 10 20 0 0
1 0 protesa 20 protesa 10 NA
0 0 20 20 40 40 2
0 0 20 20 10 10 2
1
1 1 10 10 2
0 1
1 1 0 0 0 0 0
0 0 20 20 10 30 0
0 0 full full full full 2
1 1 20 20 full 0 2
1 1 NA NA NA NA 0
0 0 full full full full 2
1 1 NA NA NA NA 0
0 0 full 20 full 10 1
0 0 20 NA 40 NA 2
1 1 20 20 40 40 0
1 0 NA full NA full 2
1 0 NA 10 NA 10 NA

0 0 full 10 full 30 0
0 1 10 20 0 20 0
0 0 full 0 full 0 0
NA 1 NA 10 NA 30 NA

0 0 full full full full 2

0 0 20 20 40 40 2
0 0 full full full full 0
1 1 full full full full 2
0 0 5 full 0 full 0
0 0 10 20 0 30 1
0 0 20 20 30 30 1
1 0 20 20 0 0 0
0 0 full full full full 2
0 0 full full full full 2
NA 0 amputasi 10 amputasi 20 NA
1 0 0 10 0
0 1 full full full full 0
0 0 10 20 10 50 0
0 0 50 full 0 full 0
0 0 full full full full 2
0 0 NA 5 NA 0 2
0 0 NA NA NA NA 0

1 1 protesa protesa protesa protesa NA

0 0 full full full full 1
0 0 20 20 40 40 0
1 0 full full full full 0
1 1 protesa protesa protesa protesa NA
0 0
1 1 protesa protesa protesa protesa NA
1 0 full full full full 0
0 0 20 20 0 0 0
1 0 full full full full 2
0 0 NA NA NA NA 0
0 0 20 20 40 40 1
0 0 10 10 10 10 0
0 0 full full full full 2
0 0 20 0 30 0
1 1 5 0 10 40 0
0 0 full full full full 0
0 0 full full full full 1
0 0 full full full full 0
0 0
0 0 full full full full 0
1 1 full full full full 0
1 0 full full full full 2
0 0 20 0 40 10 0
0 0 20 NA 50 NA 1
0 0 full protesa full protesa 2
0 0
0 0 full full full full 2
0 0 20 0 0 0 0

0 0 20 20 20 45 0
1 1 20 20 30 40 0
NA 0 20 NA 20 NA 2
1 1 20 10 15 0 0
1 0 20 20 30 30 2
1 0 NA 20 NA 10 2
0 0 29 5 20 0 0
0 0 20 20 50 40 2
0 0 20 20 40 40 2
0 1 20 20 40 40 0

0 0 20 20 50 50 1
1 0 20 20 20 25 0
0 0 20 20 30 40 0
0 1 20 20 40 10 0
0 0 20 20 35 50 0
1 1 20 20 40 30 2
0 0 10 15 30 30 0
1 1 15 10 30 20 0
0 0 20 20 40 40 0
0 0
0 1 10 30 15 40 2
 0 0 20 20 40 50 2
0 1
NA 0 protesa 20 protesa 50 NA
0 NA 20 NA 30 NA 0
0 0 20 20 30 40 0
1 1 20 20 50 35 0
0 0 20 20 50 40 0
0 0 20 25 40 30 0
0 0 20 20 30 40 0
0 0 20 20 40 40 0
1 1 5 0 0 0 0
0 0 20 20 50 50 0
1 1 10 NA 0 NA 0
1 1 20 20 40 30 2
0 0 15 10 30 20 2
1 1 20 20 40 30 0
0 0 20 20 30 50 2
0 0 20 25
30 30 40 2
0 0 20 30 40 0
0 0 20 10 40 10 0
NA 1 amputasi 5 amputasi 20 NA
0 0 20 20 40 40 2
0 0 20 20 40 40 0
0 0 20 20 40 40 2
0 0 20 20 40 40 0
0 0 20 20 20 40 0
0 NA 20 NA 40 NA 2
0 0 20 15 10 25 0
0 0 20 10 30 30 0
0 0 20 20 30 30 0
1 0 25 30 10 10 0
0 0
NA 0 NA 20 NA 50 NA
0 0 20 10 35 40 2
0 0 20 20 30 10 0
1 1 5 20 0 0 2
1 NA 15 15 20 30 0
NA 0 NA 45 NA 40 NA
1 1 NA 10 NA 20 NA
1 0 20 20 35 35 0
0 0 20 20 40 40 2
0 1 20 10 40 10 0
0 1 20 NA 20 NA 0
0 0 20 20 30 30 2
1 NA 10 amputasi 10 amoutasi 0
0 0 20 20 40 40 2
 0 0 20 20 20 20 0
NA NA NA NA NA NA NA
NA 1 NA 5 NA 10 NA
0 0 20 20 20 40 0
0 0
0 0 20 20 40 50 0
0 0 10 20 20 40 2
1 10 NA 20 NA 0
1 0 5 20 0 40 0
0 0 20 20 40 40 0
0 0 25 20 40 40 2
NA NA NA NA NA NA NA
NA NA 20 15 25 20 0
1 0 25 25 10 15 0
0 0 20 20 50 40 2
0 0 20 20 30 40 0
0 NA 20 NA 50 NA 0
10 20 30 40 0
1 0 5 20 30 50 0
0 0 25 25 40 40 0
1 1
0 0 10 20 20 40 0
0 NA 10 NA 30 NA 2
1 0 20 20 40 40 0
0 1 15 NA 30 10 0
0 NA
0 0 20 25 40 30 2
1 NA 20 NA 40 NA 0
0 0 0 10 0 0 0

0 NA 20 NA 40 NA 0
0 NA
0 0 0 0 10 90 0
NA 0 NA 20 NA 40 NA
NA 0 NA 20 NA 40 NA
0 NA 20 NA 20 NA 0
0 0 20 25 30 30 0
0 10 20 20 40 0
1 0 10 20 10 40 2
NA 0
0 1 10 20 40 30 0
NA 0 NA 20 NA 50 NA
1 1 20 10 40 25 0
1 0 20 20 30 40 0
1 0 10 10 0 20 0
0 0 10 10 40 40 2
 0 0 20 20 40 40 0
1 1 20 20 50 40 0
0 0
0 0 20 20 40 40 0
0 0 10 10 50 50 0
1 1 10 15 10 30 0
0 0 20 25 0 50 2
0 0 20 10 50 10 2
0 0 20 20 40 50 0
1 0 10 10 30 30 0
0 0
0 0 20 20 40 40 0
0 0 20 20 50 50 2
0 0 20 20 50 50 2
0 0 20 20 40 50 2
0 0 20 10 40 40 2
0 0 20 20 50 50 2
0 0 20 20 40 35 0
0 0 15 10 40 40 0
1 0 NA 20 NA 40 NA
0 0 25 20 30 40 2
NA 0
0 0
0 0 2
0 0 20 20 30 30 0
1 0 20 10 40 20 0
0 0 20 20 50 50 0
 0- tidak ada 0- tidak ada 0- tidak ada 0- tidak ada 0- tidak ada
1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - ada 1 - ada
2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 0 - tidak ada 0 - tidak ada

SENSIBILITAS MONOFILAMEN

N. SAPHENUS MEDIAL N. PERONEAL SUP N. MEDIAL PLANTAR JINJIT 20X

Kiri Kanan Kiri Kanan Kiri Kanan Kiri

0 0 0 0 0 2 2
2 2 2 2 2 2 2
 1 1 1 1 1 NA NA
0 0 0 0 0 0 0
0 0 0 0 0 2 2
2 2 2 2 2 2 2
2 2 2 2 2 2 2
2 1 2 2 2 2 2
0 0 0 0 0 2 1
0 0 0 0 0 2 2
0 0 0 0 0 NA NA
0 NA 0 NA 0 NA NA
0 0 0 0 0 NA NA
2 2 0 2 0 2 2
NA NA NA NA NA 2 2
0 0 0 0 0 NA NA
0 0 0 0 0 NA NA
2 2 2 2 2 2 2
NA NA NA NA NA NA NA
0 0 0 0 0 2 NA
1 0 1 0 1 2 NA
2 2 2 2 2 2 2

1 0 0 0 0 2 2
0 0 0 0 0 NA NA
2 NA 2 NA 2 NA NA
2 2
0 0 0 0 0
0 0 0 0 0 2 2
2 2
0 0 0 0 0 2 2
1 0 1 0 0 2 2
0 0 0 0 0 2 2

0 0 0 0 0 2 2
1 NA 1 NA 1 2 2
2 0 0 0 0 2 2

0 0 0 0 0 NA NA
0 0 0 0 0 2 2
2 2
NA 0 NA 0 NA 2 2
0 0
0 0 0 0 0 0 0
0 NA 0 NA 0 NA 1
2 1 1 1 1 2 2
2 1 1 0 0 2 2
2 2 2 2 2 NA NA
2 2
0 0 0 0 0 NA NA
0 0 0 0 0 NA NA
2 2 2 2 2 2 2
1 2 1 2 1 NA NA
0 0 0 0 0 1 1
2 2 2 0 0 2 2
0 0 0 NA NA NA NA
0 0 0 0 0
2 2 2 2 2 2 2
0 0 0 0 0 NA NA
0 0 0 0 0 2 2
0 NA 0 NA 0 NA NA

0 0 0 0 0 NA NA
0 0 0 0 0 1 1
0 0 0 0 0 NA NA
0 NA 0 NA 0 NA NA

2 0 0 0 0 NA NA
2 2 2 1 1 2 2
0 0 0 0 0 2 2
2 2 2 2 2 2 2
0 0 0 0 0 NA 2
2 1 2 1 2 2 2
2 1 0 1 0 2 2
0 0 0 0 0 NA NA
2 2 2 2 2 2 2
2 2 2 2 2
0 NA 0 NA 0 NA 2
0 0 0 0 0 NA NA
0 0 0 0 0 2 2
0 0 0 0 0 NA 2
0 0 0 0 0 2 2
2 2 0 2 0 2 2
2 0 0 0 0 0 0
0 0 0 0 0 2 2

0 NA 2 NA 0 NA NA
0 0 0 0 0 2 2
0 0 0 0 0 2 2
0 0 0 0 0 2 2
NA NA NA NA NA NA NA
2 2
NA NA NA NA NA NA NA
0 0 0 0 0 2 2
0 0 0 0 0 0 0
0 0 0 0 0 1 0
0 0 0 0 0 1 1
1 1 1 0 1
0 0 0 0 0 2 2
0 2 0 2 0 2 2
2 0 0 0 0 2 0
0 0 0 0 0 NA NA
0 0 0 0 0 2 2
1 0 0 0 0 2 2
0 0 0 0 0 2 2
1 1
0 0 0 0 0 2 2
0 0 0 0 0 2 2
2 2 2 2 2 2 2
1 0 0 0 0 2 2
1 1 1 1 1 2 2
NA 0 NA 0 NA NA NA
2 2
2 2 2 2 2 2 2
0 0 0 0 0 NA NA

0 0 1 0 0 2 2
0 0 0 2 2 2 2
NA 0 NA 0 NA NA NA
0 0 0 0 0 0 0
0 0 0 0 0 NA NA
0 0 0 0 0 2 2
1 0 0 0 0 0 0
2 0 0 0 0 2 2
2 2 0 2 2 2 2
0 0 0 0 0 0 0

2 0 0 0 0 2 2
0 0 0 0 0 1 0
0 0 0 0 0 2 2
0 0 0 0 0 2 0
0 0 0 0 0 2 2
2 2 2 2 0 2 2
0 0 0 0 0 2 2
0 0 0 0 0 NA NA
2 0 2 0 2 2 2
2 2
0 2 0 0 0 2 2
0 2 0 2 0 2 2
NA NA
0 NA 0 NA 0 NA NA
NA 0 NA 0 NA 0 0
0 0 0 0 0 2 2
0 0 0 0 0 NA NA
0 0 0 0 0 2 2
2 0 0 0 0 2 2
0 0 0 0 0 2 2
0 2 0 0 0 2 2
0 0 0 0 0 NA NA
0 0 0 2 2 2 2
0 0 0 0 0 NA NA
2 2 2 0 0 1 1
2 0 0 0 0 0 0
0 0 0 0 0 NA NA
2 2 2 2 2 2 2
2 2 0 2 0 2 2
0 0 0 0 0 1 1
0 0 0 0 0 0 0
1 NA 0 NA o 0 0
2 2 2 2 2 2 2
2 0 2 0 2 2 2
0 2 0 2 0 2 2
0 0 0 0 0 2 2
0 0 0 0 2
NA 2 NA 2 NA NA NA
2 0 0 2 0 2 2
0 0 0 2 2 0 0
0 0 0 0 0 2 2
0 0 0 0 0 2 2
2 2
2 NA 0 NA 0 NA NA
2 2 2 0 0 2 2
0 0 0 0 0 NA NA
2 2 0 2 0 NA NA
0 0 0 0 0 NA NA
2 NA 2 NA 2 NA NA
0 NA 0 NA 0 NA NA
0 0 0 0 0 1 1
2 2 1 0 1 2 2
0 0 2 0 0 NA NA
0 0 0 0 0 0 0
0 2 0 0 0 2 2
NA 0 NA 0 NA 0 NA
2 2 2 2 2 2 2
 0 0 0 0 0 NA NA
NA NA NA NA NA NA NA
0 NA 0 NA 0 NA NA
0 0 0 0 0 1 1
NA NA
0 2 2 0 2 2 2
2 0 2 0 2 2 2
NA 0 NA 0 NA 0 0
1 0 1 0 1 NA 2
0 0 0 0 0 2 2
2 2 2 2 2 2 2
NA NA NA NA NA NA NA
0 2 0 2 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 NA NA
2 0 0 0 0 2 2
NA 0 NA 0 NA NA NA
0 0 0 0 0 0 0
2 0 2 2 2 NA NA
0 0 0 0 0 2 0
NA NA
0 0 0 0 0 NA NA
NA 0 NA 0 NA NA NA
2 0 0 0 0 NA NA
0 0 0 0 0 2 2
NA NA
0 2 0 2 0 2 2
NA 0 NA 0 NA 0 0
0 2 0 0 0 NA NA

NA 2 NA 2 NA NA NA

0 0 0 2 2 NA NA
2 NA 0 NA 0 NA NA
2 NA 2 NA 2 NA NA
NA 0 NA 0 NA NA NA
2 0 2 0 2 2 2
0 0 0 0 0 NA NA
2 0 0 0 0 0 0

0 0 0 0 0 NA NA
2 NA 2 NA 2 NA NA
0 0 0 0 0 NA NA
0 0 0 0 0 NA NA
0 0 2 0 0 2 2
2 2 2 2 2 0 0
0 0 2 0 0 1 1
0 0 0 0 0 1 1
2 2
2 0 2 2 2 2 2
0 0 0 0 0 NA NA
0 0 0 1 0 2 2
2 0 0 0 0 NA NA
0 0 0 0 0 NA NA
0 0 0 0 0 2 2
0 0 0 0 0 1 1
NA NA
0 0 0 0 0 2 2
2 1 1 1 1 2 2
2 2 2 0 0 2 2
2 2 2 2 2 2 2
2 2 0 2 2 2 2
2 2 2 2 2 2 2
0 2 0 2 0 2 2
0 0 0 0 0 2 2
0 NA 0 NA 0 NA NA
2 2 2 2 2 2 2
NA NA
2 2
0 0 0 0 0 0 0
0 0 0 0 0 1 1
0 1 1 1 0 NA NA
0 0 0 0 0 1 1
 KEMAMPUA
N AMBULASI

1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada

0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada

MMT

QUADRICEPS TIBIALIS ANTERIOR HAMSTRING GASTROCNEMIUS

Kanan Kiri Kanan Kiri Kanan Kiri Kanan

11,21 12,34 11,67 10,62 8,8 8,8

19,4 14,22 18,6 15,3 15,42 10,45 14,9
13,46 NA NA NA NA NA NA
14,01 11,5 5,9
12,67 12,54 9,49 10,64 7,02 7,73 7,82
21,75 19,0 21,23 16,56 10,87 10,75
17,69 16,43 18,10 16,10 15,35 11,45 13,38
11,2 12,08 10,0 10,20 7,23 7,94 8,57
12,88 12,88 12,45 10,48 11,12 10,03 13,67
10,46 11,8 8,24 8,03 9,28
9,37 7,27 NA NA NA NA NA
NA 10,45 NA NA NA NA NA
8,95 8,49 NA 7,48 NA NA NA
14,22 15,26 6,4 10,95 9,66 8,91 8,32
NA NA NA NA NA NA NA
NA NA NA NA NA NA NA
NA NA NA NA NA NA NA
18,11 19,28 16,60 13,92 9,11 11,73 8,11
NA NA NA NA NA NA NA
13,88 11,71 11,58 9,70 10,08 9,66 10,08
22,71 21,74 20,28 NA 12,42 10,16 9,95
16,3 13,55 16,18 13,25 17,2 14,22 14

NA 11,71 12,84 10,21 NA 11,50 10,16

NA 11,98 NA NA NA 13 NA
NA 14,75 NA NA NA NA NA
NA NA NA NA NA NA NA
19,32 19,24 19,99 21,16 8,24 9,82 7,73
16,9 12,13 16,85 25,08 9,49 7,32 10,58

12,80 9,83 12,67 NA 8,95 10,91 11,54

12,21 14,37 5,27 NA 9,37 13,37 12,88
16,14 14,92 13,42 14,38 13,42 10,2 NA

16.92 14.97 14.8 11.75 13.8 13.8 NA

NA 14.7 NA 12.71 NA NA NA
10.75 11.25 12.21 12.29 12.42 10.12 6.48

10,75 10,03 NA NA NA NA NA
11,46 14,93 14,72 17,15 14,38 15,72 12,38

13,17 NA 11,04 NA NA NA NA

13,99 12,46 9,24 7,94 11,71 9,32 NA

NA 14,26 NA 13,38 NA NA NA
13,51 13,38 9,32 10,54 9,62 11,01 8,82
15 15,05 14,68 13,84 10,75 12,59 NA
22,58 NA NA NA 20 NA NA

16,10 15,55 NA NA 16,89 19,07 NA

19,99 17,40 14,8 16,2 15,5 16,48 NA
13,55 13,54 15,47 16,89 12,63 12,63 7,53
11,42 9,47 9,16 NA NA NA NA
16,1 13,2 NA NA NA NA NA
18,4 17,73 18,15 15,1 8,53 7,78 13,6
NA NA NA NA NA NA NA
15,6 NA 11,83 NA 13,3 13,63 12,04
13,8 NA 10,37 NA 13,51 NA 14,05
NA NA 8,95 7,52 NA NA NA
12,76 15,68 NA 10,12 NA NA NA
NA NA NA NA NA NA NA

16,73 17,02 NA NA 15,18 13,09 NA

14,26 11,76 NA NA 13,02 NA 5,14
13,59 10,54 NA NA NA NA NA
16,22 NA 7,9 NA

18,57 18,73 29,2 18,36 13,21 17,46 12,25

16,18 12,25 7,78 8,15 12,88 11,54 11,67
18,44 16,39 16,14 16,12 9,99 10,95 7,99
10,16 10,54 14,03 14,60 11,62 7,2 5,14
19,61 16,69 NA 12,92 16,52 18,19 NA
14,80 11,79 NA NA 12,50 11,29 NA
10,49 9,59 12,63 10,83 14,36 15,72 6,69
9,74 9.03 NA 11,46 10,75 9,2 NA
14,83 14,51 41,51 13,70 12,42 12,71 12,21
18,32 17,02 16,64 14,80 14,13 12,92 14,72
NA 19,03 NA 16,94 NA 13,17 NA
115,72 18,36 11,54 15,72 12,96 12,79 13,00
11,21 13,55 11,71 13,5 10,45 10,91 14,13
14,01 13,00 NA 9,74 10,16 11,12 NA
11,07 16,02 12,04 NA 9,32 11,79 NA
11,6 13,25 13,25 NA 10,58 NA 11,08
NA 14,8 NA 13,46 NA 12,50 NA
19,28 18,52 NA NA 17,81 20 NA

NA 12,33 NA 14,47 NA 10,45 NA

24,3 24,5 20,53 22,79 20,28 18,9 15,09
12,42 10,12 9,62 9,82 9,72 11,33 NA
14,13 13,8 13,05 12,39 10,16 13,88 6,52
NA NA NA NA NA NA NA
 NA NA NA NA NA NA NA
18,82 17,06 12,17 13,00 15,43 16,01 13,80
15,56 14,01 NA NA 13,97 14,78 NA
6,06 8,49 14,51 13,67 9,66 7,52 6,81
NA NA NA NA NA NA NA
13,09 14,43 12,12 12,88 11,16 10,02 11,92
16,77 11,89 8,82 8,15 14,26 11,54 12,42
14,55 14,43 14,38 13,76 11,29 9,11 7,4
NA 16,39 NA 13,63 NA 11,75 NA
9,37 NA NA NA NA NA NA
16,85 NA 9,87 13,56 14,80 9,82 NA
18,61 16,02 14,47 12,46 16,63 17,52 12,08
11,21 9,74 NA 7,27 2,15 8,15 NA

12,23 15,53 14,17 12,84 15,18 15,72 8,82

19,19 14,84 NA 15,85 16,22 13,34 16,81
18,27 18,11 24,49 20,53 13,93 16,52 14,55
15,26 14,56 NA 10,62 11,83 11,54 NA
11,12 NA 2,11 NA 12,01 NA 10,29
11,12 NA 13,38 NA 12,63 NA NA

14,6 14,0 11,71 16,48 10,28 11,25 11,67

14,76 12,00 NA NA 12,63 10,7 NA

14,76 14,50 12,0 10,75 10,87 12,21 11,50

18,78 16,14 NA 11,51 12,33 12,17 19,11
9,45 NA NA NA 11,71 NA NA
16,35 13,02 12,02 14,03 0 0 0
13,42 14,47 NA 10,75 9,7 9,11 NA
15,04 12,84 NA 7,36 14,89 9,32 NA
14,51 14,4 NA NA 11,06 9,11 15,26
17,58 16,77 17,35 19,82 10,40 11,66 18,40
16,98 17,14 17,02 18,73 16,77 12,40 17,3
14,86 16,89 NA 9,99 31,21 12,21 NA

18,15 16,48 10,08 12,79 13,30 12,29 11,83

18,06 16,64 16,35 16,48 12,13 11,54 16,60
10,20 10,87 11,92 11,37 11,37 7,23 NA
17,56 15,97 12,96 NA 17,06 16,86 19,40
18,86 17,12 14,06 13,46 15,18 16,58 16,81
15,60 14,30 14,32 11,67 15,22 11,92 13,71
16,35 15,10 10,58 12,17 10,08 10,12 15,89
15,06 15,85 15,85 10,41 8,24 11,25 11,87
15,22 15,62 6,23 10,46 8,26 8,95 13,25

17,52 14,31 11,16 11,92 13,88 14,59 NA

18,07 16,21 15,56 11,88 10,75 10,32 NA

18,11 NA NA NA 14,84 NA NA
11,87 NA NA NA 9,03 NA NA
14,26 13,08 13,80 12,38 8,40 9,20 16,39
12,13 12,17 12,56 10,53 13,21 11,18 11,58
14,17 10,62 10,41 9,87 9,08 12,20 NA
27,41 18,20 13,05 16,00 17,02 18,60 16,31
14,97 15,14 11,14 12,33 8,62 9,36 13,55
16,31 12,88 10,76 7,27 7,65 12,75 11,96
14,89 14,72 NA NA 12,04 10,16 NA
18,48 19,07 12,42 12,46 13,42 11,62 NA
5,94 6,65 NA NA 9,95 6,98 NA
18,15 12,55 11,79 11,67 15,85 9,24 18,11
15,01 14,64 NA NA 14,64 9,87 NA
11,25 NA 9,07 13,09 13,38 NA 11,46
16,98 15,25 NA 13,42 11,41 12,06 11,21
18,94 17,23 13,88 15,85 11,25 11,49 17,81
18,94 15,30 15,30 11,76 12,38 12,67 NA
16,05 NA 9,32 NA 14,01 NA 14,38
NA 15,22 NA 7,56 NA 12,42 NA
17,44 18,48 16,73 14,89 13,09 13,88 16,10
16,56 16,68 11,62 15,81 10,7 8,32 8,46
21,29 17,98 15,68 14,89 17,77 8,53 15,6
20,07 20,78 13,38 11,33 11,03 13,71 14,84
11,25 12,75 6,69 9,36 10,39 9,11 11,41
15,97 NA 17,44 NA 21,54 NA 14,09
15,22 15,39 12,04 13,72 13,88 11,71 18,08
18,29 17,06 12,25 13,55 12,63 14,09 17,81
21,45 18,98 16,85 16,81 15,56 14,31 17,10
16,10 16,85 12,67 14,22 11,46 10,03 NA

NA 15,72 NA 9,07 NA 9,32 NA

16,14 15,09 12,67 12,38 12,33 12,21 13,67
14,80 13,67 14,13 NA 12,08 9,28 17,52
19,15 16,64 NA NA 12,67 12,88 NA
14,55 16,31 NA NA 11,75 12,92 NA
NA 20,70 NA 12,72 NA 17,65 NA
19,07 NA NA NA 6,19 NA NA
16,02 17,06 11,37 13,17 13,05 14,17 14,05
20,57 20,70 12,88 15,22 13,13 11,92 14,78
12,79 11,79 7,36 8,19 5,27 5,85 11,75
16,85 NA NA NA 14,89 NA 17,86
18,69 14,38 12,08 9,66 6,10 6,6 14,84
18,78 NA NA NA 18,78 NA NA
15,09 14,50 13,72 10,20 11,16 10,03 13,34
 NA 12,71 NA 8,87 NA 11,58 NA
NA NA NA NA NA NA NA
NA 15,97 NA 10,75 NA 10,79 NA
10,53 10,66 7,9 8,74 6,01 7,94 12,67

17,77 18,01 12,00 10,91 13,13 11,81 14,80

12,71 12,07 NA 9,83 11,05 11,37 NA
20,29 NA 7,73 NA 5 NA 10,96
7,23 14,76 NA 12,92 8,99 12,38 NA
17,52 20,37 11,71 11,33 13,50 14,43 8,15
18,02 14,85 15,65 15m43 12,29 12,04 16,22
NA NA NA NA 12,79 NA NA
21,33 18,15 NA NA 18,82 12,71 NA
15,3 10,91 8,11 NA 8,95 6,27 NA
15,89 15,14 12,54 NA 10,79 10,58 NA
10,58 12,08 6,31 9,78 8,49 7,4 9,7
14,93 NA 10,28 NA 14,01 NA 12,04
20,07 18,36 NA NA 20,40 17,52 NA
20,83 18,57 NA 12,67 12,58 11,71 NA
16,60 18,32 16,06 NA 14,43 13,88 15,51

13,67 14,64 10,47 9,78 9,87 8,65 NA

18,74 NA NA NA 18,94 NA NA
19,44 20,69 NA NA 22,01 18,52 NA
15,10 15,81 12,08 14,01 12,50 14,22 15,18

12,38 14,38 11,34 12,54 12,68 11,66 15,18

13,43 NA 11,41 NA 13,13 NA 9,07
9,74 12,33 NA 12,84 10,12 10,70 NA

10,4 NA 9,45 NA 10,75 NA 12,59

6,81 6,44 NA NA NA NA NA
NA 12,95 NA 10,70 NA 13,22 NA
NA 14,80 NA 14,08 NA 7,86 NA
16,35 NA 9,98 NA 9,41 NA NA
14,97 14,38 9,66 11,57 9,70 11,58 14,13
8,53 9,57 NA 7,9 8,28 7,64 NA
14,51 5,22 NA NA 9,66 NA NA

15,97 NA 12,08 NA 12,06 NA 12,88

NA 13,97 NA 10,20 NA 9,11 NA
17,32 16,81 10,66 NA 14,34 12,54 12,50
18,11 17,44 11,08 13,80 14,43 10,49 13,21
17,23 16,56 NA 13,21 11,87 14,57 12,00
15,90 14,20 NA NA 15,35 14,89 NA
20,11 18,48 11,41 9,66 11,41 10,58 15,06
8,2 NA 12,46 4,09 NA 13,84

19,24 17,68 11,64 13,76 9,24 9,28 12,17

18,19 15,51 NA NA 11,41 10,58 NA
19,01 18,82 13,76 15,51 13,17 15,56 15,81
10,33 15,10 NA 9,36 11,96 22,0 NA
21,06 18,06 11,79 NA 11,63 10,03 NA
22,21 20,03 16,27 15,81 16,77 17,48 NA
17,19 12,56 11,76 12,86 10,47 10,70 15,22

20,53 18,02 12,50 13,51 12,67 15,10 NA

19,90 18,78 14,76 13,13 14,97 17,14 15,14
15,93 15,35 15,35 13,42 8,99 9,28 12,29
18,19 16,64 14,83 13,00 12,71 16,14 12,95
18,78 14,59 11,21 NA 12,09 10,79 16,85
17,27 16,60 14,78 13,76 13,21 14,68 15,47
15,06 16,31 16,31 15,22 16,60 14,64 15,26
16,27 14,47 14,97 14,38 11,25 18,73 13,88
18,25 NA NA NA 18,40 NA NA
19,82 20,57 16,14 17,73 16,69 16,10 20,24

13,92 NA NA NA 11,46 NA NA
19,36 17,31 10,16 10,91 9,78 9,62 16,48
14,76 NA 13,30 NA 11,08 NA NA
12,95 9,07 9,78 8,32 7,48 5,52 12,79
 1 - ada
0 - tidak ada

GASTROCNEMIUS KETERANGAN

Kiri

OP sepatu
16,13
 NA rekomendasi protesa sinistra
OP sepatu modifikasi
7,74

14,49
10,29
5,44 rekomendasi OP sepatu
10,16 rekomendasi OP sepatu
NA OP sepatu (Riwayat TPT) beda panjang kaki, sepatu tidak nyaman
NA Protesa dextra below knee
NA nyeri kaki kanan
9,41 OP sepatu (patela kanan instabilitas, rekom sepatu stabilisasi (KAFO DEXTRA))
NA Nyeri lutut kiri
NA OP sepatu ( sepatu diabetic bilateral) luka pada cruris
NA OP sepatu
NA
NA OP revisi prosthesis kanan : liners foam ; op sepatu : kaki kiri
8,82
4,48
12

8,74 LUKA SIRCUMFERENCE KRURIS DEXTRA

NA Protesa dextra below knee
NA OP prosthesis dextra = SACHFOOT TRANSTIBIAL PROSTHESIS ; SEPATU : KIRI
NA
7,4 luka di plantar dextra
14,8 nyeri kaki kiri - kanan
pemendekan metatarsal 1-5
NA
12,21
11,00

NA orthosis, sepatu diabetik-bilateral

NA OP sepatu (diabetic shoe)
7.02

NA OP sepatu diabetic ( antagic gait karena nyeri luka di telapak kaki kiri)
7,99 pemendekan digiti 4 dex dan pemendekan digiti 2 sin

NA protesa sinistra below knee

OP sepatu
NA OP sepatu ( diabetic shoe)
NA protesa dextra below knee dan OP sepatu sinistra
7,94
NA
 protesa below knee dextra , tungkai kiri tidak mau diperiksa
NA
OP sepatu
NA OP sepatu modifikasi
NA luka di plantar pedis (nyeri)
8,78
NA
NA OP sepatu
7,5
NA OP prothesis transtibial bilateral
10,66
NA OP sepatu modifikasi (nyeri kaki kiri)
NA OP sepatu modifikasi (nyeri kaki kanan dan kiri)
NA OP sepatu modifikasi
NA prothesa dextra

NA OP sepatu modifikasi
NA OP sepatu modifikasi
NA OP sepatu modifikasi (sudah diukur)
revisi sach foot

14,13 pasien tidak dapat melihat dan mengikuti instruksi

11,83
11,46
4,73 op sepatu modifikasi
10,66 op sepatu
NA
5,98
NA op sepatu
14,59
14,01
12,96 protesa below knee dextra
12,79
16,6
10,41 OP sepatu modifikasi dextra
NA OP sepatu modifikasi (luka dengan valgus ankle)
NA OP sepatu
8,24 PTB bilateral
NA OP sepatu modifikasi, post op drop foot dex-sin

7,19 OP Sach foot revisi

18,02
NA OP sepatu (luka pada plantar dextra)
7,57
NA protesa dextra sinistra below knee
 NA protesa ( amputasi chopart dextra dan below knee sinistra)
14,59 OP sepatu modifikasi
NA OP sepatu modifikasi
5,73 ortosis sepatu
NA
11,66
NA OP sepatu
6,52
14,17 beda panjang kaki kanan lebih pendek, OP sepatu modifikasi
NA OP sepatu modifikasi
10,54 OP sepatu modifikasi
10,91
NA OP sepatu modifikasi
OP sepatu (sudah diukur)
6,6
14,51 OP sepatu modofikasi
12,84
12,46 OP sepatu modifikasi (dextra)
NA
NA protesa sinistra below knee

12,0
NA rekom KAFO sinistra

11,33 OP sepatu modifikasi

16,94
NA prosthesisi below knee sinistra
0 rocker bottom shoes + custom insole
10,91 PTB
11,71
NA high quarter shoes + rocker bottom dengan medial strap
13,92
NA custom insole
10,66 PTB dextra

NA
NA spacer hallux valgus dextra dan sinistra
11,29
NA PTB sinistra
17,56
11,92
14,93
12,67 PTB
14,43

13,34 PTB dextra

13,53
rekomendasi prosthesis baru
NA PTB sinistra, koreksi protesa dextra
NA PTB dextra, prosthesis sinistra
15,64
NA filler shoes + custom insole total contact
11,79
15,35
11,62
11,46
NA OP sepatu modifikasi
NA PTB dextra
NA OP sepatu dengan insole
13,76
NA
13,62 OP sepatu dengan custom insole
14,63
18,48
NA rocker bottom dengan pengisisan digiti 1, sepatu dengan custom insole
NA PTB
13,55 amputasi transtibial dextra
16,85
10,79
14,01
14,72 cusion insole dextra
11,50
NA protesa sinistra
16,10
16,98
18,40
NA PTB sinistra
OP sepatu modifikasi dengan cusion insole
10,83 kaki palsu lama rusak rekomendasi ankle disartikulasi dextra
13,51
15,68
NA OP sepatu dengan custom cusion insole
NA OP sepatu (luka pada plantar sinistra)
16,64 revisi socket
NA protesa below knee dextra
13,05
18,27
NA
NA
14,97
NA PTB destra, koreksi orthosis
13,97
14,84 PTB brace
NA prosthesis bilateral
NA prosthesis dextra, PTB sinistra
14,56

14,05
12,84 OP sepatu modifikasi
NA pro adjust protesa
14,09 sepatu dengan cushion modified insole
10,45
16,81
9,53
NA
10,2
NA nyeri
11,58
NA
NA pasien menolak diperiksa
13,42
NA OP sepatu modifikasi dengan custom insole

10,98
NA protesa sinistra (rekomendasi ganti baru)
NA
14,05
protesa sinistra (rekomendasi ganti baru)
NA OP sepatu modifikasi dengan suchion insole bilateral
NA
12,76 terdapat luka pada kaki
pasien tidak mau membuka kaos kaki kanan kiri
NA prosthesis sinistra
OP sepatu modifikasi dextra , ganti protesa below knee sinisra
NA
10,08
12,08 pro adjust protesa
NA PTB dextra
14,01
11,00
7,65 OP sepatu modifikasi dengan cushion insole

NA OP sepatu modifikasi
12,29 pro adjust protesa dextra
NA PTB brace
12,67 luka pada tumit dex-sin
NA luka di plantar dextra
NA dynamic AFO dengan dorso flexor assist
14,55
NA

11,38
NA
12,71
18,48 pro AFO dextra, riw drop foot, operasi sudah 2x
NA
NA PTB bilateral
NA

11,75 OP sepatu modifikasi dengan cushion insole

11,29
14,13
NA
16,27
14,97
NA
NA pro adjust protesa dextra + dynamic AFO dorso sinistra
18,02
protesa baru dextra , AFO + PTB brace sinistra

NA modified shoes dengan cushion insole

15,05 pro PTD dextra
NA pro modified shoes dengan cusion insole
12,25
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada

AMPUTASI TRANSFEMORAL AMPUTASI TRANST

TANGGAL
AMPUTASI ada ada

tidak ada
>3 bulan - 1
<3 bulan >1 tahun <3 bulan
tahun

0
0
 0
0
0
0
0
0
0
0
0
0
0
KAFO DEXTRA)) 0
0
0
0
0
0
0
0
0

0
0
1998 0
0
0
0
0
0
0
2015 0

0
1993 0

ak kaki kiri) 0
0
0
0
0
0
0
0
0
2012 0
2017 0
0
0
0
0
0
2012 0
0
1991 0
0
0
0
0
0

2008 0
0
0
2015 0

0
0
0
1981 0
0
0
0
0
0
0

0
0
0
0
0
0
0

1985 0
0
0
0
0
0
 0
1986 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ustom insole 0
0
0
0
0
0
0
0
1984 0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
 0
2016 0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada

AMPUTASI TRANSTIBIAL AMPUTASI LISFRANC

ada ada

tidak ada tidak ada

>3 bulan - 1 >3 bulan - 1
>1 tahun <3 bulan >1 tahun
tahun tahun

0 0
0 0
1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
0 0
0 0
0 0
0 1 1
0 0
0 0
1 1
0 0
0 0
0 0

0 0
1 1
1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
1 0

0 0
0 0
0 0
1 1
0 0
0 0
1 1 0
0 0
0 0
1 1
0 1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1
0 0
0 0
0 0
0 0
1 1

0 0
0 0
0 0
1 1

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0

1 1
0 0
0 0
0 0
1 1
0 0
1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1
0 0
0 0
0 0

0 0
0 0
1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
1 1
1 1
1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1
0 0
0 0
0 0
0 0
0 0
1 1
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
1 1
1
0 0
0 0
0 0
0 0
0 0
1 1
0 0
 1 1
1 1
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1
0 0
0 0
0 0
0 0
0 0
1 1
0 0
0 0
1 1
0 0

0 0
0 0
1 1
1 1
0 0
1 1
1 1
1 1
0 0
0 0
0 0
1 1
0 0
1 1
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1
0 0
1 1
0 0
0 0
0 0
0 0
0 0
 1 - YA
2 - TIDAK

LOWER LIMB PROSTHETIC EVALUATION FORM

AMPUTASI CHOPARD AMPUTASI DIGITI

ada ada

tidak ada
>3 bulan - 1
<3 bulan >1 tahun <3 bulan >3 bulan - 1 tahun
tahun

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0

0
0
0
0
0
0
0

0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0

0
0
0

0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0

0
1 1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0

0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0

0
0
0
0
0

0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0

0
0

0
0

0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
 1 - berjalan dilu
2 - berjalan di
1 - Ya 1 - FIT 3 - berjalan ke
0 - Tidak 2 - TIDAK FIT

UTASI DIGITI

USIA
MEMAKAI PROTHESIS
CHECK OUT PROSTESIS
PROSTESIS (BILA YA) *isi
dalam tahun
tidak ada

>1 tahun

0 0
0 0
 1 10
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1 1 11
0 0
0 0
0 0
0
0 0
0 0
1 1 1
0 0
0 0
0 0

0 0
1 1 15
1 2 2
0 0
0
0
0
0 0
0 0
1 1 0

0 0
0 1 1 8

0 0
0 0
0 0
1 1 10
1 0
1 0
0 1 2 1
0
0 0
 1 1 2
1 1 1
0 0
1 1 0
0 0
0 0
1 1 0
1 1 0
0 0
1 2 3
0 0
0 0
1 1 0
1 1 0
1 1 1

1 1 0
1 1 0
0 0
1 1 3

0 0
0 0
0 0
1 1 0
0 0
0 0
0 0
1 1 0
0 0
0 0
1 1 6 bln
1 1 0
0 0
0 0
1 1 0
0 0
0 0
0 0

1 1 4
0 0
1 1 0
0 0
1 1 18
0 0
 1 2 7
1 1 0
0 0
1 1 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 1 0
0 0
0 0
0 0
1 2 7
0 0
0 0
0 0

0 0
0 0
1 2 5
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 2 18
1 2 1,5
1 1 1
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 3
0 0
0 0
0 0
0 0
0 0
1 8
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
1 2 1
1 1
0 0
0 0
0 0
0 0
0 0
1 2 7
0 0
 1 2 6 bln/6bln
1 2 2
0 0
0 0
0 0

2 5
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 2 15
0 0
0 0
0 0
0 0
0 0
1 2 5
0 0
0 0
1 2 2
0 0

0 0
0 0
1 1 3
1 2 26
0 0
1 2 10bln
1 2 2
1 1 1,5
0 0
0 0
0 0
1 1 6 bln
0 0
1 2 5
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
1 2 3,5
0 0
1 1 15
0 0
0 0
0 0
0 0
0 0
1 - berjalan diluar rumah
2 - berjalan di rumah
3 - berjalan ke toilet 1 - silicone 1 - thigt belt 1 - endoskeleton
4 - kursi roda 2 - polyetilen foam 2 - PTB 2 - eksoskeleton

REKOMENDASI PROSTHESIS BARU

KEMAMPUAN
AMBULASI

SUSPENSION OF
LINERS SOCKET TYPE SHANK
PROTHESIS
1

1 2 2 1

1
1 2 2 1

1
2 2 1

1
1
1
1 2 2 1
 2 2 1
1 2 2 1

1 2 2 1

1 2 2 1

1 2 2 1

1 2 2 1

1
1

1 2 2
1 1 2 2
1 2 2 2
1 2 2 2

1 2 2 2

1 2 2 2

1 1 2 2
1

1 2 2 2
1 2 2 2
1 2 2 2

1 2 1 2

1 1 2 2

1 2 1 2
2

1 2 2 2
1
1 2 2 2

1
1 1 2
 1 - sach
2 - multiaxis

K-LEVELS KETERANGAN

TYPE OF ANKLE

OP sepatu
 2 rekomendasi protesa sinistra
OP sepatu modifikasi

3 Protesa dextra below knee

amputasi metatarsal dextra sinistra

1 2

2 prothesis rusak dibagian lutut dan telapak kaki

1 2 REVISI FOOT

1 2 PROTESIS REVISI FOOT

3 protesa sinistra below knee

sepatu orthosis
sepatu orthosis
1 2 protesa dextra below knee ( transtibial prosthesis)
1 2 protesa dextra below knee
1 2 tidak perlu prothesis baru

sepatu orthosis modifikasi

rekomendasi rocker bottom

sepatu orthosis

1 1 protesa transtibial bilateral

sepatu orthosis
sepatu orthosis modifikasi
1 2 pretesa dextra

sepatu orthosis
sepatu orthosis
sepatu orthosis (sudah diukur)
1 revisi sach foot

sepatu orthosis modifikasi

sepatu orthosis

sepatu orthosis

3 tidak perlu prosthesis baru

sepatu orthosis modifikasi

PTB bilateral

1 2 revisi sach foot (rusak)

2 sudh diukur
 1 rekom protesa (amputasi below knee sinistra & chopart dextra)
sepatu orthosis modifikasi
sepatu orthosis modifikasi

sepatu orthosis

sepatu orthosis modifikasi

sepatu orthosis modifikasi
sepatu orthosis modifikasi

sepatu orthosis modifikasi

sepatu orthosis (sudah diukur)

sepatu orthosis modifikasi

sepatu orthosis modifikasi (dextra)

2 reparasi protesa kiri (sudah diukur)

rekom KAFO sinistra

sepatu orthosis modifikasi

1 4 prosthesis below knee sinistra

rocker bottom shoes + custom insole
PTB

custom insole

spacer hallux valgus dextra dan sinistra

PTB

PTB dextra
1 3 rekomendasi prosthesis baru
1 3 PTB sinistra, koreksi prosthesis dextra
1 4 PTB dextra, prosthesis sinistra

fitles shoes + custom insole total contact

sepatu orthosis modifikasi

PTB dexra
sepatu orthosis dengan custom insole

sepatu orthosis dengan custom insole

rocker bottom dengan pengisisan digiti 1, sepatu dengan custom insole

PTB
1 4 protesa transtibial dextra

1 4 protesa sinistra

3 protesa dextra, ankle disartikulasi

sepatu orthosis
1 2 prosthesis (tidak rekomendasi prosthesis baru)
2 pro prosthesis baru ( ukuran seperti yang lama)

1 3 PTB dextra, saran koreksi orthosis

1 4 prosthesis bilateral
1 3 koreksi prosthesis dextra, PTB sinistra

2 pro adjust protesa

sepato orthosis dengan cushion modified insole

3 pro adjust protesa below knee (bagian telapak sudah goyang )

OP sepatu modifikasi dengan custom insole

PTB destra
1 4 rekomendasi ganti prosthesis baru

1 3 protesa sinistra (rekomendasi ganti baru)

OP sepatu modifikasi dengan suchion insole bilateral

1 4 prosthesis sinistra
1 OP sepatu modifikasi dextra , ganti protesa below knee sinisra

1 3
2 pro adjust protesa
1 4 PTB dextra

2 pro adjust protesa dextra

PTB brace

dynamic AFO dengan dorso floxor assist

 pro AFO dextra

PTB bilateral

OP sepatu modifikasi dengan cushion insole

1 pro adjust protesa dextra + dynamic AFO dorso sinistra

modified shoes dengan cushion insole

pro modified shoes dengan cusion insole

0 - tidak ada
1 - HT
2 - STROKE 0 - Tidak Ada
3 - JANTUNG 2 - 1obat
- Multivitamin
yang rutin diminum (sebutkan di
5 - TBC
4 - DM> 3
(BATUK keterangan
BLN)
6 - ALERGI

Obat-obatan yang dikonsumsi

Riwayat
penyakit TB
yang diderita
Keterangan
Jenis (Khusus utk no 2)

1 2 143
1 2 amlodipin 168,5
 6 0 165
1 2 anti nyeri 144
0 2 as.mefenamat prn 149
1 2 anti-hipertensi 152
1 2 anti-hipertensi 148
1,6 2 anti-hipertensi 142
6 1 B1 163
6 0 147
0 0 149
0 0 154
6 0 157
0 0 149
1,4 2 captopril 140
0 0 156
0 0 167
1 0 150
5 0 160
0 1 170
0 0 173
0 0 155

0 0 150
1 0 143
0 0 159
0 1 160
0 0 148
1 149
0 0 146
5 0 152
0 0 153
0 0 160

0 0 159
1,6 0 159
0 153

0 0 148
0 0 154
1,5 2 lisinopril, bisoprolol, amlodopine 152
6 0 145
1 2 amlodipine 163
0 0 155
0 0 163
1 2 amlodipine (tidak teratur) 153
0 0 164,5
 0 0 155
0 0 166
1 0 160
0 0 159
1 2 148
0 0 150
1 2 amlodipine 150
0 0 153
6 0 145
1 2 115
1 142
0 0 153
0 0 155
0 0 158
0 0 158

0 0 154
0 0 147
4 0 145
1 0 147

1 2 amplodipine 163
0 0 153
4 0 160
1 0 153
0 0 168
0 0 160
1 0 153
oa genu 2 obat nyeri 152
1 0 150
1,4 2 obat dm, captopril 148
1 0 158
0 0 142
0 0 152
0 0 139
0 0 159
0 0 152
0 0 159
0 0 151

0 0 144
3 0 154
1 0 153
1,4 0 153
0 0 159
1 0 147
 4 0 149
0 0 153
1 0 161
0 0 165
6 0 158
0 0 152
0 0 144
0 0 153
0 0 163
0 0 149
0 0 169
0 0 162
0 0 147
3 2 157
0 0 168
1 0 152
0 0 171
0 0 155
0 0 163
0 0 165
1 0 151
1 0 145
1 0 162

0 0 152
0 0 141
0 0 150
0 0 165
1,3,4 146
0 0 176
6 0 151
0 0 162
1,3,4 164
3 0 154

0 0 154
5 0 sudah selesai pengobatan TBC 6 bln 158
1,4 146
0 0 159
0 0 165
0 0 138
0 0 158
1 0 158
0 0 150
1 2 amlodipine 147
1,3 145
 0 0 155
0 0 163
1 0 148
0 0 146
0 0 151
1 2 paracetamol 162
0 0 145
0 0 164
1 2 obat darah tinggi 138
1,4 2 obat darah tinggi 150
1 0 0 150
0 0 156
0 2 antalgin 177
3 0 142
6 0 146
0 0 148
1 0 162
0 0 152
0 2 paracetamol 159
1,3 2 pengencer darah 155
0 0 155
0 0 159
0 0 154
1 2 captopril 156
1,3 0 149
1,3 1 vit b1 131
0 0 164
0 0 163
0 0 156
1,6 0 158
0 0 158
0 0 170
1 0 162
0 0 176
1,4 2 captopril, metformin 146,5
1,6 2 obat darah tinggi 151
0 0 151
1,6 0 157
1 0 154
3 2 obat jantung 158
0 0 159,5
1,3,4 0 144
0 0 161
0 0 158
0 0 161
1 0 137
 0 0 155
0 0 156
1,4 2 obat HT dan obat DM 153
1 2 obat HT dan ginjal 150
0 0 145
0 0 153
0 0 161
1 2 paracetamol 145
1 0 143
0 0 160
0 0 146
3 2 obat jantung 145
0 0 158
1,2 1,2 vitamin, obat HT, obat nyeri 148
1 0 142,5
0 0 138
0 0 151
0 0 170
0 0 158
0 0 161
0 0 155
0 0 156
0 0 162
0 0 165
0 0 155,5
1 0 156
0 0 150

1 0 148
1 0 152
1 2 amlodipine 152
0 0 154
4 0 155
0 0 145
1 0 145
1,3,4 2 captopril 164
0 0 155
0 0 152
1 0 155
1,5 0 159
163
1 2 amlodipine 140
1,4 2 glikuidon 156
0 0 158
0 0 154
1 165
0 0 160
1 0 148
0 0 153
1 0 153
0 0 162
0 0 150
0 0 160
0 0 144
0 0 166
1 0 159
0 0 155

1 0 160
0 0 161
1 0 146
0 0 141
1 0 154
0 0 164
1 0 158
0 0 163,5
0 1 vit b1 159
4 0 150
0 0 153
1,2 0 159
0 0 165
0 0 148
0 0 151
 FORMULIR PE

Tekanan darah

BB BMI PCF PFR chest expans

Pre

65 31,7 300 260 2-2-3 132/76

67,5 23,7 320 430 3-4-3 110/73
69 25.34 180 400 3-4-3 130/65
63 30 250 280 157/73
60 27.02 130 3-2-2 113/59
47 20,34 120/52
70 31,95 300 320 3-2-2 169/95
39 19,34 280 260 3-2- 2 127/63
60 22,6 380 410 4-4-4 122/69
43 19,89 250 230 2-2-2 100/59
43 19,36 240 230 3-1-3 112/62
41 17,28 290 280 3-2-2 170/89
65 26,37 180 280 3-3-3 124/69
41 18,46 250 310 3-1-2 117/77
59 NA 240 320 3-2-3 141/86
42 17,2 340 460 3-4-3 115/51
54 19,3 93/62
66 29,33 260 300 3-2-2 161/97
59 23,04 160 220 3-2-3 128/77
65 22,49 260 200 3-4-3 86/57
53 NA 380 360 3-3-2 109/69
76 31,3 400 500 4-3-4 138/85

40 17,7 400 420 3-4-2 98/54

36 17,6 260 280 3-4-5 89/59
52 20,5 340 380 3-3-3 125/75
43 16,79 310 360 3-3-3 107/66
52 23,73 340 300 3-3-2 127/87
40 18,01 3-2-2 138/85
62 350 340 3-2-3 129/70
58 370 330 3-3-3 91/67
56 23,92 134/80
69 26,9 320 340 3-3-2 105/72

73 NA 310 340 3-3-2 107/50

63 470 480 3-2-2 166/116
48 20.5 280 410 3-5-6 114/60

44,5 230 170 2-2-1,5 111/61

83 34,9 360 240 2-2- 2 123/77
35 15,55 120 120 3-2-2 134/100
43 20,45 280 220 3-3-2 102/71
49 18,4 300 380 5-5-5 167/88
48 19,97 340 140 3-2-2 97/61
61,5 23,1 440 390 3-3-5 140/89
50 21,35 144/61
46 16,9 270 250 2-3-2 100/78
 49 20,39 260 290 3-3-3 105/73
60 21,77 420 400 3-4-3 97/60
70 27,3 220 3-2-2 159/97
43 17,005 400 510 5-4-4 126/65
52 390 230 3-3-3 91/76
61 27,11 300 300 3-2-3 123/95
40 17,77 210 220 3-2-2 121/89
69 29,47 160 340 3-4-3 137/78
53 25,2 NA NA 2-2-2 123/85
46 34,7 130/71
54 26,7 160 160 3-3-6 190/116
70 29,9 3-2-2 162/107
57 23,72 440 400 4-4-3 120/70
49,5 19,82 480 280 3-2-2 129/89
60 240 360 4-6-3 187/103

68 28,69 3-5-4 126/78

46 102/76
59 28,06 240 3-4-4 147/90
46 156/86

76 32,4 3-4-4 186/109

69 29,48 400 400 3-3-6 129/82
64 25 360 340 3-3-3 117/80
49 20,9 100 100 3-5-5 159/81
71 25,15 490 540 3-5-5 122/71
67 26,17 NA NA 3-2-3 183/93
58 24,77 NA 240 3-4-3 173/105
55 23,8 300 300 3-2-3 151/93
58 25,7 290 280 3-2-3 154/125
41 18,72 250 310 3-5-3 136/73
68 27,2 450 470 2-2-2 124/82
41 19,82 210 160 3-3-3 119/72
33 14,28 170 200 3-5-5 170/102
45 23,3 300 300 3-3-4 109/64
40 15,82 420 300 3-2-3 110/70
49 21,2 220 230 3-2-2 126/50
59 21,7 330 360 4-4-2 112/66
50 21,9 3-5-7 130/98

42 18,01 210 220 3-3-3 114/71

106 44,69 119/75
59 25,2 149/87
57 300 2-2-2 150/92
63 340 420 3-5-6 115/62
67 31,01 260 230 3-5-4 178/117
47 75/57
50 21,36 320 460 3-5-6 144/81
71 27,39 460 460 4-3-3 162/82
52 19,1 280 170 3-3-3 98/69
50 20,08 NA NA 3-3-5 126/86
50 21,64 3-5-5 109/82
51 22,97 3-3-3 117/75
63 26,9 260 220 3-3-5 102/74
84 3-5-5 142/88
45 20,27 350 340 3-3-3 114/72
67 23,45 360 450 3-4-3 130/75
55 20,95 470 480 3-5-6 102/65
47 21,75 250 440 3-3-6 177/130
61 3-3-5 184/110
54 19,13 360 360 4-6-6 101/63
59 300 280 3-5-5 130/83
60 260 360 3-4-4 107/77
48 19,97 320 3-2-3 113/69
45 16,98 340 340 4-6- 4 110/70
49 18,01 400 400 3-5-5 108/80
64 28,06 300 230 3-4-6 178/105
37 17,59 270 3-5-4 125/82
42 16,03 220 260 3-5-4 165/93

54 23,3 220 200 3-2-2 108/78

40 180 240 3-3-4 125/68
60 220 260 3-3-2 100/72
52 19,11 320 330 3-4-5 158/87
65 80 180 3-3-2 122/79
69,5 22,43 340 280 4-4-5 110/63
70 30,7 120 100 3-2-2
60,5 23,091 160 240 3-4-4 186/110
61 22,68 460 460 3-4-4 125/74
50 160 340 3-5-6 97/69

41 17,2 320 320 3-4-4 121/68

58 23,23 260 460 4-5-6 141/94
50 23,4 200 290 3-4-4 135/71
65 25,71 320 350 3-3-4 147/76
66 29,62 440 400 3-4-3 159/117
31 16,28 160 180 3-4-2 110/59
52 20,83 70 130 2-2-1 160/97
44 240 300 3-5-7 183/84
49,5 250 220 3-3-3 153/97
59 24,9 100 100 2-2-2 174/67
53 320 160 3-3-3 150/81
 48 100 180 3-3-3 109/77
61 23,01 440 440 4-5-6 156/95
60 27,39 340 320 2-3-3 142/105
53,5 16,9 140 320 3-4-3 114/78
58 240 270 2-2-2 173/114
46 110 100 2-2-2 121/86
40 250 210 3-3-2 111/66
76 340 380 5-4-3 141/83
64 33 60 100 3-2-2 148/80
55 220 260 3-3-2 182/106
43 160 170 2-2-2 136/73
46 360 360 3-4-5 118/69
85 300 320 2-2-2 130/71
48 23,8 160 160 2-2-2 135/82
52 24,4 3-3-2 93/70
68 31,05 240 240 3-4-5 139/90
54 20,5 230 280 3-4-3 179/85
48 20,84 260 260 4-3-3 107/79
62 29,5 400 420 3-4-4 122/75
84,5 35,2 100 170 3-3-3 134/74
51 250 270 3-3-3 127/62
51 21,51 240 200 2-3-3 207/99
62 220 280 2-2-2 149/83
58 23,86 400 420 2-2-2 84/70
47 480 470 2-2-2 204/119
45 26,3 260 210 4-3-3 128/75
64 23,8 160 110 3-2-2 134/61
48 140 100 2-2-2 147/107
75 30,8 280 320 2-2-2 182/113
62 24,89 180 320 2-2-2 143/88
56,5 260 260 2-2-2 114/65
47 280 340 5-5-4 81/59
59 22,48 140 160 3-3-3 142/72
49 15,8 110 130 2-3-3 106/71
65 30,5 280 280 2-2-1 128/71
40 17,5 260 260 3-3-3 156/101
69 170 240 1-2-1 138/74
75 450 440 4-3-4 94/78
64 260 360 3-3-3 136/70
55 22,08 220 340 3-3-3 150/91
57,5 24,26 190 270 3-2-2 133/80
50 24,11 140 170 3-2-2 122/110
66 25,4 250 340 3-3-3 1116/88
50 20,08 410 420 5-5-4 114/65
61 23,53 340 440 4-5-6 141/80
36 240 2-2-2 170/81
44 60 110 2-2-2 163/80
56 140 440 3-4-4 165/83
59 23,07 80 220 2-2-2 122/65
43 220 240 2-3-3 148/76
62 29,5 240 380 3-2-3 146/101
50 100 140 3-2-2 204/117
40 320 330 4-5-5 122,74
45 20,5 3-2-3 186/98
52 25,9 400 480 3-3-4 164/109
54 340 400 2-3-3 130/74
45 21,12 180 220 3-4-4 164,93
55 26,19 108/70
66 520 480 4-4-4 132/92
51 23,2 240 250 2-2-2 123/96
48 23,88 3-3-3 153/96
33 17,36 360 380 2-3-3 103/72
50 21,9 140 160 3-3-2 121/83
64 22,14 400 500 3-3-3 133/93
67 26,9 300 360 3-3-3 113/78
48 18,51 360 400 3-4-5 100/71
57 410 450 4-3-2 113/82
57 160 300 3-4-4 127/82
67 500 460 3-4-4 107/75
46 460 440 5-5-5 119/71
65 460 400 2-3-3 137/91
110 45,26 480 440 3-2-2 128/70
49 120 130 3-3-3 113/69

51 100 160 4-3-3 153/90

70 30,3 120 140 2-3-2 161/107
33 180 230 3-4-4 150/94
116 60 300 1-1-1 133/93
30 12,8 140 220 2-2-1 80/58
52 120 300 3-4-3 126/83
38 200 240 3-3-3 126/90
56 420 390 5-4-5 166/103
51 160 260 2-2-2 126/74
62 220 180 3-3-2 137/84
34 160 300 3-2-3 162/90
55 24,2 220 180 3-3-3 125/67
58 200 300 3-3-2 123/81
55 60 120 2-3-3 146/64
53 120 200 3-3-2 141/77
61 24,4 330 340 3-3-3 100/66
60 240 260 3-3-4 132/76
60 320 360 3-2-2 151/83
 54 160 360 5-5-5 160/66
62 240 260 3-3-3 130/83
37 120 200 3-2-2 130/60
47 140 160 3-4-3 197/112
62,5 260 200 2-2-3 154/108
46 240 220 3-4-3 107/80
71 440 350 3-3-4 133/89
49 180 220 3-3-3 123/98
56 20,36 380 360 4-4-3 131/74
73 160 260 3-2-2 198.101
44 18,3 280 380 5-5-4 126/73

53 330 300 3-3-3 113/50

50 460 400 4-4-4 122/72
56 260 260 3-3-3 165/93
40 18,26 280 300 3-4-3 143/81
39 180 360 3-4-4 119/65
52 240 250 3-4-6 132/64
78 24,9 280 4-3-3 160/86
79 160 140 3-4-3 141/85
75 31,6 420 360 3-4-3 182/74
48 210 340 2-2-2 115/78
52 22,22 260 160 3-5-3 152/68
82 200 260 3-4-3 139/79
64 23,7 290 310 3-4-4 185/110
60 29,6 300 260 3-3-3 190/111
51 140 140 3-3-2 123/74
 FORMULIR PEMERIKSAAN KARDIORESPIRASI

Tekanan darah Heart rate Respiratory rate

Post Pre Post Pre Post

79 20
73 18
 74 20
81 16
61 16
84 16
195/116 116 132 16
111 20
73 16
135/66 72 90 16
79 12
92 20
223/85 84 94 16
107/76 105 118 14
86 20
83 18
73 16
89 16
96 16
105 16
107/74 79 83 18 20
73 16

70 16
87 20
142/83 96 120 16
113/95 88 88 18 20
94 16
149/93 94 99 16 20
75 16
76 16
93 20
82 16

81 12
89 20
84 18

62 16
111 16
134/94 75 85 18
146/108 122 118 18 20
111 20
82 20
128/84 78 70 20 24
64 18
105/61 96 98 20
115/91 98 125 20 20
82 20
79 20
75 18
175/87 90 95 15
96 18
85 20
89 20
82
76 18
102 18
107 16
66 16
99
109 24

94 18
101 18
145 16
98 16

73 18
116
63 24
102 16
79 18
67 16
71
80
73 18
91 16
83
80 20
88 20
79 18
85 18
90 18
78 18
99 18

78 18
80 18
92 18
82 16
90 16
91 16
 93 24
78 18
93 20
88 18
83 20
84
96 18
75
85 20
87 16
75 16
76 18
74 16
67 16
79
75 16
80 16
89 18
56
94 16
75 20
83 16
92 16

81 16
61 16
79 16
85 16
73 21
122/88 77 96 16 20

109
81
82 20

70 16
158/95 61 66 16 20
126/65 88 89 16 18
85 16
84 16
101 16
87 16
94 20
95 20
85 20
85 20
113/82 85 89 16 20
158/95 83 86
131/103 110 123 16 20
131/80 78 80 16 20
97 20
83 16
72 14
84 16
97 20
94 16
82 16
56 16
76 16
89 16
86 16
96
54 16
57 16
88 20
102 16
71
66 16
89 20
85 16
72 16
97 16
78 16
106 16
93 16
72
87 20
72 16
68 16
79 20
74 16
80 20
69 16
190/119 103 111 18 20
87 20
81 16
73 16
91 16
69 16
78
89 16
88
 70 20
80 16
90 16
75 16
94 16
92 16
80 16
105 16
78 16
78 20
81 16
85 24
93 20
102 16
75
128/80 78 84 16 24
131/81 81 104 16 20
86 16
78
110/65 92 120 18
145/79 86 99 16 18
121/82 93 93 16 24
100,89 78 84 16 18
81
83 20
78 20
83 16

90 16
109 20
125 20
115
187 20
95
71 16
96 20
69 16
98 16
91 20
73
80 16
82 16
98 16
76 16
82 16
77
127/76 73 83 16 20
149/72 69 75 16 24
85 16
73 16
100 14
153/86 90 112 16 24
76
124/86 91 86 16 20
67 16
67 20
142/80 71 80 16 20

68 20
112/72 72 70 16 24
82 16
165/84 65 79 16
78 16
80 16
70 16
105 20
68 16
69 16
77 16
86
77 16
116 16
81 16
 BORG Scale SaO2

Jarak tempuh

Pre Post Pre Post

7-0-2 92
11-0-0 97
 7-2-0 99
6-0-0 100
6-0-2 99
6-0-0 94
6-0-0 11-1-3 95 93 454,5
11-0-0 97
6-0-2 98
6-0-0 11-0-0 99 95 427,2
13-0-2 98
9-0-0 98
13-0-3 13-3-4 99 99 300
11-3-4 16-0-7 99 99 519
7-0-2 96
6-0-2 99
6-0-0 99
11-0-0 99
NA NA
6-0-0 97
12-0-0 NA 336,7
11-0-0 99

11-0-2 100
7-0-3 97
6-0-0 15-3-3 98 98 285
9-0-0 15-0-0 98 98 286
13-0-2 97
13-0-2 11-2-3 98 98 355,8
11-0-0 97
9-0-0 99
13-0-5 96
9-2-0 98

11-0-0 99
13-2-2 AMPUTASI
6-0-0 99

11-0-3 98
7-0-3 96
13-0-2 11-0-0 99 99 428,33
6-0-0 11-0-0 98 98 336,,5
pengelihatan (-) 98
pengelihatan (-)
6-0-0 7-0-0 100 99 300
9-0-0 96
7-0-1 13-0-0 97 98 402,2
 6-0-0 11-0-0 94 99 315
7-0-0 83
6-0-0 97
12-0-0 96
12-0-5 11-0-5 99 99 375,1
11-0-0 99
6-0-3 98
99
9-2-3 96
13-5-5 99
6-0-0 97
15-0-3 98
11-0-3 97
7-0-1 92
15-0-3 99

11-0-3 98
11-0-3 98
12-0-2 97
6-0-0 96

13-2-0 98
7-0-3 96
6-1-5 98
9-3-3 97
13-5-0 97
11-0-0 94
7-0-0 99
13-0-0 95
11-0-0 97
11-0-0 94
7-0-0 99
13-0-0 99
9-0-2 99
15-0-0 99
6-0-0 96
9-3-0 97
13-0-0 99
13-0-9 99

7-0-3 97
9-0-3 96
11-0-0 99
6-0-3 96
9-0-3 95
11-3-2 99
15-0-5
11-0-0 99
13-0-2 99
13-0-3 95
9-0-0 99
11-2-3 99
6-0-3 97
11-0-2 100
7-0-3 97
11-0-3 98
13-0-0 99
6-0-0 99
12-0-3 96
13-3-3 98
11-0-0
11-0-0 95
11-0-0 98
9-0-3 96
11-0-2 95
11-0-0 97
11-0-0 99
6-0-3 99
11-0-0 98

7-0-0 98
6-0-0 95
15-3-5 99
6-0-3 95
8-0-0 97
6-0-3 6-0-0 97 98 370

6-0-0 90
96
11-0-0 89

13-3-2 98
13-0-2 13-3-4 99 98 363
6-0-2 11-0-3 100 98 318
11-0-2 98
9-0-0 84
7-0-0 98
7-0-0 98
6-0-0
7-0-2 99
11-0-3 97
12-3-0 94
11-0-1 11-0-1 99 99 360
7-0-2 99 359
13-0-2 13-3-3 99 99 297
6-0-0 9-0-2 192
11-0-0 93
13-3-0
6-0-5 96
6-0-0 97
11-0-2 96
11-0-4 99
11-0-3 99
7-0-0 99
12-0-5 97
9-0-2 99
11-0-2 99
13-4-4 95
11-0-0 99
7-0-2 99
8-3-3 99
11-2-5 97
6-0-3 94
6-0-0 97
8-0-2 98
6-0-0 98
11-0-0 97
7-3-2 97
7-0-2 96
99
12-0-0 98
13-0-3 95
7-3-0 94
9-0-2 99
9-0-0 99
9-2-3 98
7-0-5 96
17-3-0 98
7-0-3 96
6-0-0 9-0-2 99 99 318
6-0-5
13-0-0 95
11-0-0 96
11-0-7 99
11-0-0 99
11-2-3 98
9-0-0 99
7-0-0 91
11-0-1 99
93
9-0-0 98
11-0-5
11-0-4 99
11-0-0 99
11-0-0 94
13-0-0 95
6-0-0 98
6-0-3 96
11-0-0 97
15-3-3 97
13-0-4 94
15-0-3 92
7-0-0 93
7-0-0 13-0-7 98 96 345
11-0-2 11-0-0 97 98 318
6-0-0 97
7-0-0 94
11-0-0 11-3-3 95 99 427
13-0-1 13-0-5 280
12-0-0 13-4-4 90 99 271
13-0-3 13-0-5 98 95 268
13-0-2 99
7-0-3 99
6-0-2 99
7-0-0 95

11-0-0 95
11-0-1 95
6-0-0 92
7-0-0 99
85
7-0-1 99
6-0-0 97
20-2-5 99
11-0-0 99
11-0-2 98
13-0-0 99
13-2-0
13-2-3 98
15-0-1 96
11-0-0 99
11-0-3 96
11-0-0 98
11-0-2 96
11-0-3 11-1-1 99 98 435
11-0-0 13-0-0 99 99 421
11-0-0 98
13-0-7 99
7-0-0 98
7-0-0 9-0-0 97 92 468
13-0-2 99
13-0-0 13-0-0 95 99 310
9-0-0 99
8-0-3 98
11-0-0 11-0-0 99 96 410

11-0-0 96
11-0-3 13-3-3 99 99 412
11-0-0 97
6-0-0 11-0-0 98 99 470
11-0-0 97
6-0-0 98
6-0-0 99
6-3-0 96
6-0-0 96
6-0-0
6-0-0 98
11-2-2 96
9-0-2 98
7-0-3
9-0-0 96
 1 - Ya
0 - Tidak

FORMULIR TIMED UP AND GO TEST

Timed Up and Go Test Berjalan den

VO2 max METs

1 2 3 Ya / Tidak
12' 01" 12' 04" 10' 07" 0
12'68" 9'15" 10'60" 0
 17' 16'17" 13'45" 0
14'40" 14'53" 13'32" 0
15'01" 13'16" 13'01" 0
13,43 11,70 11,49 0
23,38 6,68 9,07 10,13 11,30 0
9,84 10,43 9,34 0
9,07 9,07 10,04 0
25,24 7,2 8,08 8,33 8,28 0
14,26 12,83 11,60 0
12,13 11,95 12,06 1
15,4 4,4 11,63 11,06 9,09 0
29,6 8,4 10,67 9,71 9,43 0
12,14 11,04 12,07 0
13,67 11,72 11,64 0
13,20 12,10 11,92 0
10,99 9,68 9,25 0
15,96 14,07 12,62 0
11,8 11,13 11,11 0
22,74 6,49 11,56 11,15 11,46 0
13,15 12.23 12,41 0

9,80 10,92 9,56 0

13,26 12,08 12,06 1
16,8 4,8 13,48 13,71 12,26 1
20,83 5,95 10,42 7,85 8,07 0
10,85 12,22 11,26 0
23,5 6,7 11,90 10,55 9,3 0
12,52 12,73 13,51 0
14,65 13,51 13,30 0
11,25 9,54 9,16 0
7,40 7,06 6,30 0

12,85 11,41 10,17 0

11.37 11.76 9.75 1
14.91 11.03 10.29

13,02 12 11,03 0
9,2 8,73 9,18 0
30,53 8,72 7,99 0,11 9,10 0
21,90 6,25 9,26 9,03 8,94 1

10,48 11,08 11,03 0

10,65 3,04 10,05 11,02 11,14 1
11,42 11,66 11,75 0
19,69 5,6 8,4 7,56 8,27 0
19,44 5,55 13,67 13,41 14,07 1
13,38 13,89 11,78 1
11,53 8,55 8,74 0
13,09 10,46 10,31 0
22,35 6,38 8,64 8,29 7,62 0
10,83 9,64 9,42 0
10,38 9,62 9,57 0
12,85 13,53 13,75 0
11,66 10,26 9,76 0

14,8 13,89 13,06

7,53 9,03 10,64 0
12,12 13,80 13,13 0
13,81 15,55 14,15 1

12,50 11,04 10,01 0

20,32 18,50 17,29 0

15,64 15,09 14,01 1

gangguan peng
13,41 12,23 12,54 0
12,58 10,68 10,07 0
10,75 8,72 8,3 0
9,16 7,97 8,98 0
gangguan peng
8,39 8,77 9,49 0
30,83 24,10 23,36 0
13,07 12,82 12,35 0
11,38 10,93 11,30 0
15,16 14,77 13,41 1
gangguan peng
16,76 14,48 11,84 0
8,51 10,08 10,73
10,48 11,32 12,38 0
12,77 12,76 11,79 0
8,12 7,34 7,21 0
11,78 10,23 10,43 0

15,11 14,32 13,81 1

9,68 6,87 9,10 0
10,71 9,20 10,10 0
11,10 10,62 9,66 0
14,81 14,91 12,33 1
13,21 12,37 11,43 0
 11,89 13,61 13,41 0
18,53 16,50 14,37 0
14,69 13,84 13,41 0
14,26 11,20 12,10 0
18,33 13,42 13,24 0
15,30 14,46 14,93 0
9,98 10,43 8,83 0
28,99 26,83 15,16 0
17,07 14,44 15,83 0
12,79 12,58 12,11 0
7,46 8,86 8,48 0
11,86 9,84 10,46 0
15,88 11,96 11,70 0
9,79 9,76 9,36 0
12,31 13,57 14,23 0

9,01 8,33 8,83

12,25 9,49 9,62 1

15,85 13,88 10,98 0
10,08 09,63 08,70 0
12,30 10,27 9,37 0

9,00 10,34 10,44 0

8,66 7,84 6,59 0
13,00 12,81 12,20 1
9,25 8,93 8,97 0
10,53 9,91 10,28 0
19,03 5,4 12,59 7,53 8,28 0
12,78 11,12 12,72 0
11,44 9.47 8.93 0
7,78 7,71 8,89 0
9,6 9,25 8,59 0

9,22 9,78 10,06 0

23,28 6,65 10,81 10,61 10,13 0
19,8 5,6 11,63 10,06 9,62 0
12,6 11,75 10,46 0
11,13 9,97 9,00 0
10,19 8,22 6,84 0
13,50 12,50 12,84 0
15,25 11,12 11,61 0
11,19 11,31 11,47 0
16,59 10,72 11,03 0
13,68 13,81 11,37 0
 20,11 5,7 10,00 8,00 8,22 0
21,43 6,1 10,44 0,40 10,56 1
13,38 3,82 10,60 10,43 9,71 1
14,376 4,1 14,81 11,22 12,09 1
18,38 16,97 13,75 0
10,66 9,16 10,28 0
11,19 9,66 10,16 0
8,31 9,40 8,50 0
8,44 10,06 8,47 0
10,56 11,85 11,47 0
17,31 17,61 16,22 0
8,13 8,13 7,78 0
21,15 21,78 20,19 0
8,31 8,10 7,93 0
15,91 11,53 10,94 0
12,40 10,25 10,41 0
9,67 9,87 9,15 0
10,56 10,22 10,25 0
12,79 9,78 9,63 0
14,66 13,06 13,10 0
16,84 13,34 11,53 1
11,13 10,68 10,41 0
10,09 9,90 10,33 0
10,22 8,32 8,97 0
11,4 10,75 9,91 0
15,07 14,87 15,47 0
12,56 9,91 9,59 1
11,50 9,87 9,68 0
11,40 7,87 10,19 0
12,54 12,01 11,03 0
10,59 10,41 10,62 0
8,78 10,25 10,28 0
9,06 9,97 7,97 1
10,37 9,94 9,78 0
14,88 15,87 15,44 0
13,19 9,19 9,07 0
14,63 11,84 11,28 0
17,41 4,9 122,90 10,57 8,41 1
9,28 9,72 9,19 1
8,72 8,56 9,15 0
11,50 10,10 09,13 0
14,69 13,40 12,29 0
13,30 12,13 11,10 0
10,97 8,97 10,10 0
11,78 10,13 9,44 1
11,41 11,53 11,06 0
 28,91 27,09 24,69 0
9,93 10,20 7,79 1
14,94 14,91 15,84 1
11,40 9,12 10,16 0
14,52 12,00 12,10 0
9,94 9,88 9,84 0
11,15 10,75 9,78 0
31,19 25,31 27,6 1
11,28 7,69 7,34 0
11,46 8,87 10,09 0
11,09 11,32 10,59 0

12,37 9,28 10,16 0

14,56 12,19 10,97 0
12,31 11,50 11,13 0
21,57 6,16 12,00 10,53 9,78 0
19,75 5,63 11,75 10,25 9,50 1
8,72 7,85 7,93 0
11,22 10,19 10,03 0
25,98 7,42 7,56 7,22 7,22 0
18,55 5,3 10,41 8,31 7,68 0
12,75 3,64 11,66 10,00 10,04 0
14,47 4,13 11,00 11,38 9,03 1
13,22 7,75 7,66 0
9,60 8,97 8,28 0
12,66 8,12 8,50 1
12,53 9,69 8,81 0

18,72 13,35 12,74 0

14,28 12,59 11,94 0
12,69 9,87 9,60 1
17,66 13,09 12,35 1
27,69 23,19 22,78 0
15,57 14,66 13,23 1
18,72 14,97 14,03 1
11,72 11,53 11,25 1
10,28 6,94 7,65 0
13,43 12,84 12,34 0
24,40 22,19 20,85 1
13,59 13,69 16,68 1
14,85 16,07 13,91 0
19.13 18,50 17,41 1
11,28 9,81 10,19 0
13,15 11,79 11,12 0
12,25 12,00 11,85 0
14,34 13,16 13,34 0
22,9 6,56 11,69 9,22 8,12 0
23,6 6,6 8,35 6,88 8,25 0
10,40 8,75 8,66 0
14,50 11,40 11,91 0
13,16 13,81 12,89 0
31,11 8,60 11,37 9,69 9,22 0
12,84 13,15 12,69 0
15,40 9,82 9,13 0
10,25 10,25 9,69 0
9,75 9,09 9,88 0
27,08 7,7 10,10 8,63 8,79 0

8,31 8,57 8,53 0

24,8 7,1 8,47 8,31 8,15 0
11,13 8,91 8,75 0
30,47 8,78 9,69 8,41 7,03 0
11,15 9,22 9,25 0
9,94 7,75 7,50 0
10,21 10,00 9,91 0
13,41 12,63 11,96 1
13,66 11,00 10,37 0
13,96 14,21 14,16 1
12,37 8,84 9,07 0
19,34 17,71 15,91 1
14,18 14,34 12,40 0
13,78 13,19 12,90 0
10,97 10,25 9,84 0
 1 - (20 = Mandiri)
2 - (12 -19 = Ketergantungan Ringan)
3 - (9-11 = Ketergantungan Sedang)
4 - (5-8 = Ketergantungan Berat)
5 - ( 0-4 = Ketergantungan Total)

D UP AND GO TEST

FORMULIR INDEKS BARTHEL FORMULIR DASH

Berjalan dengan alat bantu

Bila Ya, Sebutkan

1 0
1 0
 2 33
2 6,6
1 2,5
1 0,8
1 5
2 1,7
2 20
1 0
1 8,3
below knee prosthesis 1 0
1 14,6
1 18,33
2 50
1 0
1 5,83
1 0
2 17,5
1 25
1 4,16
1 0

1 7,5
prosthesis below knee 1 17,5
prosthesis below knee 2 15
1 9,17
1 23,5
1 37,5
1 9,16
1 2,5
1 29,31
1 8,3

1 12.93
prosthesis below knee 1 9.16
1

1 5
1 2,5
1 0,7
prosthesis below knee 2 10,34
2 29,1
1 33,33
prosthesis below knee dextra 1 5
1 3,3
1 15
prosthesis below knee dextra (pasien hampir jatuh) 1 10
prothesis below knee 1 34,17
1 5,83
1 1,6
1 6,6
1 8,3
1 9,16
1 10
1 1,6
2 2,5
pengelihatan turun 1 1,7
1 6,89
1 5,83
1 4,1
prothesis dexra 1 1,72

1 0
sedang menggendong anak 1 27,5
1 6,9
protesa below knee dextra 1 15,52

gangguan penglihatan (tidak dapat dilakukan) 2 55,8

2 42
1 18,3
1 2.59
1 5
gangguan penglihatan (tidak dapat dilakukan) 2 58
1 16
1 6,6
2 1,6
1 22,5
presthesis below knee dextra 1 8,3
gangguan pengelihatan (tidak bisa dilakukan) 2 25
2 18,3
1 6,03
2 20
1 0,8
1 6,6
1 0,8

prothesis below knee 1 4,31

1 2,5
1 0
2 10,83
prothesis below knee bilateral 2 53,3
1 19,1
tidak bisa dilakukan pasien pusing 2 56
1 0,8
1 0,8
1 5,8
1 4,16
1 27,5
2 16,6
1 5
1 15
1 7,5
1 10
1 0,83
1 2,5
1 5,8
1 5
1 0
tuna netra 2 30,83
1 0
1 23,1
prothesis sinistra below knee 1 15
1 0
1 5
1 12,5

1 5,8
1 15
prosthesis below knee sinistra 2 3,33
2 60
1 3,3
1 1,6
2 48,33
1 0
1 3,33
2 24,14

1 12,5
2 0
1 6.6
1 0
1 1,67
1 3,33
1 56,7
1 5
1 5
2 4,3
1 8,33
 1 5
prosthesis below knee dextra 1 19,83
prosthesis below knee dextra 1 9,17
prosthesis below knee sinistra 1 21,6
2 37
1 12,93
2 25,86
1 0
1 12,93
1 0
2 17,2
2 16,6
hampir jatuh 1 4,17
1 2,5
1 21,7
2 21,6
1 0
1 24,13
2 25
1 4,17
protesa below knee dextra 1 16,38
2 11,6
1 7,5
1 3,4
2 5,17
2 30
protesa below knee sinistra 1 0
1 0
1 6,67
1 1,7
2 16
2 12,5
protesa below knee dexra 2 21,6
1 35,83
2 14,17
1 1,67
2 42,5
prosthesis below knee dextra 1 0
prosthesis below knee dextra 2 30
1 28,44
1 7,5
2 21,55
1 11,67
1 0
prosthesis belon knee sinistra 2 19,17
1 0
 2 35,19
prostesis below knee dex - sin 20 33
protesa belom¥w knee dextra 2 34
1 10
2 0,86
1 0
1 5
prosthesis below knee sinistra 1 0
1 0
2 24,17
1 0
pasien sesak 3 68
1 4,16
2 43,1
1 1,7
1 2,5
prosthesis below knee sinistra 1 0
1 9,16
1 1,6
1 4,17
2 9,16
1 20
protesa below knee sinistra 2 17,5
2 3,33
1 6,67
prosthesis below knee sinistra 1 4,17
1 0
kursi roda 2 45
1 6
1 25
protesa below knee sinistra 1 5
protesa below knee sinistra 1 7,76
2 4,31
protesa below knee dextra 1 10
protesa below knee dextra 1 11,2
protesa below knee sinistra 2 30
1 22,4
1 9,16
0rthosis 1 3,44
orthosis 2 43,97
1 30
protesa below knee dextra 1 1,72
1 20
2 43,3
1 5,17
1 0
 1 10
1 5
2 20
1 10,83
1 17,34
1 3,33
1 2,5
1 0,8
1 0,83
1 9,2
1 0,83

1 0,83
2 4,16
1 0,83
1 2,5
1 0
1 0
1 0
protesa below knee dextra 2 22,5
1 5
protesa below knee dextra (pasien hampir jatuh) 2 24,17
1 0
protesa leg dextra 2 25
2 46,65
2 24,125
1 19,1
1 - ( 0-12 = No significant restriction)
2 - (13-22 = Mild restriction)
3 - (23-32 = Moderate restriction)
4 - (33-52 = Severe restriction)
5 - ( 53-90 = Extreme restriction)

FORMULIR PARTISIPASI

1
1
1
1
1
1
1
1
2
1
1
1
2
1
3
1
1
1
1
1
1
1

1
1
1
1
1
2
1
1
2
1

1
1
1

1
1
1
1
3
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

1
4
1
1

4
2
1
1
1
3
2
1
1
1
2
1
1
1
1
1
1
1

1
1
1
1
2
2
4
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
3
1
1
1
0
1
1

1
1
1
4
1
1
1
1
1
1

2
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
1
1
1
1
2
1
1
3
1
1
1
2
1
1
1
2
1
2
1
2
1
1
1
1
1
1
1
1
4
1
2
1
1
1
2
1
1
1
3
1
1
1
1
1
1
5
1
1
2
1
1
1
5
2
1
1
3
2
1
1
2
1
3
1
1
1
2
1
1
1
1
1
1
1

2
1
1
1
1
0
1
1
1
1
1
1
1
1
1
 1 = No
2012
: Mandiri 1 = No difficulty 1 = No difficulty 1 = No difficulty
- 19 : difficulty
2 = Mild
Ketergantungan
95--11 2 = Mild difficulty 2 = Mild difficulty 2 = Mild difficulty
8 ::
Ringan
difficulty
3 = Moderate 3 = Moderate
Ketergantungan
Ketergantungan 3 = Moderate difficulty 3 = Moderate difficulty
0 -4 :
Sedang 4 difficulty
= Severe 4 difficulty
= Severe
Berat
Ketergantungan 4 = Severe difficulty 4 = Severe difficulty
difficulty difficulty
Total 5 = Unable 5 = Unable 5 = Unable 5 = Unable
 1 = No
1 = No difficulty 1 = No difficulty 1 = No difficulty 1 = No difficulty
difficulty
2 = Mild 2 = Mild difficulty
2 = Mild difficulty 2 = Mild difficulty 2 = Mild difficulty
3 = Moderate 3 = Moderate difficulty
3= Moderate 3 = Moderate
3 = Moderate difficulty
4 difficulty
= Severe 4 difficulty
= Severe 4 difficulty
= Severe 4 difficulty
= Severe 4 = Severe difficulty
difficulty difficulty difficulty difficulty
5 = Unable 5 = Unable 5 = Unable 5 = Unable 5 = Unable
 1 = No 1 = No
1 = No difficulty 1 = No difficulty 1 = No difficulty
difficulty
2 = Mild difficulty
2 = Mild
2 = Mild difficulty 2 = Mild difficulty 2 = Mild difficulty
3=difficulty
Moderate 3 = Moderate 3=difficulty
Moderate
3 = Moderate difficulty 3 = Moderate difficulty
4 difficulty
= Severe 4 difficulty
= Severe 4 difficulty
= Severe 4 = Severe difficulty
4 = Severe difficulty difficulty difficulty difficulty
5 = Unable 5 = Unable 5 = Unable 5 = Unable 5 = Unable
 1 = No 1 = No 1 = No
1 = No difficulty 1 = No difficulty
difficulty difficulty
2 = Mild 2 = Mild difficulty 2 = Mild difficulty
2 = Mild
2 = Mild difficulty
difficulty
3 = Moderate 3 = Moderate difficulty
3 = Moderate difficulty
3 = Moderate
3 = Moderate difficulty
difficulty
4 = Severe difficulty
4 = Severe 4 = Severe 4 = Severe difficulty 4 difficulty
difficulty = Severe
difficulty difficulty difficulty difficulty
5 = Unable 5 = Unable 5 = Unable 5 = Unable 5 = Unable
 1 = No 1 = Not
1 = No difficulty 1 = Not at all 1 = None
difficulty
2 = Mild limited at all
2 = Slightly
2 = Mild difficulty 2 = Slightly 2 = Mild
difficulty
3 = Moderate limited
3=
3 = Moderate difficulty 3 = Moderately Moderately 3 = Moderate
4 difficulty
= Severe 4limited
= Very
4 = Severe difficulty 4 = Quite a bit 4 = Severe
difficulty limited
5 = Unable 5 = Unable 5 = Extremely 5 = Unable 5 = Extreme
 1 = No
1 = None 1 = None 1 = None 1 = None 1 = Strongly disagree
difficulty
2 = Mild
2 = Mild 2 = Mild 2 = Mild 2 = Mild 2 = Disagree
3 difficulty
= Moderate 3 = Neither agree nor
3 = Moderate 3 = Moderate 3 = Moderate 3 = Moderate
4 difficulty
= Severe disagree
4 = Severe 4 = Severe 4 = Severe 4 = Severe 5 difficulty
= So much 4 = Agree
5 = Extreme 5 = Extreme 5 = Extreme 5 = Extreme difficulty that 5 = Strongly agree
I cant't sleep
 Not Not Not
1 = No
specified, not specified, not 1 = No problem specified, not
problem
answered
Yes 2 = Small answered
Yes 2 = Small answered
Yes
Sometimes 3 = Medium Sometimes 3 = Medium Sometimes
Irrelevant,
No I 5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I
don’t want don’t want don’t want
to, don’t to, don’t to, don’t
have to have to have to
 Not Not Not
1 = No 1 = No
1 = No problem specified, not specified, not specified, not
problem problem
2 = Small answered
Yes 2 = Small answered
Yes 2 = Small answered
Yes
3 = Medium Sometimes 3 = Medium Sometimes 3 = Medium Sometimes
5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I
don’t want don’t want don’t want
to, don’t to, don’t to, don’t
have to have to have to
 Not Not Not
1 = No 1 = No 1 = No 1 = No
specified, not specified, not specified, not
problem problem problem problem
2 = Small answered
Yes 2 = Small answered
Yes 2 = Small answered
Yes 2 = Small
3 = Medium Sometimes 3 = Medium Sometimes 3 = Medium Sometimes 3 = Medium
5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I 5 = Large
don’t want don’t want don’t want
to, don’t to, don’t to, don’t
have to have to have to
 Not Not Not Not
1 = No 1 = No 1 = No
specified, not specified, not specified, not specified, not
problem problem problem
answered
Yes 2 = Small answered
Yes 2 = Small answered
Yes 2 = Small answered
Yes
Sometimes 3 = Medium Sometimes 3 = Medium Sometimes 3 = Medium Sometimes
Irrelevant,
No I 5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I
don’t want don’t want don’t want don’t want
to, don’t to, don’t to, don’t to, don’t
have to have to have to have to
 Not Not Not
1 = No 1 = No 1 = No 1 = No
specified, not specified, not specified, not
problem problem problem problem
2 = Small answered
Yes 2 = Small answered
Yes 2 = Small answered
Yes 2 = Small
3 = Medium Sometimes 3 = Medium Sometimes 3 = Medium Sometimes 3 = Medium
5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I 5 = Large Irrelevant,
No I 5 = Large
don’t want don’t want don’t want
to, don’t to, don’t to, don’t
have to have to have to
 Not Not
1 = No 3 = No
specified, not specified, not
problem problem
answered
Yes 2 = Small answered
Yes 5 = Small
Sometimes 3 = Medium Sometimes 0 = Medium
Irrelevant,
No I 5 = Large Irrelevant,
No I
don’t want don’t want
to, don’t to, don’t
have to have to
 IDENTITAS
NO URUT
NAMA ALAMAT RUMAH NO TELEPON

1 001 UUN MARYANAH KOMP. SERBAGUNA RT/RW 001/013

2 002 ROMLI LORONG I NO 18 RT 01/13 085211196179
3 003 ADE LORONG I SITANALA
4 004 POPON GUNAKARYA RT 01/13 NO 20
5 005 UMSIYAH DEPAN GOR SITANALA
6 006 SATNAH SITANALA
7 007 SUHAETI KOMPLEK SITANALA NO 40
8 008 MASUYAH DEPAN GOR SITANALA
9 009 TUTI KOMPLEK SITANALA NO 40 081210864085
10 010 MARHUMAH KOMPLEK SITANALA NO 36
11 011 SAMSIYAH KOMPLEK SITANALA NO 40 082299599472
12 012 MARTA KOMPLEK SITANALA NO 39 RT 01/13
13 013 MARYAM KOMPLEK SITANALA NO 71 0895610763219
14 014 ELI HERAWATI KOMPLEK SITANALA NO 36
15 015 KOMARIAH KOMPLEK SITANALA 30/31
16 016 ABDUL RASYID KOMPLEK SITANALA NO 23 RT 01
17 017 ROSYID KOMPLEK SITANALA NO 71
18 018 MIMIK KOMPLEK SITANALA NO 38
19 020 RASMA KOMPLEK SITANALA RT 01/13
20 021 HASAN KOMPLEK SITANALA NO 28 RT 01/13
21 022 SAFARI KOMPLEK SITANALA
22 023 SUBUR KOMPLEK SITANALA GUNA KARYA NO 37
23 024 ABDURAHMAN KOMPLEK SITANALA RT 01/13
24 026 JULEHA KOMPLEK SITANALA RT 01/ RW 013
25 027 EMI KOMPLEK SITANALA RT 01/ RW 013
26 028 ZAENAL ABIDIN KOMPLEK SITANALA RT 01/ RW 013 NO 40 081287512324
27 030 RUBIEM KOMPLEK SITANALA NO 113
28 031 MAEMUNAH KOMPLEK SITANALA RT 01/ RW 13
29 032 TASWI KOMPLEK SITANALA RT 1/ RW 13
30 033 TASIM KOMPLEK SITANALA RT 01/ RW 013 NO 51
31 034 ERNI KOMPLEK SITANALA RT 01/ RW 013 NO 51
32 035 IWAN KOMPLEK SITANALA RT 01/ RW 013
33 037 SURTINI KOMPLEK SITANALA RT 01/ RW 013
34 038 MUSA KOMPLEK SITANALA RT 01/ RW 013
35 039 WATI KOMPLEK SITANALA NO 106
36 040 SAMSUDIN KOMPLEK SITANALA RT 01/ RW 013 083895901926
37 041 ATA KOMPLEK SITANALA NO 90 081210003842
38 042 NYAI SUMIATI KOMPLEK SITANALA
39 043 PULUNG KOMPLEK SITANALA RT 01/ RW 013 NO 133 085214096513
40 044 AAM KOMPLEK SITANALA
41 045 ISKANDAR KOMPLEK SITANALA RT 01/ RW 013
42 046 JONYAH KOMPLEK SITANALA RT 01/ RW 013
43 047 YUNUS PRIHADI KOMPLEK SITANALA RT 01/ RW 013
44 048 TAHIYAR KOMPLEK SITANALA RT 01/ RW 013 NO. 5
45 049 RAHMAT KOMPLEK SITANALA RT 01/ RW 013 0895633697172
46 050 BOY PUNDOKO KOMPLEK SITANALA RT 02/ RW 013
47 051 MARUDIN KOMPLEK SITANALA RT 01/ RW 013
48 052 EPI KOMPLEK SITANALA RT 01/ RW 013 NO 52
49 053 SLAMET PURWADI KOMPLEK SITANALA RT 01/ RW 013 NO 187
50 054 ELI MARULI KOMPLEK SITANALA RT 01/ RW 013
51 055 SUPRIYANTONO HADI KOMPLEK SITANALA RT 01/ RW 013
52 056 NENGSIH KOMPLEK SITANALA RT 01/ RW 013
53 057 KARNI KOMPLEK SITANALA RT 01/ RW 013 NO 87 089630099176
54 058 ANISAH KOMPLEK SITANALA RT 01/ RW 013 NO 42 081286013405
55 059 BUNYAMIN KOMPLEK SITANALA RT 01/ RW 013 081280998190
56 060 MURSITI KOMPLEK SITANALA RT 01/ RW 013
57 061 GEMI KOMPLEK SITANALA RT 01/ RW 013
58 062 YATI KOMPLEK SITANALA RT 04/ RW 013
59 063 CASTIWI KOMPLEK SITANALA RT 04/ RW 013
60 064 ALI KOMPLEK SITANALA RT 01/ RW 013 NO 35
61 065 SAJAN KOMPLEK SITANALA RT 01/ RW 013
62 066 SUHARTO KOMPLEK SITANALA RT 02/ RW 013
63 067 AKLANI KOMPLEK SITANALA RT 01/ RW 013
64 068 FATULLAH KOMPLEK SITANALA RT 01/ RW 013
65 069 NURBISNA KOMPLEK SITANALA RT 01/ RW 013 NO 66
66 070 HADIJAH KOMPLEK SITANALA RT 02/ RW 013
67 071 ALI M RSK SITANALA BANGSAL KUSTA TERPADU
68 072 KOMARUDIN KOMPLEK SITANALA RT 04/ RW 013 087884029090
69 073 SUDIN SITANALA
70 074 YATI KOMPLEK SITANALA NO 94
71 075 ASHARI KOMPLEK SITANALA NO 94 RT 01/ RW 13
72 076 SACA KOMPLEK SITANALA RT 01/ RW 13
73 077 AGUNG KOMPLEK SITANALA RT 02/ RW 013 081272712440
74 078 DASUKI KOMPLEK SITANALA RT 01/ RW 13 087773765890
75 079 YAYAH CAHYATI KOMP SERBAGUNA RT 02/ RW 13
76 080 MARIYATI SITANALA
77 081 JUMINEM KOMPLEK SITANALA RT 01/ RW 13 081219660876
78 082 CASMADI KOMPLEK SITANALA RT 01/ RW 13
79 083 RONI KOMPLEK SITANALA RT 01/ RW 13
80 084 TITIN KOMPLEK SITANALA RT 01/ RW 13 NO 24
81 085 USMAN KOMPLEK SITANALA RT 01/ RW 13 NO 93 081289013143
82 086 INDAYATI KOMPLEK SITANALA RT 05/ RW 13 089675219071
 83 087 HARTONO KOMPLEK SITANALA RT 01/ RW 13 NO 163
84 088 UTI KOMPLEK SITANALA RT 01/ RW 13
85 089 ROJALI KOMPLEK SITANALA RT 01/ RW 13
86 090 SAPEI KOMPLEK SITANALA RT 01/ RW 13 081293460757
87 091 SRIWAHYUNINGSIH KOMPLEK SITANALA RT 01/ RW 13 081905550501
88 092 YUMIATI KOMPLEK SITANALA RT 01/ RW 13 083896857423
89 093 SISWANTO KOMPLEK SITANALA RT 01/ RW 13 081807198701
90 094 RATNAWATI KOMPLEK SITANALA RT 01/ RW 13
91 095 DOMIN KOMPLEK SITANALA RT 01/ RW 13
92 096 KASMIN KOMPLEK SITANALA RT 01/ RW 13
93 097 ESEM KOMPLEK SITANALA RT 01/ RW 13
94 098 TITIN KOMPLEK SITANALA RT 01/ RW 13
95 099 ISMAIL KOMPLEK SITANALA
96 100 ITAH KOMPLEK SITANALA RT 01/ RW 13
97 101 MARKUS UTONO KOMPLEK SITANALA RT 01/ RW 13 NO 148
98 102 SITI JENAH KOMPLEK SITANALA RT 01/ RW 13
99 103 DEWI KOMPLEK SITANALA RT 01/ RW 13 087782887636
100 104 SUTINEM KOMPLEK SITANALA RT 05/ RW 13
101 105 ENAH KOMPLEK SITANALA RT 04/ RW 13
102 106 HERI KOMPLEK SITANALA RT 01/ RW 13 NO 50 08210229747
103 107 MERNI KOMPLEK SITANALA RT 02/ RW 13
104 108 OTONG KOMPLEK SITANALA RT 03/ RW 13
105 109 KACUNG BAMBANGRETNO KOMPLEK SITANALA RT 02/ RW 13 082311551454
106 110 ARMAIN KOMPLEK SITANALA RT 01/ RW 13
107 111 ROSIAH KOMPLEK SITANALA RT 04/ RW 13 NO 14
108 112 SURAHMAN KOMPLEK SITANALA RT 01/ RW 13 081221710554
109 113 SUJIMAN KOMPLEK SITANALA RT 01/ RW 13
110 114 TAUFIK KOMPLEK SITANALA RT 01/ RW 13 081289090807/ 083813211065
111 115 MARDIANA KOMPLEK SITANALA RT 01/ RW 13 083813211065
112 116 MIAN KOMPLEK SITANALA RT 01/ RW 13 085312141476
113 117 CATA KOMPLEK SITANALA RT 01/ RW 13 085714221126
114 118 DAKMIN KOMPLEK SITANALA RT 01/ RW 13 083878382450
115 119 IDEH KOMPLEK SITANALA RT 01/ RW 13
116 120 MUNAWAROH KOMPLEK SITANALA RT 01/ RW 13 LORONG 3
117 121 MARYAM KOMPLEK SITANALA LORONG 9 NO 108 082110312726
118 122 ANININGSIH KOMPLEK SERBAGUNA RT 01/013
119 123 ASMADI KOMPLEK SERBAGUNA RT 02/013 081399844209
120 124 HIKMAH KOMPLEK SITANALA RT 01/ RW 013 081293500390
121 125 MUNAWIR KOMPLEK SERBAGUNA RT 003/RW 013 087808475375
122 126 HARTINI KOMPLEK SITANALA
123 127 TONI SILALAHI KOMPLEK SERBAGUNA RT 003/ RW 013 081291663114
124 128 SEHADI KOMPLEK SERBAGUNA RT 01
125 129 AMIR KOMPLEK SERBAGUNA RT 03/13
126 130 WARDI KOMPLEK SITANALA RT 003/013
127 131 AMIN KOMPLEK SERBAGUNA RT 05/RW 13 LORONG 9
128 132 DAENG MATAJANG KOMPLEK SERBAGUNA SITANALA RT 03/ RW 013 089604229925
129 133 SOMA KOMPLEK SITANALA RT 01/ RW 013
130 134 M. SLAMET SUPRIYADI KOMPLEK SERBAGUNA RT 003/RW 013 081210936130
131 135 MASTUROH KOMPLEK SERBAGUNA RT 003/RW 013
132 136 SUSANTO KOMPLEK SERBAGUNA RT 003/RW 013 082211724008
133 137 LUKMAN SUMANTI KOMPLEK SERBAGUNA SITANALA RT 02/RW013 081282796080
134 138 AGUS BADARUDIN KOMPLEK SERBAGUNA SITANALA RT 03/RW 013
135 139 YAS SITANALA LORONG 10 RT 05/ RW 13
136 140 JOSEPH SIRBOLON KOMPLEK SITANALA LORONG 5 RT 02/RW 013 081270227654
137 141 ANA SITANALA RT 03/ RW 013
138 142 SITI SALBIAH KOMPLEK SERBAGUNA SITANALA RT 05/ RW 013
139 143 ABDUL SUKUR KOMPLEK SITANALA RT 04/ RW 013
140 144 ANITI KOMPLEK SITANALA RT 05/ RW 013
141 145 NADIN KOMPLEK SITANALA RT 05/ RW 013
142 146 PROSI KUSUMAWATI KOMPLEK SERBAGUNA RT 03/RW013
143 147 RINA KOMPLEK SITANALA RT 05/ RW 013 81384085285
144 148 ITA MUNJAITA KOMPLEK SERBAGUNA SITANALA RT 03/ RW 013 02155791403
145 149 SIDUP KOMPLEK SITANALA RT 05/RW 013 081290406768
146 150 SURYATI KOMPLEK SERBAGUNA SITANALA RT 05/ RW 013 NO 4
147 151 SUTARJO KOMPLEK SERBAGUNA RT 03/ RW 013 085773408572
148 152 JUARI ISMAIL KOMPLEK SITANALA RT 04/ RW 013
149 153 YATMI KOMPLEK SERBAGUNA RT 03/ RW 013 085773408572
150 154 MA'AH KOMPLEK SERBAGUNA RT 03/ RW 013 083893157048
151 155 NASRULLAH KOMPLEK SERBAGUNA SITANALA RT05/RW013
152 156 D. EFFENDI KOMPLEK SERBAGUNA SITANALA RT 04/RW 013 081381625133
153 157 MUHAMAD KOMPLEK SERBAGUNA RT 03/ RW 013
154 158 MONZILA KOMPLEK SEBAGUNA SITANALA RT 03/RW 013 0818906010339
155 159 BUSIRIH H KOMPLEK SERBAGUNA RT 003/ RW 013 085817441671
156 160 MIAN KOMPLEK SERBAGUNA RT 02/RW013
157 161 KADIR KOMPLEK SERBAGUNA RT 02/RW 013
158 162 USIN KOMPLEK SITANALA RT 03/RW013
159 163 WINAL KOMPLEK SERBAGUNA RT 03/RW013
160 164 JAMIUN KOMPLEK SERBAGUNA LORONG 7 RT 06/RW 013
161 165 AMAN KOMPLEK SITANALA LORONG 9 RT 03/RW013
162 166 LAPADUAI KOMPLEK SITANALA RT 05/ RW 013
163 167 SULHI PRASISTYAN KOMPLEK SERBAGUNA RT 02/ RW 013 081340335338
164 168 MAKKA KOMPLEK SERBAGUNA SITANALA RT 04/ RW 013 081287222141
165 169 SAROH KOMPLEK SERBAGUNA RT 03/ RW 013
166 170 AGUS MITE KOMPLEK SERBAGUNA LORONG 5 RT 02/ RW 013
167 171 UDIN BURHANUDIN KOMPLEK SITANALA RT 04/013
168 172 SAHRIM KOMPLEK SERBAGUNA SITANALA
169 173 YOHADI KOMPLEK SERBAGUNA SITANALA RT 04/013
170 174 UDIN KOSENG KOMPLEK SERBAGUNA SITANALA RT 03/013
171 175 EMAT KOMPLEK SERBAGUNA SITANALA RT 03/013
172 176 SYAMSUDIN KOMPLEK SITANALA LORONG 8 RT 01/013 085280094504
173 177 NURSEN KOMPLEK SERBAGUNA SITANALA RT 01/013 081340335480
174 178 WARSINAH KOMPLEK SERBAGUNA SITANALA RT 04/013
175 179 MARTONO KOMPLEK SERBAGUNA LORONG 5 SITANALA RT 06/013
176 180 BUDI KOMPLEK SERBAGUNA SITANALA RT 04/013
177 181 BASOR KOMPLEK SERBAGUNA SITANALA RT 01/013 081380881562
178 182 SADIN KOMPLEK SITANALA RT 03/013
179 183 ABU BAKAR KOMPLEK SERBAGUNA SITANALA RT 04/013
180 184 DARUN KOMPLEK SERBAGUNA SITANALA
181 185 IDA FARIDA KOMPLEK SITANALA RT 02/013 081218223277
182 186 NAMAN KOMPLEK SITANALA RT 01/013
183 187 YOSWA SUMINTO KOMPLEK SERBAGUNA SRT 02/013 081287859164
184 188 WALIM KOMPEK SERBAGUNA SITANALA RT 02/013 085772214873
185 190 MARIA KOMPLEK SERBAGUNA SITANALA LORONG 5
186 191 ANTONIUS KOMPLEK SITANALA
187 192 CUNSAN KOMPLEK SERBAGUNA RT 02/013
188 193 CECE KOMPLEK SITANALA LORONG 9 RT 03/013
189 194 NURAINI KOMPLEK SITANALA RT 03/013 081289098707
190 195 KOKOM KOMPLEK SERBAGUNA SITANALA RT 03/013
191 196 ZULAMIN KOMPLEK SERBAGUNA SITANALA RT 04/013
192 197 ABDUL WAHAB KOMPLEK SERBAGUNA RT 03/013
193 198 ANIK KOMPLEK SITANALA RT 02/RW 013
194 199 SITI AISAH KOMPLEK SERBAGUNA RT 03/013 085285362020
195 200 HERI SETIAWAN KOMPLEK SITANALA RT 05/013
196 201 NINING DAHLIA KOMPLEK SITANALA RT 05/013
197 202 IYANG KOSASIH KOMPLEK SITANALA RT 03/013
198 203 FERI LEWANDATU KOMPLEK SERBAGUNA RT 04/013 081277431128
199 204 NURLAELA KOMPLEK SERBAGUNA SITANALA RT 04/013
200 205 AMINAH KOMPLEK SERBAGUNA LORONG 7, RT 03/013
201 206 ADE KRISTINA KOMPLEK SERBAGUNA SITANALA RT 03/013
202 207 KHOLIFAH KOMPLEK SERBAGUNA SITANALA RT 03/013
203 208 MININ KOMPLEK SERBAGUNA SITANALA RW 03/013 085945775806
204 209 PIO KOMPLEK SITANALA RT 03/013
205 210 SUWITO KOMPLEK SERBAGUNA SITANALA RT 03/013
206 211 NUR SAPTADDY KOMPLEK SERBAGUNA SITANALA RT 01/013
207 212 KUSNAMI DEWI KOMPLEK SERBAGUNA SITANALA RT 01/013
208 213 WARHUDI KOMPLEK SERBAGUNA SITANALA RT 03/013 081906010339
209 214 SUBAGYO KOMPLEK SERBAGUNA SITANALA RT 01/013
210 215 SUGONO KOMPLEK SERBAGUNA SITANALA RT 01/013
211 216 SITI ASIYAH KOMPLEK SERBAGUNA SITANALA RT 02/013 085891168928
212 217 ACEM KOMPLEK SERBAGUNA SITANALA RT 04/013
213 218 ONYONG KOMPLEK SERBAGUNA SITANALA RT 04/013
214 219 DARSIH KOMPLEK SERBAGUNA SITANALA RT 04/013
215 220 KHADIR KOMPLEK SITANALA RT 01/013
216 221 YOHANES SUPARJI KOMPLEK SITANALA RT 04/013
217 223 SAPRI KOMPLEK SITANALA NO 172, RT 04/013
218 224 ANDRE KOMPLEK SITANALA NO 224 RT 01/013
219 225 MARDIYATI KOMPLEKS SITANALA LORONG II RT 04/013
220 226 SUMAAH KOMPLEK SITANALA RT 03/013
221 227 SING KOMPLEKS SITANALA NO 5 RT 02/013
222 228 WATI KOMPLEK SITANALA RT 05/013
223 229 EEM KOMPLEK SITANALA LORONG 5 RT 02/013 081210895801
224 230 ABDUL BAKAR KOMPLEK SITANALA RT 04/013
225 231 MASWANTO KOMPLEKS SITANALA RT 02/013
226 232 HAMBALI KOMPLEK SITANALA NO 81 RT 03/013 081394703443
227 233 MARYATIN KOMPLEK SERBAGUNA LORONG 9 RT 04/013
228 234 DEDE SISMANA KOMPLEKS SITANALA NO 37 LORONG 8, RT 03/013 081213936601
229 235 GIOK PERMANA KOMPLEK SITANALA NO 19, RT 04/013
230 236 KHOLIL KOMPLEK SITANALA NO 236 RT 02/ RW 013
231 237 DURAHMAN KOMPLEK SERBAGUNA NO 192 RT 04/ RW 013 081210005549
232 238 OBAY KOMPLEK SERBAGUNA SITANALA RT 01/ RW 013 085717444733
233 239 NURLELI SITANALA LORONG 8 RT 03/RW013 081319752566
234 240 LIDYA KOMPLEKS SITANALA NO 52 RT 02/RW013 082139706020
235 241 BAHARUDIN KOMPLEK SERBAGUNA RT 02/RW013
236 242 ANDU KOMPLEK SERBAGUNA RT 02/RW013
237 243 TAJUDIN KOMPLEK SITANALA RT 001/ RW 013
238 244 AHMAD TOLIBIN KOMPLEKS SITANALA NO 147 RT 01/ RW 013
239 245 ENENG ROHAYAH KOMPLEK SITANALA 0857777191898
240 246 DUDUNG ABDURAHMAN KOMPLEK SERBAGUNA RT 02/ RW 013 081380336019
241 247 SUEB KOMPLEKS SERBAGUNA RT 02/ RW 013
242 248 DARI KOMPLEKS SITANALA RT 01/ RW 01
243 250 KOSIM KOMPLEK SERBAGUNA RT 04/ RW 013
244 251 AHMAD SUDARTO KOMPLEK SITANALA RT 01/ RW 013 081286729199
245 252 SOPIAH KOMPLEKS SITANALA LORONG 6 RT 02/ RW 013
246 253 MARULLOH KOMPLEKS SITANALA NO 35 RT 04/RW 013
247 254 SALIM KOMPLEKS SITANALA RT 05/RW013
248 255 UMANG KOMPLEKS SITANALA LORONG 9 RT 04/ RW 013 081210005547
249 256 CARITEM KOMPLEKS SERBAGUNA RT 04/ RW 13 082297654426
250 257 MUH. ABADI KOMPLEKS SITANALA NO 171 RT 02/RW13 081291657771
251 258 SUBAKAR DKI RT 05/013
252 259 SARTINI KOMPLEK SERBAGUNA LORONG 8 RT 03/RW13 081315761730
253 260 SUNU KOMPLEK SITANALA NO 5 RT 02/ RW 13 081298856143
254 261 KOMARUDIN KOMPLEK SERBAGUNA RT 03/RW13
255 262 RUNDA KOMPLEK SITANALA RT 01/RW 13
256 263 ASMANAH KOMPLEK SITANALA NO 88 RT 03/RW 13
257 264 HESTI KOMPLEK BULAK NO 27 RT 05/RW13
258 265 MANSYUR KOMPLEK SITANALA RT 05/RW 13

JUMLAH STATUS YANG DI RULE OUT : 2

NO STATUS YANG DI RULE OUT : 025, 249
1. Pasien kusta
yang 2. Telah
KRITERIA INKLUSI DAN EKSKLUSI
sedang/pernah KRITERIA INKLUSI
memberikan
menjalani persetujuan ikut 3. Bersedia
pengobatan penelitian yang KRITERIA EKSKLUSI HARI PEREKRUTAN TANGGAL LAHIR
mengikuti
monoterapi/MD terdokumentasi prosedur
T di Rumah kan sebelum penelitian
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berdasarkan 1
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1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 09/02/1968
1 1 1 0 1 23/04/2018 10/04/1973
1 1 1 0 1 23/04/2018 02/05/1975
1 1 1 0 1 23/04/2018 19/02/1959
1 1 1 0 1 23/04/2018 19/11/1974
1 1 1 0 1 23/04/2018 26/04/1979
1 1 1 0 1 23/04/2018 LUPA
1 1 1 0 1 23/04/2018 31/06/1956
1 1 1 0 1 23/04/2018 01/01/1957
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 08/08/1960
1 1 1 0 1 23/04/2018 15/01/1971
1 1 1 0 1 23/04/2018 10/11/1964
1 1 1 0 1 23/04/2018 18/05/1950
1 1 1 0 1 23/04/2018 18/07/1984
1 1 1 0 1 23/04/2018 1972
1 1 1 0 1 23/04/2018 1973
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 1961
1 1 1 0 1 23/04/2018 02/02/1969
1 1 1 0 1 23/04/2018 1956
1 1 1 0 1 23/04/2018 05/05/1979
1 1 1 0 1 23/04/2018
0 1 1 0 1 23/04/2018 12/06/1974
1 1 1 0 1 23/04/2018 1975
1 1 1 0 1 23/04/2018 1960
1 1 1 0 1 23/04/2018 1977
1 1 1 0 1 23/04/2018 1956
1 1 1 0 1 23/04/2018 05/05/1963
0 1 1 0 1 23/04/2018 1969
1 1 1 0 1 23/04/2018 08/08/1968
1 1 1 0 1 23/04/2018 1974
1 1 1 0 1 23/04/2018 1969
1 1 1 0 1 23/04/2018 08/09/1954
1 1 1 0 1 23/04/2018 1952
1 1 1 0 1 23/04/2018 16/09/1983
1 1 1 0 1 23/04/2018 04/01/1956
1 1 1 0 1 23/04/2018 1971
1 1 1 0 1 23/04/2018 27/03/1972
0 1 1 0 1 23/04/2018 15/06/1975
1 1 1 0 1 23/04/2018 13/03/1967
1 1 1 0 1 23/04/2018 27/02/1953
1 1 1 0 1 23/04/2018 1969
1 1 1 0 1 23/04/2018 14/03/1980
1 1 1 0 1 23/04/2018 04/07/1965
1 1 1 1 1 23/04/2018 10/06/1956
1 1 1 0 1 23/04/2018 1963
1 1 1 0 1 23/04/2018 1973
1 1 1 0 1 23/04/2018 1976
1 1 1 0 1 23/04/2018 12/08/1973
1 1 1 0 1 23/04/2018 21/01/1977
1 1 1 0 1 23/04/2018 1978
1 1 1 0 1 23/04/2018 16/09/1954
1 1 1 0 1 23/04/2018 1978
1 1 1 0 1 23/04/2018 1982
1 1 1 0 1 23/04/2018 05/05/1983
1 1 1 0 1 23/04/2018 1954
1 1 1 0 1 23/04/2018 1955
1 1 1 0 1 23/04/2018 03/06/1949
1 1 1 0 1 23/04/2018 1950
1 1 1 0 1 23/04/2018 08/02/1978
1 1 1 0 1 23/04/2018 16/09/1976
1 1 1 0 1 23/04/2018 1940
1 1 1 0 1 23/04/2018 08/08/1974
1 1 1 0 1 23/04/2018 05/05/1965
1 1 1 0 1 23/04/2018 15/02/1973
1 1 1 0 1 23/04/2018 1956
1 1 1 0 1 23/04/2018 10/10/1959
1 1 1 0 1 23/04/2018 1939
1 1 1 0 1 23/04/2018 02/06/1969
1 1 1 0 1 23/04/2018 14/07/1966
1 1 1 0 1 23/04/2018 29/05/1948
1 1 1 0 1 23/04/2018 01/03/1967
1 1 1 0 1 23/04/2018 24/06/1966
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 1961
1 1 1 0 1 23/04/2018 01/09/1977
1 1 1 0 1 23/04/2018 14/12/1965
1 1 1 0 1 23/04/2018 24/08/1973
1 1 1 1 1 23/04/2018 1966
1 1 1 0 1 23/04/2018 1977
1 1 1 0 1 23/04/2018 1959
1 1 1 0 1 23/04/2018 1962
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 13/12/1972
1 1 1 0 1 23/04/2018 1959
1 1 1 0 1 23/04/2018 20/05/1966
1 1 1 0 1 23/04/2018 01/01/1959
1 1 1 0 1 23/04/2018 1968
1 1 1 0 1 23/04/2018 1974
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 04/09/1972
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 1976
1 1 1 0 1 23/04/2018 1973
1 1 1 0 1 23/04/2018 06/06/1972
1 1 1 0 1 23/04/2018 30/04/1979
1 1 1 0 1 23/04/2018 1964
1 1 1 0 1 23/04/2018 10/06/1976
1 1 1 0 1 23/04/2018 05/05/1974
1 1 1 0 1 23/04/2018 1971
1 1 1 0 1 23/04/2018 15/03/1978
1 1 1 0 1 23/04/2018 1974
1 1 1 0 1 23/04/2018 01/07/1984
1 1 1 0 1 23/04/2018 05/07/1961
1 1 1 0 1 23/04/2018 1988
1 1 1 0 1 23/04/2018 1978
1 1 1 0 1 23/04/2018 05/04/1957
0 1 1 1 2 24/04/2018 05/12/1971
1 1 1 0 2 24/04/2018 12/03/1963
1 1 1 0 2 24/04/2018 27/08/1975
1 1 1 0 2 24/04/2018 17/06/1959
1 1 1 0 2 24/04/2018 tidak tau
1 1 1 0 2 24/04/2018 30/01/1981
1 1 1 0 2 24/04/2018 01/01/1962
0 1 1 0 2 24/04/2018 19/06/1954
1 1 1 0 2 24/04/2018 19/02/1967
0 1 1 0 2 24/04/2018 01/02/1958
1 1 1 0 2 24/04/2018 11/07/1945
1 1 1 0 2 24/04/2018 10/02/1966
1 1 1 0 2 24/04/2018 11/11/1969
1 1 1 0 2 24/04/2018 tidak tau
1 1 1 0 2 24/04/2018 01/06/1962
1 1 1 0 2 24/04/2018 05/03/1963
1 1 1 0 2 24/04/2018 15/02/1963
1 1 1 0 2 24/04/2018 1972
1 1 1 0 2 24/04/2018 15/07/1944
1 1 1 0 2 24/04/2018 07/02/1975
1 1 1 0 2 24/04/2018 01/01/1953
1 1 1 0 2 24/04/2018 05/01/1951
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 18/03/1979
1 1 1 0 2 24/04/2018 18/06/1986
0 1 1 0 2 24/04/2018 29/07/1974
1 1 1 0 2 24/04/2018 9/11/1952
1 1 1 0 2 24/04/2018 19/10/1950
1 1 1 0 2 24/04/2018 04/04/1961
1 1 1 0 2 24/04/2018 01/11/1964
1 1 1 0 2 24/04/2018 06/03/1948
0 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 00/12/1949
1 1 1 0 2 24/04/2018 23/11/1968
0 1 1 0 2 24/04/2018 05/02/1959
1 1 1 0 2 24/04/2018 18/10/1960
1 1 1 0 2 24/04/2018 22/06/1965
0 1 1 0 2 24/04/2018 12/08/1960
1 1 1 0 2 24/04/2018 00/00/1963
1 1 1 0 2 24/04/2018 00/08/1954
1 1 1 0 2 24/04/2018 00/11/1954
0 1 1 0 2 24/04/2018 03/05/1957
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 00/00/1942
1 1 1 0 2 24/04/2018 03/06/1947
1 1 1 0 2 24/04/2018 19/06/1968
1 1 1 0 2 24/04/2018 05/09/1959
0 1 1 0 2 24/04/2018
0 1 1 0 2 24/04/2018 02/07/1949
1 1 1 0 2 24/04/2018 18/11/1968
1 1 1 0 2 24/04/2018 1962
1 1 1 0 2 24/04/2018 1962
1 1 1 0 2 24/04/2018 08/08/1952
1 1 1 0 2 24/04/2018 12/12/1978
1 1 1 0 2 24/04/2018 1960
1 1 1 0 2 24/04/2018 1950
1 1 1 0 2 24/04/2018 02/02/1952
1 1 1 0 2 24/04/2018 1965
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 10/02/1973
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 24/10/1957
1 1 1 0 2 24/04/2018 01/10/1957
0 1 1 0 2 24/04/2018 12/07/1978
1 1 1 0 2 24/04/2018 1958
1 1 1 0 2 24/04/2018 23/10/1952
1 1 1 0 2 24/04/2018 1959
0 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 13/07/1936
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 03/04/1973
1 1 1 0 2 24/04/2018 23/08/1970
1 1 1 0 2 24/04/2018 20/11/1964
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 23/12/1943
0 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 03/04/1975
1 1 1 0 2 24/04/2018 1968
1 1 1 0 2 24/04/2018 23/07/1973
1 1 1 0 2 24/04/2018 30/05/1965
1 1 1 0 2 24/04/2018 27/10/1973
1 1 1 0 2 24/04/2018 1959
1 1 1 0 2 24/04/2018
0 1 1 0 2 24/04/2018 19/01/1979
1 1 1 0 2 24/04/2018 20/10/1969
1 1 1 0 2 24/04/2018 09/03/1965
1 1 1 0 2 24/04/2018 10/10/1961
1 1 1 0 2 24/04/2018 18/12/1982
1 1 1 0 2 24/04/2018 03/02/1972
1 1 1 0 2 24/04/2018 04/04/1985
1 1 1 0 2 24/04/2018 1980
1 1 1 0 2 24/04/2018 1964
1 1 1 0 2 24/04/2018 1966
0 1 1 0 2 24/04/2018 15/04/1974
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 25/12/1946
1 1 1 0 2 24/04/2018 03/06/1964
1 1 1 0 2 24/04/2018 1950
1 1 1 0 2 24/04/2018 01/01/1944
0 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 18/04/1959
1 1 1 0 2 24/04/2018 08/10/1966
1 1 1 0 2 24/04/2018 11/11/1953
0 1 1 0 2 24/04/2018 1972
1 1 1 0 2 24/04/2018 1965
1 1 1 0 2 24/04/2018 31/05/1972
0 1 1 0 2 24/04/2018 08/01/1966
1 1 1 0 2 24/04/2018 1939
1 1 1 0 2 24/04/2018 05/10/1976
1 1 1 0 2 24/04/2018 09/1949
1 1 1 0 2 24/04/2018 05/10/1959
1 1 1 0 2 24/04/2018 14/01/1968
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 24/06/1946
1 1 1 0 2 24/04/2018 05/01/1991
1 1 1 0 2 24/04/2018 15/04/1968
1 1 1 0 2 24/04/2018 15/09/1952
1 1 1 0 2 24/04/2018 06/08/1954
1 1 1 0 2 24/04/2018 10/12/1962
1 1 1 0 2 24/04/2018 12/01/1970
1 1 1 0 2 24/04/2018 03/05/1971
1 1 1 0 2 24/04/2018 08/04/1975
1 1 1 0 2 24/04/2018 31/12/1958
0 1 1 0 2 24/04/2018 05/11/1957
1 1 1 0 2 24/04/2018 25/07/1945
1 1 1 0 2 24/04/2018 17/08/1962
1 1 1 0 2 24/04/2018 17/10/1980
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 02/12/1958
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 1966
1 1 1 0 2 24/04/2018 18/08/1967
1 1 1 0 2 24/04/2018 1949
0 1 1 0 2 24/04/2018 17/07/1965
1 1 1 0 2 24/04/2018 26/06/1963
1 1 1 0 2 24/04/2018 31/12/1960
1 1 1 0 2 24/04/2018 1960
0 1 1 0 2 24/04/2018 24/12/1963
0 1 1 0 2 24/04/2018 09/10/1972
1 1 1 0 2 24/04/2018 1957
 DEMOGRAFI
PEKERJAAN UTAMA
USIA JENIS KELAMIN PENGHASILAN/BLN TINGKAT PENDIDIKAN
KODE KETERANGAN
65 2 6 4 1
64 1 99 PENDORONG MAKANAN KE BANGSAL KUSTA 1 2
55 1 10 1 1
65 2 6 1 2
65 6 1 1 1
50 2 6 1 1
40 2 6 1 2
2 6 4 1
50 2 99 GURU 4 3
45 2 6 1 1
43 2 6 1 2
59 1 10 1 2
43 2 6 1 1
39 2 6 1 3
2 99 PEDAGANG 2 1
61 1 99 TUKANG SAPU 1 1
61 1 99 CLEANING SERVICE 1 1
55 2 6 1 1
55 1 10 1 1
57 1 99 TUKANG SAPU 2 2
47 1 99 PEMULUNG 1 3
53 1 99 PETUGAS KEBERSIHAN 3 4
68 1 10 4 2
33 2 6 1 2
46 2 6 4 1
45 1 99 PETUGAS KEBERSIHAN 1 2
50 2 99 PEDAGANG 1 1
57 2 6 1 2
49 2 99 PEDAGANG 1 1
62 1 99 CLEANING SERVICE 1 1
39 2 6 1 2
34 1 2 1 1
43 2 10 4 4
43 1 2 1 2
58 2 10 4 1
41 1 2 1 2
62 1 99 cleaning service 1 1
55 2 6 4 2
49 1 10 4 1
49 2 99 cleaning service 1 2
44 1 99 cleaning service 2 3
49 2 6 1 1
63 1 10 4 4
66 1 2 1 1
34 1 99 cleaning service 1 4
62 1 99 cleaning service 1 2
47 1 99 cleaning service 1 2
46 2 6 1 4
42 1 99 PEMULUNG 4 2
51 1 99 WIRASWASTA 2 4
65 1 99 CLEANING SERVICE 1 4
49 2 6 1 1
38 2 6 2 2
52 2 6 1 1
61 1 99 SERABUTAN 1 3
55 2 6 1 2
45 2 6 1 1
42 2 6 1 1
44 2 99 TUKANG SAPU 2 1
41 1 99 CLEANING SERVICE 1 2
40 1 2 1 2
63 1 10 1 4
40 1 10 1 1
36 1 99 PETUGAS KEBERSIHAN 2 1
35 2 6 2 2
64 2 6 4 1
63 1 10 4 1
68 1 99 WIRASWASTA 1 3
68 1 10 1 1
40 2 99 TUKANG SAPU 2 1
42 1 2 1 2
78 1 10 1 2
43 1 99 SUPIR 2 1
53 1 10 4 3
45 2 99 TUKANG SAPU JALAN 3 1
62 2 99 TUKANG SAPU JALAN 1 1
58 2 6 1 1
79 1 99 PETANI 1 1
48 1 99 TUKANG CUKUR RAMBUT 4 3
51 2 6 1 1
70 1 10 4 2
51 2 6 4 1
51 1 99 PEDAGANG 1 2
2 99 TIM KEBERSIHAN PEMDA 2 1
57 1 10 4 1
40 1 2 1 2
52 2 6 1 4
44 2 6 4 3
52 1 10 1 1
41 2 6 1 1
59 1 99 PETANI 1 1
56 1 10 4 1
2 6 4 1
45 2 6 4 2
59 1 99 TUKANG SAMPAH 1 1
52 1 2 1 1
59 1 99 PEMBANTU 4 2
50 2 99 PEDAGANG 1 1
44 2 99 CLEANING SERVICE 1 2
2 6 1 2
45 2 99 CLEANING SERVICE 1 2
1 99 TUKANG PARKIR 1 4
42 2 6 1 1
45 1 99 CLEANING SERVICE 2 2
45 1 99 SUPIR ANGKOT 1 4
39 1 99 TUKANG KEBERSIHAN JALANAN 2 2
54 2 99 TUKANG SAPU 1 1
41 1 99 CLEANING SERVICE 1 4
44 1 99 CLEANING SERVICE 2 1
47 1 10 1 2
40 2 99 WIRASWASTA 4 4
44 1 99 CLEANING SERVICE 1 2
33 1 99 PETANI 4 2
56 1 99 KARYAWAN SWASTA 1 1
30 2 6 2 1
40 2 6 1 1
61 2 6 2 1
46 2 6 4 3
55 1 99 WIRASWASTA 1 2
42 2 99 PEDAGANG 1 4
58 1 99 PENJAHIT 1 1
- 2 99 MENYAPU JALAN 2 1
37 1 99 ANTAR JEMPUT SEKOLAH 1 1
56 1 10 1 1
63 1 4 1 2
51 1 2 1 4
60 1 10 4 1
72 2 10 1 1
52 1 3 2 2
48 1 99 MENYAPU JALAN 2 4
2 10 4 1
55 1 99 TUKANG BECAK 1 2
55 1 2 4 1
55 1 99 PEDAGANG 1 1
46 1 10 4 1
73 1 10 4 1
43 2 6 1 1
65 2 6 1 1
67 1 99 WIRASWASTA 1 2
37 2 99 PENYAPU JALAN 2 2
39 1 99 BURUH SAPU JALANAN 3 1
31 2 6 2 2
43 2 6 4 2
65 2 6 4 2
67 1 10 1 1
57 2 6 4 1
53 1 10 1 1
70 1 10 1 4
2 99 SAPU JALANAN 2 1
68 2 6 1 1
49 1 2 1 3
59 1 4 4 3
57 1 99 PENJAHIT KONVEKSI 1 1
53 2 6 1 1
57 1 99 KEBERSIHAN 3 1
55 1 99 DINAS KEBERSIHAN 2 1
63 1 99 SUPIR ANGKOT 1 2
63 1 10 1 2
61 2 6 4 1
60 1 99 TUKANG BECAK 1 1
76 1 99 PENGEMIS 4 1
70 1 99 NARIK BECAK 1 1
49 1 4 1 4
58 1 99 BURUH MEBEL 1 1
2 6 4 1
68 1 10 4 3
49 1 99 PEMULUNG 1 3
56 1 10 1 2
56 1 99 PENJAGA SEKOLAH 1 3
65 1 10 1 1
39 1 99 CLEANING SERVICE 1 1
58 1 10 1 2
68 1 2 1 2
66 2 6 4 1
53 1 10 1 1
1 10 1 1
45 1 99 SERABUTAN 4 1
1 99 PEMBANTU RUMAH 4 2
60 1 2 1 1
60 1 99 TUKANG BECAK 1 2
39 2 6 4 1
60 1 10 1 1
65 1 4 1 3
59 1 10 1 2
2 6 4 1
81 1 2 1 1
1 99 PENJAHIT 1 1
45 1 6 1 1
47 2 6 1 1
53 2 6 1 1
1 10 1 1
74 1 10 1 3
60 2 6 4 1
43 2 6 4 2
50 1 2 1 2
44 2 6 4 2
53 1 10 1 2
44 1 4 2 4
59 2 6 1 2
47 2 6 1 1
39 2 6 4 1
48 2 99 PENJAHIT 2 2
53 1 99 DINAS LINGKUNGAN HIDUP 2 3
56 1 99 1 2
35 1 99 CLEANING SERVICE 2 4
43 1 99 CLEANING SERVICE 1 1
33 2 6 1 2
38 1 99 TUKANG BECAK 1 2
54 1 99 KARYAWAN 2 4
52 1 99 TUKANG BECAK 1 2
44 2 6 4 3
71 2 10 1 1
71 1 10 1 1
54 2 6 1 2
1 99 PEDAGANG 2 1
74 1 10 1 2
1 99 TUKANG PARKIR 4 2
59 1 10 1 2
2 6 1 2
2 10 1 2
1 99 SERABUTAN 4 1
2 6 1 2
2 6 2 1
1 10 4 2
1 10 4 1
1 99 SUPIR ANGKOT 1 2
2 10 1 1
 1 10 1 4
1 99 TUKANG SAPU 2 3
1 99 CLEANING SERVICE 1 1
1 10 1 2
1 8 1 1
2 6 1 4
2 6 4 2
1 10 1 1
1 99 TUKANG SAPU 2 1
1 99 TUKANG PARKIR 2 2
1 8 1 4
2 6 2 2
1 10 1 3
1 99 4 1
2 6 1 1
1 99 DINAS KEBERSIHAN 1 1
1 99 TUKANG SAPU 2 4
2 99 PEDAGANG 1 3
1 99 1 4
1 8 1 2
70 1 10 4 2
52 2 6 4 1
1 99 WIRASWASTA 2 2
69 1 99 TUKANG SAPU 2 1
2 6 4 1
1 10 1 2
1 10 2 2
58 1 99 PEMULUNG 1 2
2 6 4 1
 2 6 4 1
61 1 10 1 1
I

JUMLAH ORANG TINGGAL JUMLAH PENDERITA KUSTA

TINGKAT PENDIDIKAN STATUS PERNIKAHAN SUKU (DARI AYAH) SERUMAH SERUMAH

1 2 4 4 1
2 2 4 3 1
1 2 2 4 3
2 2 2 4 3
1 2 2 4 3
1 2 2 4 3
2 2 1 4 3
1 2 2 1 1
3 2 4 3 2
1 2 4 4 3
2 2 2 4 3
2 2 2 4 1
1 2 2 4 3
3 3 2 4 2
1 2 1 4 2
1 2 1 1 5
1 2 4 4 3
1 3 2 4 2
1 2 1 4 2
2 2 4 4 1
3 2 4 4 1
4 2 4 4 2
2 2 2 3 1
2 2 1 4 3
1 2 1 4 1
2 2 6 3 1
1 2 1 4 3
2 2 2 4 1
1 2 1 4 3
1 2 2 3 3
2 2 8 3 3
1 3 2 1 2
4 2 4 4 2
2 2 2 4 3
1 3 2 4 1
2 2 2 3 3
1 3 2 2 2
2 2 2 4 2
1 2 2 4 4
2 2 2 2 2
3 2 2 4 3
1 3 4 3 2
4 2 2 4 2
1 3 2 1 2
4 2 2 4 3
2 2 8 (MENADO) 4 2
2 2 4 3 3
4 2 2 3 3
2 2 1 4 2
4 2 8 (BATAK) 3 2
4 2 1 4 3
1 2 2 4 4
2 2 2 4 3
1 3 2 4 2
3 2 4 1 2
2 2 2 4 3
1 2 1 4 3
1 3 4 4 2
1 3 1 4 2
2 2 2 4 3
2 2 1 4 2
4 2 1 3 3
1 1 1 1 2
1 2 1 4 3
2 2 4 4 3
1 2 4 3 3
1 1 6 1 2
3 2 1 4 3
1 2 2 4 2
1 2 2 4 2
2 2 2 4 2
2 3 2 4 2
1 2 2 4 2
3 2 4 3 3
1 3 4 4 2
1 2 4 3 3
1 2 1 4 3
1 2 2 3 3
3 1 1 1 2
1 2 2 4 3
2 2 1 1 2
1 2 4 2 2
2 2 1 4 3
1 2 2 4 3
1 2 4 3 2
2 2 1 4 4
4 2 1 4 3
3 2 2 4 3
1 2 6 4 2
1 2 8 (PALEMBANG) 4 3
1 2 1 3 2
1 3 4 3 3
1 2 2 4 3
2 2 1 4 2
1 2 2 3 2
1 2 2 4 2
2 3 1 1 2
1 2 1 4 3
2 3 2 3 2
2 2 1 4 2
2 2 2 4 3
4 4 2 1 2
1 2 2 4 3
2 2 2 3 3
4 2 1 4 2
2 2 1 4 2
1 2 2 4 2
4 2 2 1 2
1 4 2 4 3
2 2 4 4 3
4 2 2 4 3
2 2 2 3 2
2 3 2 1 2
1 2 2 3 3
1 2 2 3 3
1 2 2 3 3
1 2 1 4 3
3 2 2 4 2
2 2 8 4 3
4 2 1 4 3
1 3 6 1 2
1 2 1 4 3
1 2 2 3 2
1 1 2 4 4
2 2 4 2 4
4 2 2 3 2
1 2 4 4 3
1 2 8 4 3
2 2 2 3 3
4 2 1 4 3
1 2 4 3 3
2 2 2 4 2
1 2 4 4 3
1 2 8 3 3
1 2 1 4 2
1 2 8 3 3
1 2 8 4 3
1 2 4 4 2
2 2 1 4 2
2 2 1 4 3
1 2 4 4 3
2 2 4 4 3
2 2 2 4 3
2 2 1 3 3
1 2 4 3 3
1 2 2 4 3
1 2 1 4 3
4 2 1 4 3
1 2 2 4 3
1 2 4 4 2
3 2 4 4 3
3 2 4 4 3
1 2 8 3 2
1 2 4 3 3
1 2 6 4 3
1 2 2 3 2
2 3 4 4 2
2 2 2 4 3
1 2 4 4 3
1 2 1 4 3
1 2 4 3 2
1 2 8 4 2
4 2 4 2 1
1 2 8 2 2
1 2 4 4 2
3 2 8 4 4
3 2 4 4 2
2 2 2 4 2
3 1 4 4 2
1 2 2 4 3
1 2 2 4 3
2 2 8 4 2
2 2 2 4 3
1 2 4 3 3
1 3 1 3 2
1 2 4 4 2
1 2 2 4 2
2 2 8 (KALIMANTAN) 4 2
1 2 4 4 2
2 2 2 1 2
1 2 2 4 3
1 2 4 3 3
3 2 1 3 2
2 1 2 4 2
1 2 1 4 3
1 2 8 (FLORES) 4 3
1 2 8 (CINA) 4 2
1 2 4 4 3
1 2 4 3 3
1 3 4 3 2
1 2 2 2 2
3 2 8 (PALEMBANG) 4 3
1 2 2 1 2
2 2 2 4 2
2 2 2 4 3
2 2 2 4 3
2 2 2 4 3
4 2 8 (MANADO) 3 3
2 2 4 3 2
1 3 2 4 2
1 2 2 4 3
2 2 1 3 2
3 2 4 4 3
2 2 1 4 2
4 2 1 4 3
1 2 1 4 3
2 2 2 4 3
2 2 2 3 3
4 2 1 4 3
2 2 1 2 2
3 2 4 4 3
1 2 8 (AMBON) 3 3
1 2 8 (AMBON) 3 3
2 2 2 4 3
1 2 8 (PADANG) 3 2
2 4 1 4 2
2 2 2 4 3
2 2 4 4 3
2 2 1 4 2
2 3 1 3 2
1 2 2 4 3
2 3 4 4 2
1 2 2 4 3
2 2 2 4 2
1 2 2 3 2
2 4 2 4 2
1 3 1 4 2
4 2 2 4 2
3 2 4 4 3
1 1 1 4 3
2 2 1 3 2
1 2 2 4 2
4 2 8 4 3
2 2 8 4 3
1 2 8 4 2
1 3 8 2 2
2 2 2 4 2
4 2 1 4 3
2 2 2 4 3
3 2 4 4 2
1 2 4 4 3
1 3 4 2 2
1 2 5 4 3
4 2 1 4 2
3 2 4 4 3
4 2 2 4 3
2 2 2 4 2
2 2 4 4 4
1 2 1 4 3
2 2 8 (SUMATRA) 4 2
1 3 1 2 2
1 2 1 4 3
2 3 1 2 2
2 2 2 4 2
2 2 1 4 2
1 2 1 3 2
1 2 4 4 3
1 2 8 (BUGIS) 4 2
No 1 No 2 No 3 No 4 No 5 No 6 No 7 No 8 No 9

5 5 3 1 3 2 2 1 1
4 1 1 1 2 1 1 1 1
3 4 3 2 2 3 3 2 3
5 5 2 2 1 1 1 1 2
4 2 1 3 5 1 1 1 1
4 1 1 1 1 1 1 1 1
4 4 2 2 3 3 2 1 2
5 4 4 1 3 3 2 2 3
3 3 3 2 2 3 1 3 1
4 5 4 3 3 2 2 2 4
4 4 4 2 2 3 2 2 2
4 1 2 3 3 1 1 1 4
5 5 4 4 3 1 1 1 1
4 4 2 2 3 2 2 2 2
4 5 2 2 3 2 1 3 2
3 4 2 3 3 1 2 2 2
5 3 2 2 3 1 1 1 1
3 3 1 1 1 1 1 1 1
3 4 3 3 3 2 2 2 3
5 3 3 1 4 4 4 3 3
4 4 1 1 4 1 1 1 1
3 3 1 1 1 1 1 1 1
5 5 4 1 1 1 1 1 1
2 2 1 2 1 1 1 1 1
5 5 5 2 3 2 1 1 2
4 1 2 2 3 1 1 1 1
4 4 3 3 2 2 2 2 2
4 1 2 2 4 1 1 1 3
4 4 2 2 2 1 1 1 1
4 4 4 3 2 2 2 2 2
4 4 2 3 3 2 1 1 1
3 5 2 2 1 1 1 1 1
3 3 1 1 1 2 1 1 2
2 3 2 2 2 2 1 1 1
4 3 1 1 1 1 1 1 1
5 4 3 3 3 1 3 1 1
3 5 4 3 3 1 1 2 3
4 4 4 1 1 1 1 1 1
4 4 2 1 2 1 1 1 2
3 4 1 1 3 1 1 1 1
4 1 2 1 3 2 2 2 2
3 3 2 2 2 2 2 2 2
5 6 5 1 4 4 4 4 3
4 5 4 3 4 4 4 4 4
3 3 2 2 1 1 1 1 1
5 5 3 1 3 2 1 2 2
3 4 2 2 2 2 1 1 1
4 1 1 2 2 1 2 1 2
4 4 3 3 4 3 3 2 2
4 5 5 1 3 1 1 1 1
3 4 1 1 1 1 1 1 1
3 4 4 3 2 2 1 1 1
5 5 4 1 1 1 1 1 1
4 4 4 1 3 3 3 3 3
4 4 1 1 2 1 1 2 2
5 4 4 4 3 2 2 2 2
4 3 2 2 0 3 3 2 1
4 6 3 1 4 3 2 1 3
5 5 4 3 2 2 1 1 2
4 4 3 3 3 2 1 1 1
4 3 1 1 1 1 1 1 1
2 5 4 2 3 3 2 1 1
3 2 3 3 1 1 1 1 1
4 3 3 2 1 1 1 1 1
4 4 2 2 3 1 3 2 2
5 4 2 2 5 5 1 2 5
4 1 1 2 3 1 1 2 1
4 4 2 2 3 2 3 1 2
5 6 5 1 4 4 4 4 4
3 4 2 1 2 1 1 2 1
3 5 4 2 2 1 3 1 1
5 5 4 1 1 1 1 1 3
5 4 2 3 2 2 1 2 1
5 6 5 5 4 4 4 4 4
3 5 5 1 2 1 1 1 1
4 4 1 1 1 1 1 1 1
4 3 2 1 3 2 2 1 1
4 1 2 1 3 1 1 1 1
3 4 2 2 1 1 1 1 1
5 6 5 3 4 3 4 4 4
4 5 2 2 2 2 1 2 2
4 4 3 3 3 3 1 1 2
4 4 3 2 4 1 1 1 1
3 4 1 1 2 2 1 1 1
4 4 3 3 3 3 3 3 3
4 1 2 3 3 1 1 1 1
3 4 2 2 2 1 1 2 1
3 4 3 2 4 2 2 2 1
4 4 2 2 3 3 2 2 2
4 3 2 2 3 2 2 2 1
4 5 2 3 2 2 3 3 2
4 4 3 3 4 4 3 2 3
4 4 2 2 2 2 1 2 1
5 5 2 2 2 3 1 2 5
3 3 3 2 3 3 2 3 3
4 3 2 2 3 2 2 2 2
4 4 3 3 5 5 3 3 3
3 3 3 2 4 3 2 2 2
3 3 2 3 2 2 2 2 2
4 1 1 2 3 1 1 1 1
4 4 2 2 2 2 1 1 1
4 2 3 2 3 3 2 2 2
4 4 2 2 3 1 1 1 2
4 4 3 3 2 2 1 1 1
3 3 2 2 2 2 2 1 1
4 4 2 2 2 2 1 2 2
5 5 2 2 2 2 2 2 1
5 3 4 2 3 3 3 2 3
5 5 4 3 5 5 2 2 2
5 5 5 3 4 4 4 4 4
5 2 1 1 2 1 1 1 1
4 4 2 1 3 1 1 2 2
5 2 1 1 1 1 1 1 1
4 3 2 3 2 2 1 1 1
3 5 1 1 1 1 1 1 1
3 4 3 2 0 1 1 1 1
2 6 5 4 3 3 3 4 3
4 4 3 2 3 3 3 3 3
3 5 2 1 4 3 3 3 3
3 3 3 4 3 3 1 1 1
4 5 4 3 3 2 2 1 3
3 3 1 1 2 1 3 1 1
4 4 3 3 1 1 1 1 1
2 4 4 5 4 4 3 1 1
4 3 3 3 3 3 3 3 3
3 4 3 1 3 3 3 3 3
4 5 3 4 4 3 4 3 4
5 5 2 4 5 5 4 4 4
4 4 4 3 3 3 3 3 3
4 4 2 2 3 2 2 2 2
3 4 4 3 5 4 1 2 1
4 4 2 2 3 2 3 3 2
4 4 3 3 3 3 3 3 3
1 5 1 1 5 1 3 1 3
4 5 4 3 4 4 4 4 4
5 5 5 4 4 4 4 4 4
3 4 2 1 3 3 2 2 2
3 4 2 1 2 3 1 1 2
4 4 3 2 3 3 3 3 3
5 5 4 4 2 1 1 3 1
3 4 3 3 3 3 3 3 3
4 4 2 1 3 3 3 3 3
3 3 1 2 1 1 1 1 1
5 5 4 3 4 4 1 1 2
4 4 2 1 2 1 1 1 1
4 4 3 3 4 4 3 3 3
3 4 4 1 2 2 2 2 2
4 5 4 2 4 3 3 3
4 4 2 2 3 3 3 3 3
4 4 2 1 3 2 1 1 1
4 4 3 1 3 3 3 3 3
4 4 4 3 3 3 3 3 3
5 5 4 1 5 3 1 1 1
3 5 4 3 4 1 1 1 1
5 4 3 4 3 2 1 1 2
3 4 2 2 4 4 3 1 2
5 5 5 3 4 4 3 3 3
4 5 4 1 4 3 3 3 3
4 4 3 3 2 3 2 2 2
4 5 3 3 2 1 1 1 1
3 5 4 1 2 3 1 3 4
4 4 3 2 3 3 3 3 3
4 2 1 1 1 1 1 1 1
4 4 2 3 3 2 2 2 2
4 4 4 3 3 3 3 3 3
4 4 3 3 3 3 3 3 3
4 5 4 2 4 3 3 3 3
4 4 4 2 4 3 3 3 3
4 4 3 1 3 3 3 3 3
1 1 1 2 2 1 1 1 1
3 1 1 1 1 1 1 1 1
4 5 4 1 3 3 3 3 3
4 5 4 2 3 3 3 3 3
4 4 4 1 3 4 3 3 4
5 5 1 2 5 3 1 1 3
4 5 3 2 3 3 3 3 3
4 4 3 3 4 3 3 3 3
4 4 3 3 4 2 3 3 3
5 4 3 2 3 4 3 2 2
4 4 3 2 3 3 3 3 3
4 4 3 3 4 1 1 2 1
3 5 3 2 4 3 3 3 3
3 4 2 1 3 3 1 1 2
4 4 2 1 3 3 3 3 3
4 4 2 3 3 2 3 3 2
4 4 3 4 5 5 5 5 3
5 4 3 1 3 2 1 2 2
5 5 4 3 5 2 2 1 3
3 4 3 1 3 1 1 1 1
5 3 2 2 3 3 3 3 3
3 4 2 1 2 2 2 2 2
4 5 3 2 3 4 3 1 3
4 4 5 3 4 3 3 3 3
1 1 1 1 1 1 1 1 1
4 5 3 2 3 3 3 3 3
4 6 5 3 3 2 2 2 2
4 5 3 2 3 3 3 3 3
4 3 4 4 2 1 3 1 1
3 4 3 1 3 3 3 3 3
2 4 1 1 2 1 1 1 1
4 4 3 3 2 1 1 1 1
3 4 3 2 2 2 2 2 2
2 5 3 1 1 2 1 1 1
3 5 3 2 3 3 3 3 3
1 5 3 1 1 1 2 2 1
3 5 1 2 0 3 1 1 3
4 4 3 2 5 5 3 1 1
3 4 3 1 2 2 2 2 2
3 5 4 1 3 3 3 3 3
3 5 3 2 3 3 3 3 3
4 4 2 3 4 2 2 1 1
5 2 1 1 5 1 1 1 3
1 1 1 2 3 5 5 2 3
3 5 3 2 3 3 3 3 3
1 1 1 2 1 5 5 1 1
4 5 4 2 3 3 3 3 3
4 4 3 3 4 3 3 3 2
5 2 1 1 1 2 1 1 1
3 4 2 1 3 3 1 1 1
2 4 1 1 5 1 1 2 1
4 4 3 3 3 2 2 2 2
3 5 2 2 3 3 3 3 3
5 5 3 1 3 1 1 1 2
4 4 3 3 4 2 2 2 3
3 5 1 1 3 3 2 2 3
4 4 3 1 3 3 3 3 3
4 3 1 1 2 1 1 1 1
4 4 2 2 2 2 2 2 2
4 4 3 1 3 3 3 3 3
2 3 1 1 3 3 1 1 1
3 3 1 1 1 1 1 1 1
2 3 2 2 1 1 1 1 1
3 5 3 2 4 1 2 1 3
4 3 3 3 4 2 2 2 4
5 4 3 2 1 2 2 1 2
4 4 2 1 2 2 2 2 2
2 5 5 1 1 1 1 1 1
2 2 2 1 3 3 1 1 1
2 5 2 2 2 1 1 1 1
4 4 2 1 2 2 2 2 2
4 4 4 3 4 2 3 3 3
5 6 4 4 5 3 2 4 4
3 4 3 2 4 4 2 2 3
3 4 3 3 2 2 1 1 1
2 2 1 1 2 2 1 1 1
2 3 2 1 3 3 1 1 1
4 4 1 1 3 3 1 1 1
4 4 3 3 3 3 2 2 3
3 5 4 3 4 3 3 2 4
3 3 3 2 1 1 1 2 1
4 2 1 1 5 1 1 1 1
4 4 3 3 4 2 2 2 2
4 4 2 1 2 2 2 2 2
5 2 3 2 2 3 1 1 1
4 5 2 2 2 3 3 3 3
4 4 3 2 2 3 3 3 3
4 4 3 3 4 3 3 3 3
3 5 1 2 5 1 3 3 3
 INDEKS KUALITAS HIDUP OFTALMOLOGI

No 10 No 11 No 12 No 13 No 14 No 15 No 15a No 15b No 15c

2 2 2 2 2 2 2 2 0
1 1 1 1 1 1 0 0 1
3 2 2 2 2 1 0 0 3
1 1 1 1 1 2 1 0 0
1 1 1 1 1 2 1 0 0
1 1 1 1 1 2 1 0 0
2 2 1 3 2 2 1 0 0
3 3 3 2 3 2 1 0 0
1 1 1 1 2 1 0 0 1
4 3 1 1 2 2 1 0 0
2 2 3 3 3 2 2 0 0
1 1 1 1 1 2 2 1 0
2 2 1 1 1 2 1 0 0
1 2 2 2 2 2 0 0 0
2 1 1 1 1 2 1 2 0
1 2 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
1 1 1 1 1 2 1 0 0
3 2 2 2 2 2 2 0 0
1 1 1 1 1 2 2 1 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
1 1 1 1 1 2 2 0 0
1 1 1 1 1 2 1 0 0
1 2 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 1
2 2 2 2 2 2 1 0 0
2 1 1 1 1 2 1 0 0
1 1 1 1 1 2 1 0 0
3 3 1 2 1 2 1 0 0
1 1 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 1
2 1 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
4 1 1 1 1 1 0 0 2
4 1 3 3 3 1 0 0 1
1 1 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 2 1 0 0
2 1 1 1 1 1 0 0 1
2 2 1 2 2 1 1 0 0
3 3 4 4 4 2 2 0 0
4 4 1 3 1 2 1 0 0
1 1 1 1 1 2 1 0 0
1 1 1 1 2 2 2 1 0
1 1 1 1 1 1 0 0 1
2 2 1 1 1 2 2 2 0
2 2 2 2 2 2 2 3 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
1 1 1 2 1 2 2 3 0
1 1 1 1 1 1 0 0 1
3 2 2 2 2 1 1 0 0
1 1 1 1 1 2 1 0 0
2 2 1 2 2 2 1 0 0
1 1 1 1 1 2 0 0 0
3 3 3 3 3 2 1 0 0
2 1 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 2
1 1 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 2
1 1 1 1 2 2 1 0 0
1 1 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 1
2 2 2 2 2 1 0 0 3
4 4 4 4 4 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 2 1 0 0 1
3 1 1 1 1 2 2 2 0
1 1 1 1 1 1 0 0 1
4 4 4 4 4 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 2 1 0 0
2 2 1 1 2 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
4 4 3 3 4 1 1 0 0
1 1 1 1 1 2 1 0 0
2 2 1 2 2 2 1 0 0
1 1 1 1 2 1 0 0 1
1 1 1 1 1 2 1 0 0
3 3 2 2 3 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 2 1 0 0
2 2 1 2 2 2 1 0 0
2 2 1 1 1 2 1 0 0
2 1 1 1 2 2 1 0 0
2 2 1 1 3 2 2 1 0
3 3 3 3 2 2 1 0 0
1 1 1 1 1 2 1 0 0
5 1 1 1 1 2 1 0 0
2 2 1 1 2 2 1 0 0
2 1 1 1 2 2 1 0 0
3 3 3 3 3 2 2 3 5
2 2 2 1 2 2 1 0 0
1 2 2 1 1 2 1 0 0
1 1 1 1 1 2 2 2 0
1 1 1 1 1 2 1 0 0
2 2 2 2 2 2 1 0 0
1 1 1 1 1 2 1 0 0
1 2 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 2 1 0 0
1 2 1 1 1 2 1 0 0
2 2 3 3 3 2 1 0 0
2 3 3 3 3 2 1 0 0
4 4 3 4 4 2 2 1 0
1 1 1 1 1 1 0 0 1
2 2 1 1 2 1 0 0 2
1 1 1 1 1 1 0 0 1
1 1 1 2 1 1 0 0 1
1 1 1 1 1 2 1 0 0
1 1 1 1 1 2 1 0 0
3 1 1 3 3 1 0 0 1
3 3 3 3 5 0 1 0 0
3 3 3 3 3 1 0 0 3
1 1 1 1 1 2 2 2 0
3 1 1 1 1 1 0 0 1
1 1 1 1 1 2 1 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
3 3 3 3 1 2 2 3 3
3 3 2 2 2 1 0 0 2
4 4 3 3 4 2 1 1 4
4 3 3 4 4 2 1 0 0
3 3 3 3 3 1 0 0 3
2 2 2 2 2 1 0 0 2
1 1 1 1 1 2 1 0 0
3 3 2 3 3 2 1 3 0
3 3 3 3 3 2 1 2 3
3 2 1 1 5 1 0 0 1
4 4 4 3 4 2 1 0 0
4 4 4 4 4 2 1 0 0
2 2 2 2 2 2 1 0 0
2 1 1 2 1 2 1 0 0
3 3 3 3 3 1 0 0 3
1 2 1 1 5 1 0 0 1
3 3 3 3 3 2 1 2 5
3 3 3 3 3 2 1 0 0
1 1 1 1 1 1 2 1 1
2 1 1 1 5 2 2 1 0
1 1 1 1 1 1 0 0 2
3 2 3 3 3 2 1 0 0
2 2 2 2 2 1 0 0 2
3 3 3 3 3 2 2 3 0
3 3 2 2 2 2 0 0 0
1 1 1 1 1 2 1 0 0
3 3 3 3 3 1 0 0 3
3 3 3 2 3 2 1 2 3
1 1 1 1 5 1 0 0 1
1 1 1 1 5 2 1 0 0
1 1 5 1 5 1 0 0 1
1 2 1 1 1 1 0 0 1
2 2 1 3 3 2 2 1 3
3 3 3 3 3 2 1 0 0
2 2 3 3 3 2 1 0 0
1 1 1 1 2 1 0 0 2
4 3 3 3 3 2 1 0 0
3 3 3 3 3 2 1 0 0
1 1 1 1 1 1 0 0 1
2 2 2 2 2 2 1 0 0
3 3 3 3 3 2 1 0 0
3 3 3 3 3 1 2 2 3
3 3 3 3 3 2 2 3 0
3 3 3 3 3 2 2 3 0
3 3 3 3 3 2 1 0 0
1 1 5 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
3 3 3 3 3 2 1 0 0
3 3 3 3 3 2 1 0 0
3 3 2 3 3 1 0 0 3
3 1 1 1 5 1 0 0 1
3 3 3 3 3 2 1 0 0
3 3 3 2 2 2 1 0 0
3 3 3 3 3 2 1 0 0
2 2 1 2 2 1 0 0 2
3 3 3 3 3 2 1 0 0
1 1 1 1 1 2 1 0 0
3 3 3 3 3 2 1 0 0
1 1 1 1 1 1 0 0 1
3 3 3 3 3 2 1 0 0
2 2 2 2 2 2 1 0 0
3 3 5 2 2 2 2 2 5
1 2 1 2 2 1 0 0 2
3 1 2 2 4 2 1 0 0
1 1 1 1 5 1 0 0 1
4 1 1 1 2 1 0 0 2
2 2 2 2 2 2 1 0 0
1 1 1 1 1 1 0 0 1
3 2 2 2 2 2 1 0 0
1 1 1 1 1 1 0 0 1
3 3 3 3 3 2 1 0 0
2 2 2 2 1 2 1 0 0
3 3 3 3 3 2 1 0 0
4 1 5 1 1 1 0 0 1
3 3 3 3 3 2 1 0 0
1 1 1 1 5 2 1 0 0
1 1 1 1 1 2 1 0 0
2 2 2 2 2 2 1 0 0
1 1 1 1 5 1 0 0 1
3 3 3 3 3 2 1 0 0
1 1 1 1 5 1 0 0 1
3 1 1 1 5 1 0 0 1
1 1 5 1 2 1 0 0 1
2 2 2 2 2 2 1 0 0
3 3 3 3 3 2 1 0 0
3 3 3 3 3 2 1 0 0
1 1 1 1 1 2 1 0 0
3 1 1 1 5 2 1 0 0
1 2 5 1 1 2 1 0 0
3 3 3 3 3 2 1 0 0
1 1 5 1 1 1 0 0 1
3 3 3 3 3 2 1 0 0
3 3 3 2 3 2 1 0 0
1 1 1 1 5 2 2 2 0
1 1 1 1 1 1 0 0 1
1 1 1 1 5 2 1 0 0
2 3 2 2 1 2 1 0 0
3 3 3 3 3 2 1 0 0
2 1 1 1 5 1 0 0 1
2 2 2 2 2 2 1 0 0
3 1 1 1 2 2 0 0 0
3 3 3 3 3 1 0 0 2
1 1 1 1 5 2 1 0 0
2 2 2 2 2 2 1 0 0
3 3 3 3 3 2 1 0 0
1 1 1 1 1 1 0 0 2
1 1 1 5 5 1 0 0 1
1 1 1 1 1 1 0 0 1
3 1 1 1 1 1 0 0 1
2 2 1 2 2 1 0 0 2
2 1 1 1 1 1 0 0 1
2 2 2 2 2 2 1 0 0
1 1 1 1 5 1 0 0 1
1 1 1 1 1 1 0 0 1
1 1 1 1 5 1 0 0 1
2 2 2 2 2 1 2 3 3
3 1 1 1 1 1 2 1 4
4 2 1 5 2 2 2 1 0
2 2 1 2 2 1 0 0 2
1 1 1 5 5 1 0 0 2
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
1 1 1 1 1 1 0 0 1
2 3 1 2 2 1 0 0 3
2 3 2 2 2 1 0 0 3
1 1 1 1 5 1 0 0 1
1 1 1 1 5 1 0 0 1
3 2 2 5 5 2 1 0 0
2 2 2 2 2 2 1 0 0
1 1 1 1 5 1 0 0 1
3 3 3 3 3 2 1 0 0
3 3 3 3 2 2 1 0 0
3 3 2 2 2 2 1 0 0
3 3 1 1 5 1 0 0 1
No 16 No 16a No 17 No 18 No 19 No 20 No 21 No 22 No 23

0 0 5 5 5 4 5 5 3
1 1 5 5 5 5 5 5 5
4 4 3 4 3 2 3 3 5
0 0 5 5 5 5 5 5 5
0 0 5 5 5 5 5 5 5
0 0 5 5 4 5 5 5 5
5 5 4 5 3 4 3 3 3
0 0 2 2 5 2 5 3 4
3 3 4 4 4 2 4 4 5
0 0 4 5 4 5 3 3 5
4 5 4 4 4 4 4 3 3
0 0 5 4 5 5 5 5
0 0 4 5 3 5 5 5 5
5 5 4 4 4 2 4 3 4
0 0 5 4 5 5 4 4 4
1 2 4 4 2 4 4 3 4
4 3 3 3 3 5 5 4 5
0 0 5 5 5 5 5 5 5
2 3 2 3 3 3 3 2 4
0 0 5 4 5 5 5 5 5
1 1 5 5 5 5 5 5 5
2 2 5 5 5 5 5 5 5
0 0 5 5 5 4 4 4 4
0 0 5 5 5 5 5 5 5
0 0 3 4 4 4 4 4 5
1 1 5 4 5 5 5 5 5
0 0 4 4 3 4 4 5 5
0 0 5 4 4 5 5 5 5
0 0 5 5 5 5 5 5 5
0 0 4 4 4 3 4 3 4
0 0 4 4 4 5 5 1 5
1 1 5 5 5 5 5 5 5
0 0 5 5 5 5 5 5 5
1 1 4 4 5 5 5 4 4
1 1 5 5 4 5 5 5 5
3 3 5 4 4 5 2 5 5
4 4 2 3 3 4 2 3 5
0 0 5 5 5 4 5 5 5
2 2 4 4 5 5 5 5 5
0 0 5 5 4 5 5 5 5
2 2 4 4 4 5 2 5 5
0 0 4 4 4 4 4 3 3
0 0 1 1 4 2 3 2 1
0 0 1 1 1 4 1 3 2
0 0 5 5 4 5 5 5 5
0 0 4 4 5 5 5 2 5
1 2 4 5 4 4 5 4 5
0 0 5 5 5 5 5 5 5
0 0 3 3 3 2 2 2 2
2 3 4 5 5 5 5 4 5
1 1 5 5 5 5 5 5 5
4 5 4 4 4 4 5 4 5
2 2 5 5 5 5 5 5 5
0 0 3 3 5 4 4 4 4
0 0 5 5 5 5 5 4 5
4 4 3 4 4 2 4 2 4
0 0 4 4 2 5 5 5 5
0 0 1 1 5 2 2 3 1
0 0 3 3 3 3 2 4 5
2 2 4 5 5 5 5 5 5
1 1 5 5 5 5 5 5 5
4 4 2 2 3 1 4
0 0 5 5 5 5 5 5 5
1 1 4 5 5 5 5 5 5
0 0 4 4 4 5 5 5 4
0 0 4 2 1 5 5 4 5
1 1 5 5 5 5 5 5 5
4 4 5 5 5 5 2 5 5
0 0 1 1 5 1 2 1 1
4 4 4 5 5 5 5 5 5
3 3 3 3 4 5 2 5 5
0 0 5 5 2 2 5 4 5
3 2 4 4 3 5 5 3 5
0 0 1 1 2 1 1 1 1
2 1 5 5 5 5 1 5 5
0 0 5 5 4 5 5 5 5
0 0 5 5 4 5 5 5 5
1 1 4 5 5 5 5 5 5
1 1 4 3 4 4 4 4 4
0 0 1 1 2 1 1 1 1
0 0 4 3 4 5 5 3 5
0 0 3 3 3 2 2 4 4
1 1 5 5 5 5 5 5 5
0 0 4 5 5 5 5 3 5
0 0 2 2 3 2 2 2 4
1 1 4 4 4 5 5 5 5
0 0 4 4 4 5 3 5 5
0 0 4 4 4 4 4 4 4
0 0 5 4 4 5 5 5 5
0 0 4 4 4 5 4 4 5
0 0 3 3 3 4 2 5 5
0 0 2 2 2 4 2 2 2
0 0 4 5 4 5 5 3 5
0 0 4 4 4 5 5 4 5
0 0 3 3 4 4 4 4 4
0 0 4 4 4 4 4 4 4
5 5 3 3 3 2 2 2 4
0 0 3 4 4 4 3 4 4
0 0 4 4 4 5 5 4 5
0 0 5 5 5 5 5 5 5
0 0 4 5 4 5 5 4 5
0 0 3 4 4 4 4 4 4
0 0 5 5 5 5 2 5 5
0 0 3 4 4 4 4 4 4
1 1 4 5 5 5 5 4 5
0 0 4 5 4 5 5 4 5
0 0 4 4 4 3 5 4 5
0 0 3 3 4 4 3 3 3
0 0 3 3 3 4 4 4 4
4 4 2 2 2 2 2 2 2
1 1 5 5 5 5 5 5 5
2 2 4 5 5 5 5 5 5
1 1 5 5 5 5 5 5 5
1 2 4 4 4 5 5 3 5
0 0 5 5 5 5 5 5 5
0 0 4 3 4 4 5 4 4
4 4 2 2 2 1 2 3 1
3 3 4 3 3 3 3 3 3
3 3 3 3 4 4 3 4 4
0 0 3 4 4 5 5 3 5
4 2 2 2 2 1 1 4 1
0 0 4 5 5 5 5 5 5
1 1 1 5 5 4 5 5 5
4 4 5 5 3 5 3 5 5
3 3 3 3 3 3 3 3 3
2 2 4 4 5 4 4 4
3 3 3 3 3 3 3 3 3
0 0 1 1 1 1 4 2 5
3 3 2 2 3 5 5 3 5
2 2 4 4 5 4 4 4 4
0 0 5 5 5 5 5 5 5
0 0 3 3 4 4 4 4 4
3 3 3 3 3 3 3 3 3
4 2 5 5 4 5 5 5 5
0 0 2 1 2 1 2 3 2
4 4 1 1 1 1 1 1 1
0 0 4 4 5 4 4 4 4
0 0 2 4 5 5 5 4 4
3 3 3 3 4 3 4 4 4
2 1 1 2 2 5 4 5 5
3 3 3 3 3 3 3 3 3
0 0 3 3 4 3 3 3 4
1 1 1 1 1 1 1 1 1
0 0 2 1 1 2 1 1 5
4 2 4 4 5 4 5 4 5
0 0 3 3 3 3 3 3 3
2 2 4 4 4 4 4 4 4
0 0 3 2 4 2 3 2 2
2 2 4 4 4 4 3 3 3
0 0 4 5 5 5 5 4 4
3 3 3 3 3 3 3 4 4
3 3 4 3 3 3 3 3 3
2 1 5 2 5 5 5 5 5
0 0 3 3 3 5 5 5 5
1 1 5 4 2 3 5 2 5
2 2 5 4 5 5 5 4 5
4 4 2 2 3 2 2 2 2
0 0 2 2 4 3 3 2 2
3 3 4 4 4 3 3 3 4
2 2 3 3 3 4 4 4 4
0 0 2 2 2 3 5 1 1
0 0 3 3 4 3 3 4 4
2 1 5 5 5 5 5 5 5
2 2 3 3 3 5 5 5 5
3 3 3 3 3 3 3 3 3
3 3 3 3 3 3 3 3 3
0 0 2 2 4 2 3 2 2
0 0 3 3 4 3 3 3 2
3 3 3 3 3 3 3 4 3
1 1 5 5 4 5 5 4 5
1 1 5 5 5 5 5 5 5
0 0 2 2 4 2 3 2 2
0 0 3 3 4 3 3 4 3
4 4 2 2 3 2 2 2 2
3 4 3 3 3 5 5 5 4
0 0 3 3 4 4 4 2 2
0 0 4 3 4 5 5 3 3
3 3 3 3 3 4 4 4 4
4 4 3 3 3 2 3 2 2
0 0 3 3 3 3 3 3 4
0 0 4 5 4 5 5 2 5
0 0 3 3 4 3 4 3 2
2 2 4 5 5 5 5 4 5
0 0 3 3 3 3 3 4 4
0 0 3 4 4 5 5 3 3
5 5 3 3 3 2 3 4 3
4 4 3 3 5 4 4 3 4
0 0 2 3 2 2 2 5 2
1 1 5 5 5 5 5 5 5
3 3 5 4 4 3 5 3 4
0 0 4 4 4 4 4 4 4
3 2 5 3 4 2 4 1 2
0 0 3 3 3 4 4 3 3
2 2 4 4 5 5 5 5 5
0 0 3 3 3 3 3 4 4
0 0 3 3 2 4 4 2 3
0 0 3 3 3 2 3 2 2
2 3 5 5 5 4 2 1 5
3 3 3 3 4 2 3 4 4
0 0 5 5 5 5 5 5 5
0 0 5 5 4 5 5 2 5
0 0 4 4 4 4 4 4 4
1 1 5 5 5 5 5 5 5
0 0 3 3 3 4 4 4 4
2 1 5 5 5 5 5 5 5
3 3 5 5 5 5 5 5 5
1 3 5 5 3 1 1 2 5
0 0 4 4 4 4 4 4 4
0 0 4 3 3 4 4 4 4
0 0 3 3 4 4 4 4 4
0 0 4 5 3 5 5 5 5
0 0 5 5 5 5 5 5 5
0 0 3 5 3 2 3 2 5
0 0 3 4 4 4 4 4 4
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0 0 1 1 1 1 1 3 2
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 IDENTITAS
NO URUT
NAMA ALAMAT RUMAH NO TELEPON

1 001 UUN MARYANAH KOMP. SERBAGUNA RT/RW 001/013

2 002 ROMLI LORONG I NO 18 RT 01/13 085211196179
3 003 ADE LORONG I SITANALA
4 004 POPON GUNAKARYA RT 01/13 NO 20
5 005 UMSIYAH DEPAN GOR SITANALA
6 006 SATNAH SITANALA
7 007 SUHAETI KOMPLEK SITANALA NO 40
8 008 MASUYAH DEPAN GOR SITANALA
9 009 TUTI KOMPLEK SITANALA NO 40 081210864085
10 010 MARHUMAH KOMPLEK SITANALA NO 36
11 011 SAMSIYAH KOMPLEK SITANALA NO 40 082299599472
12 012 MARTA KOMPLEK SITANALA NO 39 RT 01/13
13 013 MARYAM KOMPLEK SITANALA NO 71 0895610763219
14 014 ELI HERAWATI KOMPLEK SITANALA NO 36
15 015 KOMARIAH KOMPLEK SITANALA 30/31
16 016 ABDUL RASYID KOMPLEK SITANALA NO 23 RT 01
17 017 ROSYID KOMPLEK SITANALA NO 71
18 018 MIMIK KOMPLEK SITANALA NO 38
19 020 RASMA KOMPLEK SITANALA RT 01/13
20 021 HASAN KOMPLEK SITANALA NO 28 RT 01/13
21 022 SAFARI KOMPLEK SITANALA
22 023 SUBUR KOMPLEK SITANALA GUNA KARYA NO 37
23 024 ABDURAHMAN KOMPLEK SITANALA RT 01/13
24 025 ABAN KOMPLEK SITANALA NO 115
25 026 JULEHA KOMPLEK SITANALA RT 01/ RW 013
26 027 EMI KOMPLEK SITANALA RT 01/ RW 013
27 028 ZAENAL ABIDIN KOMPLEK SITANALA RT 01/ RW 013 NO 40 081287512324
28 030 RUBIEM KOMPLEK SITANALA NO 113
29 031 MAEMUNAH KOMPLEK SITANALA RT 01/ RW 13
30 032 TASWI KOMPLEK SITANALA RT 1/ RW 13
31 033 TASIM KOMPLEK SITANALA RT 01/ RW 013 NO 51
32 034 ERNI KOMPLEK SITANALA RT 01/ RW 013 NO 51
33 035 IWAN KOMPLEK SITANALA RT 01/ RW 013
34 039 WATI KOMPLEK SITANALA NO 106
35 040 SAMSUDIN KOMPLEK SITANALA RT 01/ RW 013 083895901926
36 041 ATA KOMPLEK SITANALA NO 90 081210003842
37 042 NYAI SUMIATI KOMPLEK SITANALA
38 043 PULUNG KOMPLEK SITANALA RT 01/ RW 013 NO 133 085214096513
39 044 AAM KOMPLEK SITANALA
40 045 ISKANDAR KOMPLEK SITANALA RT 01/ RW 013
41 046 JONYAH KOMPLEK SITANALA RT 01/ RW 013
42 047 YUNUS PRIHADI KOMPLEK SITANALA RT 01/ RW 013
43 048 TAHIYAR KOMPLEK SITANALA RT 01/ RW 013 NO. 5
44 049 RAHMAT KOMPLEK SITANALA RT 01/ RW 013 0895633697172
45 050 BOY PUNDOKO KOMPLEK SITANALA RT 02/ RW 013
46 051 MARUDIN KOMPLEK SITANALA RT 01/ RW 013
47 052 EPI KOMPLEK SITANALA RT 01/ RW 013 NO 52
48 053 SLAMET PURWADI KOMPLEK SITANALA RT 01/ RW 013 NO 187
49 054 ELI MARULI KOMPLEK SITANALA RT 01/ RW 013
50 055 SUPRIYANTONO HADI KOMPLEK SITANALA RT 01/ RW 013
51 056 NENGSIH KOMPLEK SITANALA RT 01/ RW 013
52 057 KARNI KOMPLEK SITANALA RT 01/ RW 013 NO 87 089630099176
53 058 ANISAH KOMPLEK SITANALA RT 01/ RW 013 NO 42 081286013405
54 059 BUNYAMIN KOMPLEK SITANALA RT 01/ RW 013 081280998190
55 060 MURSITI KOMPLEK SITANALA RT 01/ RW 013
56 061 GEMI KOMPLEK SITANALA RT 01/ RW 013
57 062 YATI KOMPLEK SITANALA RT 04/ RW 013
58 063 CASTIWI KOMPLEK SITANALA RT 04/ RW 013
59 064 ALI KOMPLEK SITANALA RT 01/ RW 013 NO 35
60 065 SAJAN KOMPLEK SITANALA RT 01/ RW 013
61 066 SUHARTO KOMPLEK SITANALA RT 02/ RW 013
62 067 AKLANI KOMPLEK SITANALA RT 01/ RW 013
63 068 FATULLAH KOMPLEK SITANALA RT 01/ RW 013
64 069 NURBISNA KOMPLEK SITANALA RT 01/ RW 013 NO 66
65 070 HADIJAH KOMPLEK SITANALA RT 02/ RW 013
66 071 ALI M RSK SITANALA BANGSAL KUSTA TERPADU
67 072 KOMARUDIN KOMPLEK SITANALA RT 04/ RW 013 087884029090
68 073 SUDIN SITANALA
69 074 YATI KOMPLEK SITANALA NO 94
70 075 ASHARI KOMPLEK SITANALA NO 94 RT 01/ RW 13
71 076 SACA KOMPLEK SITANALA RT 01/ RW 13
72 077 AGUNG KOMPLEK SITANALA RT 02/ RW 013 081272712440
73 078 DASUKI KOMPLEK SITANALA RT 01/ RW 13 087773765890
74 079 YAYAH CAHYATI KOMP SERBAGUNA RT 02/ RW 13
75 080 MARIYATI SITANALA
76 081 JUMINEM KOMPLEK SITANALA RT 01/ RW 13 081219660876
77 082 CASMADI KOMPLEK SITANALA RT 01/ RW 13
78 083 RONI KOMPLEK SITANALA RT 01/ RW 13
79 084 TITIN KOMPLEK SITANALA RT 01/ RW 13 NO 24
80 085 USMAN KOMPLEK SITANALA RT 01/ RW 13 NO 93 081289013143
81 086 INDAYATI KOMPLEK SITANALA RT 05/ RW 13 089675219071
82 087 HARTONO KOMPLEK SITANALA RT 01/ RW 13 NO 163
 83 088 UTI KOMPLEK SITANALA RT 01/ RW 13
84 089 ROJALI KOMPLEK SITANALA RT 01/ RW 13
85 090 SAPEI KOMPLEK SITANALA RT 01/ RW 13 081293460757
86 091 SRIWAHYUNINGSIH KOMPLEK SITANALA RT 01/ RW 13 081905550501
87 092 YUMIATI KOMPLEK SITANALA RT 01/ RW 13 083896857423
88 093 SISWANTO KOMPLEK SITANALA RT 01/ RW 13 081807198701
89 094 RATNAWATI KOMPLEK SITANALA RT 01/ RW 13
90 095 DOMIN KOMPLEK SITANALA RT 01/ RW 13
91 096 KASMIN KOMPLEK SITANALA RT 01/ RW 13
92 097 ESEM KOMPLEK SITANALA RT 01/ RW 13
93 098 TITIN KOMPLEK SITANALA RT 01/ RW 13
94 099 ISMAIL KOMPLEK SITANALA
95 100 ITAH KOMPLEK SITANALA RT 01/ RW 13
96 101 MARKUS UTONO KOMPLEK SITANALA RT 01/ RW 13 NO 148
97 102 SITI JENAH KOMPLEK SITANALA RT 01/ RW 13
98 103 DEWI KOMPLEK SITANALA RT 01/ RW 13 087782887636
99 104 SUTINEM KOMPLEK SITANALA RT 05/ RW 13
100 105 ENAH KOMPLEK SITANALA RT 04/ RW 13
101 106 HERI KOMPLEK SITANALA RT 01/ RW 13 NO 50 08210229747
102 108 OTONG KOMPLEK SITANALA RT 03/ RW 13
103 109 KACUNG BAMBANGRETNO KOMPLEK SITANALA RT 02/ RW 13 082311551454
104 110 ARMAIN KOMPLEK SITANALA RT 01/ RW 13
105 111 ROSIAH KOMPLEK SITANALA RT 04/ RW 13 NO 14
106 112 SURAHMAN KOMPLEK SITANALA RT 01/ RW 13 081221710554
107 113 SUJIMAN KOMPLEK SITANALA RT 01/ RW 13
108 114 TAUFIK KOMPLEK SITANALA RT 01/ RW 13 081289090807/ 083813211065
109 115 MARDIANA KOMPLEK SITANALA RT 01/ RW 13 083813211065
110 116 MIAN KOMPLEK SITANALA RT 01/ RW 13 085312141476
111 117 CATA KOMPLEK SITANALA RT 01/ RW 13 085714221126
112 118 DAKMIN KOMPLEK SITANALA RT 01/ RW 13 083878382450
113 119 IDEH KOMPLEK SITANALA RT 01/ RW 13
114 120 MUNAWAROH KOMPLEK SITANALA RT 01/ RW 13 LORONG 3
115 121 MARYAM KOMPLEK SITANALA LORONG 9 NO 108 082110312726
116 122 ANININGSIH KOMPLEK SERBAGUNA RT 01/013
117 123 ASMADI KOMPLEK SERBAGUNA RT 02/013 081399844209
118 124 HIKMAH KOMPLEK SITANALA RT 01/ RW 013 081293500390
119 125 MUNAWIR KOMPLEK SERBAGUNA RT 003/RW 013 087808475375
120 126 HARTINI KOMPLEK SITANALA
121 127 TONI SILALAHI KOMPLEK SERBAGUNA RT 003/ RW 013 081291663114
122 128 SEHADI KOMPLEK SERBAGUNA RT 01
123 129 AMIR KOMPLEK SERBAGUNA RT 03/13
124 130 WARDI KOMPLEK SITANALA RT 003/013
125 131 AMIN KOMPLEK SERBAGUNA RT 05/RW 13 LORONG 9
126 132 DAENG MATAJANG KOMPLEK SERBAGUNA SITANALA RT 03/ RW 013 089604229925
127 133 SOMA KOMPLEK SITANALA RT 01/ RW 013
128 134 M. SLAMET SUPRIYADI KOMPLEK SERBAGUNA RT 003/RW 013 081210936130
129 135 MASTUROH KOMPLEK SERBAGUNA RT 003/RW 013
130 136 SUSANTO KOMPLEK SERBAGUNA RT 003/RW 013 082211724008
131 137 LUKMAN SUMANTI KOMPLEK SERBAGUNA SITANALA RT 02/RW013 081282796080
132 138 AGUS BADARUDIN KOMPLEK SERBAGUNA SITANALA RT 03/RW 013
133 139 YAS SITANALA LORONG 10 RT 05/ RW 13
134 140 JOSEPH SIRBOLON KOMPLEK SITANALA LORONG 5 RT 02/RW 013 081270227654
135 141 ANA SITANALA RT 03/ RW 013
136 142 SITI SALBIAH KOMPLEK SERBAGUNA SITANALA RT 05/ RW 013
137 143 ABDUL SUKUR KOMPLEK SITANALA RT 04/ RW 013
138 144 ANITI KOMPLEK SITANALA RT 05/ RW 013
139 145 NADIN KOMPLEK SITANALA RT 05/ RW 013
140 146 PROSI KUSUMAWATI KOMPLEK SERBAGUNA RT 03/RW013
141 147 RINA KOMPLEK SITANALA RT 05/ RW 013 81384085285
142 148 ITA MUNJAITA KOMPLEK SERBAGUNA SITANALA RT 03/ RW 013 02155791403
143 149 SIDUP KOMPLEK SITANALA RT 05/RW 013 081290406768
144 150 SURYATI KOMPLEK SERBAGUNA SITANALA RT 05/ RW 013 NO 4
145 151 SUTARJO KOMPLEK SERBAGUNA RT 03/ RW 013 085773408572
146 152 JUARI ISMAIL KOMPLEK SITANALA RT 04/ RW 013
147 153 YATMI KOMPLEK SERBAGUNA RT 03/ RW 013 085773408572
148 154 MA'AH KOMPLEK SERBAGUNA RT 03/ RW 013 083893157048
149 155 NASRULLAH KOMPLEK SERBAGUNA SITANALA RT05/RW013
150 156 D. EFFENDI KOMPLEK SERBAGUNA SITANALA RT 04/RW 013 081381625133
151 157 MUHAMAD KOMPLEK SERBAGUNA RT 03/ RW 013
152 158 MONZILA KOMPLEK SEBAGUNA SITANALA RT 03/RW 013 0818906010339
153 159 BUSIRIH H KOMPLEK SERBAGUNA RT 003/ RW 013 085817441671
154 160 MIAN KOMPLEK SERBAGUNA RT 02/RW013
155 161 KADIR KOMPLEK SERBAGUNA RT 02/RW 013
156 162 USIN KOMPLEK SITANALA RT 03/RW013
157 163 WINAL KOMPLEK SERBAGUNA RT 03/RW013
158 164 JAMIUN KOMPLEK SERBAGUNA LORONG 7 RT 06/RW 013
159 165 AMAN KOMPLEK SITANALA LORONG 9 RT 03/RW013
160 166 LAPADUAI KOMPLEK SITANALA RT 05/ RW 013
161 167 SULHI PRASISTYAN KOMPLEK SERBAGUNA RT 02/ RW 013 081340335338
162 168 MAKKA KOMPLEK SERBAGUNA SITANALA RT 04/ RW 013 081287222141
163 169 SAROH KOMPLEK SERBAGUNA RT 03/ RW 013
164 170 AGUS MITE KOMPLEK SERBAGUNA LORONG 5 RT 02/ RW 013
165 171 UDIN BURHANUDIN KOMPLEK SITANALA RT 04/013
166 172 SAHRIM KOMPLEK SERBAGUNA SITANALA
167 173 YOHADI KOMPLEK SERBAGUNA SITANALA RT 04/013
168 174 UDIN KOSENG KOMPLEK SERBAGUNA SITANALA RT 03/013
169 175 EMAT KOMPLEK SERBAGUNA SITANALA RT 03/013
170 176 SYAMSUDIN KOMPLEK SITANALA LORONG 8 RT 01/013 085280094504
171 177 NURSEN KOMPLEK SERBAGUNA SITANALA RT 01/013 081340335480
172 178 WARSINAH KOMPLEK SERBAGUNA SITANALA RT 04/013
173 179 MARTONO KOMPLEK SERBAGUNA LORONG 5 SITANALA RT 06/013
174 180 BUDI KOMPLEK SERBAGUNA SITANALA RT 04/013
175 181 BASOR KOMPLEK SERBAGUNA SITANALA RT 01/013 081380881562
176 182 SADIN KOMPLEK SITANALA RT 03/013
177 183 ABU BAKAR KOMPLEK SERBAGUNA SITANALA RT 04/013
178 184 DARUN KOMPLEK SERBAGUNA SITANALA
179 185 IDA FARIDA KOMPLEK SITANALA RT 02/013 081218223277
180 186 NAMAN KOMPLEK SITANALA RT 01/013
181 187 YOSWA SUMINTO KOMPLEK SERBAGUNA SRT 02/013 081287859164
182 188 WALIM KOMPEK SERBAGUNA SITANALA RT 02/013 085772214873
183 190 MARIA KOMPLEK SERBAGUNA SITANALA LORONG 5
184 191 ANTONIUS KOMPLEK SITANALA
185 192 CUNSAN KOMPLEK SERBAGUNA RT 02/013
186 193 CECE KOMPLEK SITANALA LORONG 9 RT 03/013
187 194 NURAINI KOMPLEK SITANALA RT 03/013 081289098707
188 195 KOKOM KOMPLEK SERBAGUNA SITANALA RT 03/013
189 196 ZULAMIN KOMPLEK SERBAGUNA SITANALA RT 04/013
190 197 ABDUL WAHAB KOMPLEK SERBAGUNA RT 03/013
191 198 ANIK KOMPLEK SITANALA RT 02/RW 013
192 199 SITI AISAH KOMPLEK SERBAGUNA RT 03/013 085285362020
193 200 HERI SETIAWAN KOMPLEK SITANALA RT 05/013
194 201 NINING DAHLIA KOMPLEK SITANALA RT 05/013
195 202 IYANG KOSASIH KOMPLEK SITANALA RT 03/013
196 203 FERI LEWANDATU KOMPLEK SERBAGUNA RT 04/013 081277431128
197 204 NURLAELA KOMPLEK SERBAGUNA SITANALA RT 04/013
198 205 AMINAH KOMPLEK SERBAGUNA LORONG 7, RT 03/013
199 206 ADE KRISTINA KOMPLEK SERBAGUNA SITANALA RT 03/013
200 207 KHOLIFAH KOMPLEK SERBAGUNA SITANALA RT 03/013
201 208 MININ KOMPLEK SERBAGUNA SITANALA RW 03/013 085945775806
202 209 PIO KOMPLEK SITANALA RT 03/013
203 210 SUWITO KOMPLEK SERBAGUNA SITANALA RT 03/013
204 211 NUR SAPTADDY KOMPLEK SERBAGUNA SITANALA RT 01/013
205 212 KUSNAMI DEWI KOMPLEK SERBAGUNA SITANALA RT 01/013
206 213 WARHUDI KOMPLEK SERBAGUNA SITANALA RT 03/013 081906010339
207 214 SUBAGYO KOMPLEK SERBAGUNA SITANALA RT 01/013
208 215 SUGONO KOMPLEK SERBAGUNA SITANALA RT 01/013
209 216 SITI ASIYAH KOMPLEK SERBAGUNA SITANALA RT 02/013 085891168928
210 217 ACEM KOMPLEK SERBAGUNA SITANALA RT 04/013
211 218 ONYONG KOMPLEK SERBAGUNA SITANALA RT 04/013
212 219 DARSIH KOMPLEK SERBAGUNA SITANALA RT 04/013
213 220 KHADIR KOMPLEK SITANALA RT 01/013
214 221 YOHANES SUPARJI KOMPLEK SITANALA RT 04/013
215 223 SAPRI KOMPLEK SITANALA NO 172, RT 04/013
216 224 ANDRE KOMPLEK SITANALA NO 224 RT 01/013
217 225 MARDIYATI KOMPLEKS SITANALA LORONG II RT 04/013
218 226 SUMAAH KOMPLEK SITANALA RT 03/013
219 227 SING KOMPLEKS SITANALA NO 5 RT 02/013
220 228 WATI KOMPLEK SITANALA RT 05/013
221 229 EEM KOMPLEK SITANALA LORONG 5 RT 02/013 081210895801
222 230 ABDUL BAKAR KOMPLEK SITANALA RT 04/013
223 231 MASWANTO KOMPLEKS SITANALA RT 02/013
224 232 HAMBALI KOMPLEK SITANALA NO 81 RT 03/013 081394703443
225 233 MARYATIN KOMPLEK SERBAGUNA LORONG 9 RT 04/013
226 234 DEDE SISMANA KOMPLEKS SITANALA NO 37 LORONG 8, RT 03/013 081213936601
227 235 GIOK PERMANA KOMPLEK SITANALA NO 19, RT 04/013
228 236 KHOLIL KOMPLEK SITANALA NO 236 RT 02/ RW 013
229 237 DURAHMAN KOMPLEK SERBAGUNA NO 192 RT 04/ RW 013 081210005549
230 238 OBAY KOMPLEK SERBAGUNA SITANALA RT 01/ RW 013 085717444733
231 239 NURLELI SITANALA LORONG 8 RT 03/RW013 081319752566
232 240 LIDYA KOMPLEKS SITANALA NO 52 RT 02/RW013 082139706020
233 241 BAHARUDIN KOMPLEK SERBAGUNA RT 02/RW013
234 242 ANDU KOMPLEK SERBAGUNA RT 02/RW013
235 243 TAJUDIN KOMPLEK SITANALA RT 001/ RW 013
236 244 AHMAD TOLIBIN KOMPLEKS SITANALA NO 147 RT 01/ RW 013
237 245 ENENG ROHAYAH KOMPLEK SITANALA 0857777191898
238 246 DUDUNG ABDURAHMAN KOMPLEK SERBAGUNA RT 02/ RW 013 081380336019
239 247 SUEB KOMPLEKS SERBAGUNA RT 02/ RW 013
240 248 DARI KOMPLEKS SITANALA RT 01/ RW 01
241 249 MUCHTAR KOMPLEKS SERBAGUNA NO 27 RT 03/ RW 013
242 250 KOSIM KOMPLEK SERBAGUNA RT 04/ RW 013
243 251 AHMAD SUDARTO KOMPLEK SITANALA RT 01/ RW 013 081286729199
244 252 SOPIAH KOMPLEKS SITANALA LORONG 6 RT 02/ RW 013
245 253 MARULLOH KOMPLEKS SITANALA NO 35 RT 04/RW 013
246 254 SALIM KOMPLEKS SITANALA RT 05/RW013
247 255 UMANG KOMPLEKS SITANALA LORONG 9 RT 04/ RW 013 081210005547
248 256 CARITEM KOMPLEKS SERBAGUNA RT 04/ RW 13 082297654426
249 257 MUH. ABADI KOMPLEKS SITANALA NO 171 RT 02/RW13 081291657771
250 258 SUBAKAR DKI RT 05/013
251 259 SARTINI KOMPLEK SERBAGUNA LORONG 8 RT 03/RW13 081315761730
252 260 SUNU KOMPLEK SITANALA NO 5 RT 02/ RW 13 081298856143
253 261 KOMARUDIN KOMPLEK SERBAGUNA RT 03/RW13
254 262 RUNDA KOMPLEK SITANALA RT 01/RW 13
255 263 ASMANAH KOMPLEK SITANALA NO 88 RT 03/RW 13
256 264 HESTI KOMPLEK BULAK NO 27 RT 05/RW13
257 265 MANSYUR KOMPLEK SITANALA RT 05/RW 13

JUMLAH YANG DI RULE OUT : 3

NO STATUS : 037, 038, 107
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1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 09/02/1968
1 1 1 0 1 23/04/2018 10/04/1973
1 1 1 0 1 23/04/2018 02/05/1975
1 1 1 0 1 23/04/2018 19/02/1959
1 1 1 0 1 23/04/2018 19/11/1974
1 1 1 0 1 23/04/2018 26/04/1979
1 1 1 0 1 23/04/2018 LUPA
1 1 1 0 1 23/04/2018 31/06/1956
1 1 1 0 1 23/04/2018 01/01/1957
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 08/08/1960
1 1 1 0 1 23/04/2018 15/01/1971
1 1 1 0 1 23/04/2018 10/11/1964
1 1 1 0 1 23/04/2018 18/05/1950
1 1 1 0 1 23/04/2018 18/07/1984
1 1 1 0 1 23/04/2018 1972
1 1 1 0 1 23/04/2018 1973
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 1961
1 1 1 0 1 23/04/2018 02/02/1969
1 1 1 0 1 23/04/2018 1956
1 1 1 0 1 23/04/2018 05/05/1979
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 1960
1 1 1 0 1 23/04/2018 1977
1 1 1 0 1 23/04/2018 1956
1 1 1 0 1 23/04/2018 05/05/1963
0 1 1 0 1 23/04/2018 1969
1 1 1 0 1 23/04/2018 08/08/1968
1 1 1 0 1 23/04/2018 1974
1 1 1 0 1 23/04/2018 1969
1 1 1 0 1 23/04/2018 08/09/1954
1 1 1 0 1 23/04/2018 1952
1 1 1 0 1 23/04/2018 16/09/1983
1 1 1 0 1 23/04/2018 04/01/1956
1 1 1 0 1 23/04/2018 1971
1 1 1 0 1 23/04/2018 27/03/1972
0 1 1 0 1 23/04/2018 15/06/1975
1 1 1 0 1 23/04/2018 13/03/1967
1 1 1 0 1 23/04/2018 27/02/1953
1 1 1 0 1 23/04/2018 1969
1 1 1 0 1 23/04/2018 14/03/1980
1 1 1 0 1 23/04/2018 04/07/1965
1 1 1 1 1 23/04/2018 10/06/1956
1 1 1 0 1 23/04/2018 1963
1 1 1 0 1 23/04/2018 1973
1 1 1 0 1 23/04/2018 1976
1 1 1 0 1 23/04/2018 12/08/1973
1 1 1 0 1 23/04/2018 21/01/1977
1 1 1 0 1 23/04/2018 1978
1 1 1 0 1 23/04/2018 16/09/1954
1 1 1 0 1 23/04/2018 1978
1 1 1 0 1 23/04/2018 1982
1 1 1 0 1 23/04/2018 05/05/1983
1 1 1 0 1 23/04/2018 1954
1 1 1 0 1 23/04/2018 1955
1 1 1 0 1 23/04/2018 03/06/1949
1 1 1 0 1 23/04/2018 1950
1 1 1 0 1 23/04/2018 08/02/1978
1 1 1 0 1 23/04/2018 16/09/1976
1 1 1 0 1 23/04/2018 1940
1 1 1 0 1 23/04/2018 08/08/1974
1 1 1 0 1 23/04/2018 05/05/1965
1 1 1 0 1 23/04/2018 15/02/1973
1 1 1 0 1 23/04/2018 1956
1 1 1 0 1 23/04/2018 10/10/1959
1 1 1 0 1 23/04/2018 1939
1 1 1 0 1 23/04/2018 02/06/1969
1 1 1 0 1 23/04/2018 14/07/1966
1 1 1 0 1 23/04/2018 29/05/1948
1 1 1 0 1 23/04/2018 01/03/1967
1 1 1 0 1 23/04/2018 24/06/1966
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 1961
1 1 1 0 1 23/04/2018 01/09/1977
1 1 1 0 1 23/04/2018 14/12/1965
1 1 1 0 1 23/04/2018 24/08/1973
1 1 1 1 1 23/04/2018 1966
1 1 1 0 1 23/04/2018 1977
1 1 1 0 1 23/04/2018 1959
1 1 1 0 1 23/04/2018 1962
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 13/12/1972
1 1 1 0 1 23/04/2018 1959
1 1 1 0 1 23/04/2018 20/05/1966
1 1 1 0 1 23/04/2018 01/01/1959
1 1 1 0 1 23/04/2018 1968
1 1 1 0 1 23/04/2018 1974
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 04/09/1972
1 1 1 0 1 23/04/2018
1 1 1 0 1 23/04/2018 1973
1 1 1 0 1 23/04/2018 06/06/1972
1 1 1 0 1 23/04/2018 30/04/1979
1 1 1 0 1 23/04/2018 1964
1 1 1 0 1 23/04/2018 10/06/1976
1 1 1 0 1 23/04/2018 05/05/1974
1 1 1 0 1 23/04/2018 1971
1 1 1 0 1 23/04/2018 15/03/1978
1 1 1 0 1 23/04/2018 1974
1 1 1 0 1 23/04/2018 01/07/1984
1 1 1 0 1 23/04/2018 05/07/1961
1 1 1 0 1 23/04/2018 1988
1 1 1 0 1 23/04/2018 1978
1 1 1 0 1 23/04/2018 05/04/1957
0 1 1 1 2 24/04/2018 05/12/1971
1 1 1 0 2 24/04/2018 12/03/1963
1 1 1 0 2 24/04/2018 27/08/1975
1 1 1 0 2 24/04/2018 17/06/1959
1 1 1 0 2 24/04/2018 tidak tau
1 1 1 0 2 24/04/2018 30/01/1981
1 1 1 0 2 24/04/2018 01/01/1962
0 1 1 0 2 24/04/2018 19/06/1954
1 1 1 0 2 24/04/2018 19/02/1967
0 1 1 0 2 24/04/2018 01/02/1958
1 1 1 0 2 24/04/2018 11/07/1945
1 1 1 0 2 24/04/2018 10/02/1966
1 1 1 0 2 24/04/2018 11/11/1969
1 1 1 0 2 24/04/2018 tidak tau
1 1 1 0 2 24/04/2018 01/06/1962
1 1 1 0 2 24/04/2018 05/03/1963
1 1 1 0 2 24/04/2018 15/02/1963
1 1 1 0 2 24/04/2018 1972
1 1 1 0 2 24/04/2018 15/07/1944
1 1 1 0 2 24/04/2018 07/02/1975
1 1 1 0 2 24/04/2018 01/01/1953
1 1 1 0 2 24/04/2018 05/01/1951
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 18/03/1979
1 1 1 0 2 24/04/2018 18/06/1986
0 1 1 0 2 24/04/2018 29/07/1974
1 1 1 0 2 24/04/2018 9/11/1952
1 1 1 0 2 24/04/2018 19/10/1950
1 1 1 0 2 24/04/2018 04/04/1961
1 1 1 0 2 24/04/2018 01/11/1964
1 1 1 0 2 24/04/2018 06/03/1948
0 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 00/12/1949
1 1 1 0 2 24/04/2018 23/11/1968
0 1 1 0 2 24/04/2018 05/02/1959
1 1 1 0 2 24/04/2018 18/10/1960
1 1 1 0 2 24/04/2018 22/06/1965
0 1 1 0 2 24/04/2018 12/08/1960
1 1 1 0 2 24/04/2018 00/00/1963
1 1 1 0 2 24/04/2018 00/08/1954
1 1 1 0 2 24/04/2018 00/11/1954
0 1 1 0 2 24/04/2018 03/05/1957
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 00/00/1942
1 1 1 0 2 24/04/2018 03/06/1947
1 1 1 0 2 24/04/2018 19/06/1968
1 1 1 0 2 24/04/2018 05/09/1959
0 1 1 0 2 24/04/2018
0 1 1 0 2 24/04/2018 02/07/1949
1 1 1 0 2 24/04/2018 18/11/1968
1 1 1 0 2 24/04/2018 1962
1 1 1 0 2 24/04/2018 1962
1 1 1 0 2 24/04/2018 08/08/1952
1 1 1 0 2 24/04/2018 12/12/1978
1 1 1 0 2 24/04/2018 1960
1 1 1 0 2 24/04/2018 1950
1 1 1 0 2 24/04/2018 02/02/1952
1 1 1 0 2 24/04/2018 1965
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 10/02/1973
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 24/10/1957
1 1 1 0 2 24/04/2018 01/10/1957
0 1 1 0 2 24/04/2018 12/07/1978
1 1 1 0 2 24/04/2018 1958
1 1 1 0 2 24/04/2018 23/10/1952
1 1 1 0 2 24/04/2018 1959
0 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 13/07/1936
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 03/04/1973
1 1 1 0 2 24/04/2018 23/08/1970
1 1 1 0 2 24/04/2018 20/11/1964
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 23/12/1943
0 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 03/04/1975
1 1 1 0 2 24/04/2018 1968
1 1 1 0 2 24/04/2018 23/07/1973
1 1 1 0 2 24/04/2018 30/05/1965
1 1 1 0 2 24/04/2018 27/10/1973
1 1 1 0 2 24/04/2018 1959
1 1 1 0 2 24/04/2018
0 1 1 0 2 24/04/2018 19/01/1979
1 1 1 0 2 24/04/2018 20/10/1969
1 1 1 0 2 24/04/2018 09/03/1965
1 1 1 0 2 24/04/2018 10/10/1961
1 1 1 0 2 24/04/2018 18/12/1982
1 1 1 0 2 24/04/2018 03/02/1972
1 1 1 0 2 24/04/2018 04/04/1985
1 1 1 0 2 24/04/2018 1980
1 1 1 0 2 24/04/2018 1964
1 1 1 0 2 24/04/2018 1966
0 1 1 0 2 24/04/2018 15/04/1974
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 25/12/1946
1 1 1 0 2 24/04/2018 03/06/1964
1 1 1 0 2 24/04/2018 1950
1 1 1 0 2 24/04/2018 01/01/1944
0 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 18/04/1959
1 1 1 0 2 24/04/2018 08/10/1966
1 1 1 0 2 24/04/2018 11/11/1953
0 1 1 0 2 24/04/2018 1972
1 1 1 0 2 24/04/2018 1965
1 1 1 0 2 24/04/2018 31/05/1972
0 1 1 0 2 24/04/2018 08/01/1966
1 1 1 0 2 24/04/2018 1939
1 1 1 0 2 24/04/2018 05/10/1976
1 1 1 0 2 24/04/2018 09/1949
1 1 1 0 2 24/04/2018 05/10/1959
1 1 1 0 2 24/04/2018 14/01/1968
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 24/06/1946
1 1 1 0 2 24/04/2018 05/01/1991
1 1 1 0 2 24/04/2018 15/04/1968
1 1 1 0 2 24/04/2018 15/09/1952
1 1 1 0 2 24/04/2018 06/08/1954
1 1 1 0 2 24/04/2018 10/12/1962
1 1 1 0 2 24/04/2018 12/01/1970
1 1 1 0 2 24/04/2018 03/05/1971
1 1 1 0 2 24/04/2018 08/04/1975
1 1 1 0 2 24/04/2018 31/12/1958
0 1 1 0 2 24/04/2018 05/11/1957
1 1 1 0 2 24/04/2018 25/07/1945
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 17/08/1962
1 1 1 0 2 24/04/2018 17/10/1980
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 02/12/1958
1 1 1 0 2 24/04/2018
1 1 1 0 2 24/04/2018 1966
1 1 1 0 2 24/04/2018 18/08/1967
1 1 1 0 2 24/04/2018 1949
0 1 1 0 2 24/04/2018 17/07/1965
1 1 1 0 2 24/04/2018 26/06/1963
1 1 1 0 2 24/04/2018 31/12/1960
1 1 1 0 2 24/04/2018 1960
0 1 1 0 2 24/04/2018 24/12/1963
0 1 1 0 2 24/04/2018 09/10/1972
1 1 1 0 2 24/04/2018 1957
 DEMOGRAFI
PEKERJAAN UTAMA
USIA JENIS KELAMIN PENGHASILAN/BLN TINGKAT PENDIDIKAN
KETERANGA
KODE N
65 2 6 4 1
64 1 PENDORONG
99 MAKANAN KE BANGSAL KUSTA
1 2
55 1 10 1 1
65 2 6 1 2
65 6 1 1 1
50 2 6 1 1
40 2 6 1 2
2 6 4 1
50 2 99 GURU 4 3
45 2 6 1 1
43 2 6 1 2
59 1 10 1 2
43 2 6 1 1
39 2 6 1 3
2 99 PEDAGANG 2 1
61 1 99 TUKANG SAPU 1 1
61 1 99 CLEANING SERVICE 1 1
55 2 6 1 1
55 1 10 1 1
57 1 99 TUKANG SAPU 2 2
47 1 99 PEMULUNG 1 3
53 1 99 PETUGAS KEBERSIHAN 3 4
68 1 10 4 2
1 2
33 2 6 4 1
46 2 6 1 2
45 1 99 PETUGAS KEBERSIHAN 1 1
50 2 99 PEDAGANG 1 2
57 2 6 1 1
49 2 99 PEDAGANG 1 1
62 1 99 CLEANING SERVICE 1 2
39 2 6 1 1
34 1 2 4 4
58 2 10 1 2
41 1 2 1 1
62 1 99 cleaning service 4 2
55 2 6 4 1
49 1 10 1 2
49 2 99 cleaning service 2 3
44 1 99 cleaning service 1 1
49 2 6 4 4
63 1 10 1 1
66 1 2 1 4
34 1 99 cleaning service 1 2
62 1 99 cleaning service 1 2
47 1 99 cleaning service 1 4
46 2 6 4 2
42 1 99 PEMULUNG 2 4
51 1 99 WIRASWASTA 1 4
65 1 99 CLEANING SERVICE 1 1
49 2 6 2 2
38 2 6 1 1
52 2 6 1 3
61 1 99 SERABUTAN 1 2
55 2 6 1 1
45 2 6 1 1
42 2 6 2 1
44 2 99 TUKANG SAPU 1 2
41 1 99 CLEANING SERVICE 1 2
40 1 2 1 4
63 1 10 1 1
40 1 10 2 1
36 1 99 PETUGAS KEBERSIHAN 2 2
35 2 6 4 1
64 2 6 4 1
63 1 10 1 3
68 1 99 WIRASWASTA 1 1
68 1 10 2 1
40 2 99 TUKANG SAPU 1 2
42 1 2 1 2
78 1 10 2 1
43 1 99 SUPIR 4 3
53 1 10 3 1
45 2 99 TUKANG SAPU JALAN 1 1
62 2 99 TUKANG SAPU JALAN 1 1
58 2 6 1 1
79 1 99 PETANI 4 3
48 1 99TUKANG CUKUR RAMBUT 1 1
51 2 6 4 2
70 1 10 4 1
51 2 6 1 2
51 1 99 PEDAGANG 2 1
 2 99 TIM KEBERSIHAN PEMDA 4 1
57 1 10 1 2
40 1 2 1 4
52 2 6 4 3
44 2 6 1 1
52 1 10 1 1
41 2 6 1 1
59 1 99 PETANI 4 1
56 1 10 4 1
2 6 4 2
45 2 6 1 1
59 1 99 TUKANG SAMPAH 1 1
52 1 2 4 2
59 1 99 PEMBANTU 1 1
50 2 99 PEDAGANG 1 2
44 2 99 CLEANING SERVICE 1 2
2 6 1 2
45 2 99 CLEANING SERVICE 1 4
1 99 TUKANG PARKIR 1 1
45 1 99 CLEANING SERVICE 1 4
45 1 99 SUPIR ANGKOT 2 2
39 1 TUKANG
99 KEBERSIHAN JALANAN 1 1
54 2 99 TUKANG SAPU 1 4
41 1 99 CLEANING SERVICE 2 1
44 1 99 CLEANING SERVICE 1 2
47 1 10 4 4
40 2 99 WIRASWASTA 1 2
44 1 99 CLEANING SERVICE 4 2
33 1 99 PETANI 1 1
56 1 99 KARYAWAN SWASTA 2 1
30 2 6 1 1
40 2 6 2 1
61 2 6 4 3
46 2 6 1 2
55 1 99 WIRASWASTA 1 4
42 2 99 PEDAGANG 1 1
58 1 99 PENJAHIT 2 1
- 2 99 MENYAPU JALAN 1 1
37 1 99 ANTAR JEMPUT SEKOLAH 1 1
56 1 10 1 2
63 1 4 1 4
51 1 2 4 1
60 1 10 1 1
72 2 10 2 2
52 1 3 2 4
48 1 99 MENYAPU JALAN 4 1
2 10 1 2
55 1 99 TUKANG BECAK 4 1
55 1 2 1 1
55 1 99 PEDAGANG 4 1
46 1 10 4 1
73 1 10 1 1
43 2 6 1 1
65 2 6 1 2
67 1 99 WIRASWASTA 2 2
37 2 99 PENYAPU JALAN 3 1
39 1 99 BURUH SAPU JALANAN 2 2
31 2 6 4 2
43 2 6 4 2
65 2 6 1 1
67 1 10 4 1
57 2 6 1 1
53 1 10 1 4
70 1 10 2 1
2 99 SAPU JALANAN 1 1
68 2 6 1 3
49 1 2 4 3
59 1 4 1 1
57 1 99 PENJAHIT KONVEKSI 1 1
53 2 6 3 1
57 1 99 KEBERSIHAN 2 1
55 1 99 DINAS KEBERSIHAN 1 2
63 1 99 SUPIR ANGKOT 1 2
63 1 10 4 1
61 2 6 1 1
60 1 99 TUKANG BECAK 4 1
76 1 99 PENGEMIS 1 1
70 1 99 NARIK BECAK 1 4
49 1 4 1 1
58 1 99 BURUH MEBEL 4 1
2 6 4 3
68 1 10 1 3
49 1 99 PEMULUNG 1 2
56 1 10 1 3
56 1 99 PENJAGA SEKOLAH 1 1
65 1 10 1 1
39 1 99 CLEANING SERVICE 1 2
58 1 10 1 2
68 1 2 4 1
66 2 6 1 1
53 1 10 1 1
1 10 4 1
45 1 99 SERABUTAN 4 2
1 99 PEMBANTU RUMAH 1 1
60 1 2 1 2
60 1 99 TUKANG BECAK 4 1
39 2 6 1 1
60 1 10 1 3
65 1 4 1 2
59 1 10 4 1
2 6 1 1
81 1 2 1 1
1 99 PENJAHIT 1 1
45 1 6 1 1
47 2 6 1 1
53 2 6 1 1
1 10 1 3
74 1 10 4 1
60 2 6 4 2
43 2 6 1 2
50 1 2 4 2
44 2 6 1 2
53 1 10 2 4
44 1 4 1 2
59 2 6 1 1
47 2 6 4 1
39 2 6 2 2
48 2 99 PENJAHIT 2 3
53 1 99DINAS LINGKUNGAN HIDUP 1 2
56 1 99 2 4
35 1 99 CLEANING SERVICE 1 1
43 1 99 CLEANING SERVICE 1 2
33 2 6 1 2
38 1 99 TUKANG BECAK 2 4
54 1 99 KARYAWAN 1 2
52 1 99 TUKANG BECAK 4 3
44 2 6 1 1
71 2 10 1 1
71 1 10 1 2
54 2 6 2 1
1 99 PEDAGANG 1 2
74 1 10 4 2
1 99 TUKANG PARKIR 1 2
59 1 10 1 2
2 6 1 2
2 10 4 1
1 99 SERABUTAN 1 2
2 6 2 1
2 6 4 2
1 10 4 1
1 10 1 2
1 99 SUPIR ANGKOT 1 1
2 10 1 4
1 10 2 3
1 99 TUKANG SAPU 1 1
 1 99 CLEANING SERVICE 1 2
1 10 1 1
1 8 1 4
2 6 4 2
2 6 1 1
1 10 2 1
1 99 TUKANG SAPU 2 2
1 99 TUKANG PARKIR 1 4
1 8 2 2
2 6 1 3
1 10 4 1
1 99 1 1
2 6 1 1
2 4
1 99 DINAS KEBERSIHAN 1 3
1 99 TUKANG SAPU 1 4
2 99 PEDAGANG 1 2
1 99 4 2
1 8 4 1
70 1 10 2 2
52 2 6 2 1
1 99 WIRASWASTA 4 1
69 1 99 TUKANG SAPU 1 2
2 6 2 2
1 10 1 2
1 10 4 1
58 1 99 PEMULUNG 4 1
2 6 1 1
2 6 4 1
61 1 10 1 1
 UCVA SNEL
JUMLAH ORANG TINGGAL JUMLAH PENDERITA KUSTA
STATUS PERNIKAHAN SUKU (DARI AYAH) SERUMAH SERUMAH
OD
2 4 4 1 6/30
2 4 3 1 6/30
2 2 4 3 6/30
2 2 4 3 6/30
2 2 4 3 6/20
2 2 4 3 6/20
2 1 4 3 6/6
2 2 1 1 6/30
2 4 3 2 6/15
2 4 4 3 6/15
2 2 4 3 6/15
2 2 4 1 6/30
2 2 4 3 6/9
3 2 4 2 6/9
2 1 4 2 6/9
2 1 1 5 6/15
2 4 4 3 6/15
3 2 4 2 1/60
2 1 4 2 6/15
2 4 4 1 6/9
2 4 4 1 6/9
2 4 4 2 6/15
2 2 3 1 6/60
2 1 4 3 6/15
2 1 4 1 6/6
2 6 3 1 6/15
2 1 4 3 6/9
2 2 4 1 6/9
2 1 4 3 6/9
2 2 3 3 6/9
2 8 3 3 6/15
3 2 1 2 6/20
2 4 4 2 6/15
2 2 3 3 6/15
3 2 2 2 6/6
2 2 4 2 6/15
2 2 4 4 6/15
2 2 2 2 6/20
2 2 4 3 6/9
3 4 3 2 6/9
2 2 4 2 6/9
3 2 1 2 1/300
2 2 4 3 6/30
2 8 (MENADO) 4 2 6/6
2 4 3 3 3/60
2 2 3 3 6/9
2 1 4 2 6/30
2 8 (BATAK) 3 2 6/15
2 1 4 3 6/30
2 2 4 4 6/15
2 2 4 3 6/9
3 2 4 2 6/9
2 4 1 2 6/9
2 2 4 3 6/20
2 1 4 3 6/15
3 4 4 2 6/15
3 1 4 2 ANOFTHALMIA
2 2 4 3 1/-
2 1 4 2 6/15
2 1 3 3 6/6
1 1 1 2 1/60
2 1 4 3 6/9
2 4 4 3 6/6
2 4 3 3 6/9
1 6 1 2 6/20
2 1 4 3 6/30
2 2 4 2 4/300
2 2 4 2 1/300
2 2 4 2 6/20
3 2 4 2 6/9
2 2 4 2 1/-
2 4 3 3 6/9
3 4 4 2 NLP
2 4 3 3 ANOFTALMIA
2 1 4 3 6/30
2 2 3 3 6/20
1 1 1 2 6/30
2 2 4 3 6/9
2 1 1 2 6/60
2 4 2 2 6/15
2 1 4 3 6/15
2 2 4 3 6/9
2 4 3 2 6/9
2 1 4 4 6/15
2 1 4 3 6/15
2 2 4 3 6/9
2 6 4 2 6/15
2 8 (PALEMBANG) 4 3 6/30
2 1 3 2 6/9
3 4 3 3 6/15
2 2 4 3 6/15
2 1 4 2 6/15
2 2 3 2 6/9
2 2 4 2 6/9
3 1 1 2 6/15
2 1 4 3 6/15
3 2 3 2 6/15
2 1 4 2 6/9
2 2 4 3 6/9
4 2 1 2 6/9
2 2 4 3 6/30
2 1 4 2 1/60
2 1 4 2 6/6
2 2 4 2 6/9
2 2 1 2 6/15
4 2 4 3 1/60
2 4 4 3 6/15
2 2 4 3 1/300
2 2 3 2 6/9
3 2 1 2 6/30
2 2 3 3 6/9
2 2 3 3 6/20 (K)
2 2 3 3 6/15 (K)
2 1 4 3 6/15
2 2 4 2 NLP
2 8 4 3 6/30
2 1 4 3 3/60
3 6 1 2 6/9
2 1 4 3 6/20
2 2 3 2 6/15
1 2 4 4 6/9
2 4 2 4 1/300
2 2 3 2 6/15
2 4 4 3 6/9
2 8 4 3 1/60
2 2 3 3
2 1 4 3 6/60
2 4 3 3 6/9
2 2 4 2 6/30
2 4 4 3 6/15
2 8 3 3 6/30
2 1 4 2 6/60
2 8 3 3 4/60
2 8 4 3 6/30
2 4 4 2 6/9
2 1 4 2 6/15
2 1 4 3 6/20
2 4 4 3 1/60
2 4 4 3 6/9
2 2 4 3 3/60
2 1 3 3 6/30
2 4 3 3 6/20
2 2 4 3 6/60
2 1 4 3 6/15
2 1 4 3 1/300
2 2 4 3 6/15
2 4 4 2 6/15
2 4 4 3 6/30
2 4 4 3 6/15
2 8 3 2 6/30
2 4 3 3 6/9
2 6 4 3 1/60
2 2 3 2 6/15
3 4 4 2 6/9
2 2 4 3 6/30
2 4 4 3 LP
2 1 4 3 6/15
2 4 3 2 6/20
2 8 4 2 LP
2 4 2 1 6/15
2 8 2 2 6/15
2 4 4 2 6/15
2 8 4 4 3/60
2 4 4 2 6/15
2 2 4 2 1/300
1 4 4 2 6/20
2 2 4 3 2/300
2 2 4 3 6/9
2 8 4 2 6/6
2 2 4 3 6/9
2 4 3 3 6/60
3 1 3 2 6/15
2 4 4 2 6/15
2 2 4 2 6/15
2 8 (KALIMANTAN) 4 2 6/9
2 4 4 2 6/15
2 2 1 2 2/60
2 2 4 3 6/60
2 4 3 3 6/9
2 1 3 2 2/60
1 2 4 2 6/20
2 1 4 3 6/15
2 8 (FLORES) 4 3 6/20
2 8 (CINA) 4 2 1/60
2 4 4 3 6/30
2 4 3 3 LP
3 4 3 2 6/30
2 2 2 2 6/15
2 8 (PALEMBANG) 4 3 2/60
2 2 1 2 6/20
2 2 4 2 1/60
2 2 4 3 6/6
2 2 4 3 6/20
2 2 4 3 2/60
2 8 (MANADO) 3 3 6/9
2 4 3 2 6/9
3 2 4 2 6/9
2 2 4 3 6/9
2 1 3 2 6/9
2 4 4 3 6/15
2 1 4 2 6/9
2 1 4 3 6/15
2 1 4 3 6/60
2 2 4 3 6/9
2 2 3 3 6/9
2 1 4 3 6/9
2 1 2 2 6/60
2 4 4 3 6/20
2 8 (AMBON) 3 3 6/9
2 8 (AMBON) 3 3 6/20
2 2 4 3 6/15
2 8 (PADANG) 3 2 6/15
4 1 4 2 6/15
2 2 4 3 2/60
2 4 4 3 3/60
2 1 4 2 6/9
3 1 3 2 6/20
2 2 4 3 6/60
3 4 4 2 6/20
2 2 4 3 6/9
2 2 4 2 6/9
2 2 3 2 6/15
4 2 4 2 6/60
3 1 4 2 6/15
2 2 4 2 6/15
2 4 4 3 6/30
1 1 4 3 6/15
2 1 3 2 1/60
2 2 4 2 6/20
2 8 4 3 6/9
2 8 4 3 6/60
2 8 4 2 6/15
3 8 2 2 6/20
2 2 4 2 4/60
2 1 4 3 6/30
2 2 4 3 6/9
2 4 4 2 6/6
2 4 4 3 6/30
3 4 2 2 6/30
2 5 4 3 6/30
2 1 4 2 6/9
2 4 4 3 6/60
2 2 4 3 6/15
2 2 4 2 6/15
2 4 4 4 6/15
2 1 4 3 6/15
2 8 (SUMATRA) 4 2 6/30
3 1 2 2 6/9
2 1 4 3 6/20
3 1 2 2 6/30
2 2 4 2 1/300
2 1 4 2 6/15
2 1 3 2 6/9
2 4 4 3 2/60
2 8 (BUGIS) 4 2 6/15
2 4 4 3 6/15
2 8 (BUGIS) 4 2 6/30
 PEMERIKSAA
UCVA SNELLEN UPEEK UREFRAKSI A

KLASIFIKASI KLASIFIKASI KLASIFIKASI OD

OS OD OS OD OS
OD OS KEDUA MATA S
2 6/30 2 2 6/18 6/18 5/60 6/60 -0.50
2 6/30 2 2 6/12 6/12 6/30 6/30 +0.50
2 6/30 2 2 6/15 6/15 6/20 6/20 +1.50
2 6/30 2 2 6/18 6/18 6/40 6/30 -0.00
2 6/15 1 1 6/15 6/12 6/60 6/12 +1.50
2 6/9 1 1 6/9 6/7.5 6/15 6/15 +2.25
0 6/9 1 0 6/12 6/7.5
2 6/60 2 2 6/18 1/60 1/60 1/60
1 6/9 1 1 6/6 6/5
1 6/15 1 1 6/18 6/18
1 6/15 1 1 6/18 6/12
2 6/30 2 2 6/12 6/18 6/30 4/60 -1.50
1 6/9 1 1 6/9 6/9
1 6/9 1 1 6/7.5 6/6
1 6/9 1 1 6/7.5 6/9
1 6/15 1 1 6/18 6/15 +0.50
1 6/15 1 1 6/9 6/7.5 6/6 6/6 -0.00
4 1/60 4 4 1/60 1/60 1/60 1/60 -6.50
1 6/15 1 1 6/15 6/24 +2.25
1 6/15 1 1 6/7.5 6/12 +0.50
1 6/15 1 1 6/9 6/15 +0.75
1 6/60 2 1 6/12 6/15 6/30 6/30 +1.50
2 3/60 3 2 3/60 6/48 3/60 5/60 -4.50
1 6/15 1 1 6/18 6/12
0 6/9 1 0 6/4.8 6/5
1 6/15 1 1 6/9.5 6/18 -0.25
1 6/15 1 1 6/9 6/15 +1.50
1 6/15 1 1 6/7.5 6/9
1 6/9 1 1 6/7.5 6/9 6/75 6/10
1 6/9 1 1 6/7.5 6/6
1 6/20 2 1 6/19 6/12 6/20 6/20 +1.50
2 6/20 2 2 6/30 6/48 6/20 6/20 -0.50
1 6/9 1 1 6/9 6/6
1 6/15 1 1 6/12 6/12 -0.75
0 6/6 0 0 6/6 6/6
1 6/60 2 1 6/9 3/60 6/20 4/60 +0.25
1 6/20 2 1 6/24 6/36 6/30 6/30 +3.50
2 6/15 1 1 6/7.5 6/18 6/30 6/10 +0.75
1 6/9 1 1 6/5 6/6
1 6/9 1 1 6/7.5 6/7.5
1 6/6 0 0 6/7.5 6/6 6/6 6/6
4 1/- 4 4 1/60 1/60 1/300 1/300
2 1/- 4 2 6/60 1/60 6/60 1/300
0 6/6 0 0 6/6 6/7.5
3 6/30 2 2 3/60 6/48 3/60 5/60 +4.00
1 6/9 1 1 6/7.5 6/12
2 6/30 2 2 6/30 6/36 6/30 6/30 -1.00
1 6/15 1 1 6/9 6/7.5
2 6/30 2 2 6/7.5 6/6 6/6 6/6 +0.50
1 6/15 1 1 6/7.5 6/6 6/15 6/15
1 6/6 0 0 6/6 6/6
1 6/6 0 0 6/6 6/6
1 1/- 4 1 6/6 1/- 6/6 NLP +0.75
2 6/15 1 1 6/15 6/5 -1.25
1 6/20 2 1 6/24 6/6 5/60 6/20
1 6/15 1 1 6/9.5 6/9.5 6/6 6/6 +0.25
4 1/60 4 4 - 1/60
4 6/30 2 2 1/- 6/15 1/- 6/20 +0.75
1 6/15 1 1 6/6 6/4.8 +1.00
0 6/6 0 0 6/6 6/18
4 6/30 2 2 1/60 6/36 1/60 5/60 -3.75
1 6/9 1 1 6/7.5 6/7.5
0 6/6 0 0 6/6 6/5
1 6/9 1 1 6/12 6/9
2 6/15 1 1 6/30 6/24 6/30 6/20 +2.25
2 6/30 2 2 6/12 6/30 6/40 6/30 +1.75
4 6/20 2 2 3/60 6/15 5/60 6/30
4 1/- 4 4 1/60 1/- 1/300 1/-
2 6/20 2 2 6/24 6/15 6/20 6/30 -1.75
1 6/9 1 1 6/6 6/6
4 2/60 4 4 1/- 6/60 1/- 5/60
1 6/9 1 1 6/9 6/9
4 1/300 4 4 NLP 1/300
4 6/20 2 2 NLP 6/9 NLP 6/6
2 6/15 1 1 3/60 6/15 6/40 6/15 -0.25
2 6/15 1 1 6/24 6/19 6/30 6/20 +2.25
2 NLP 4 2 6/36 NLP 6/40 NLP -0.00
1 6/9 1 1
2 NLP 4 2 1/60 NLP 1/60 NLP +4.25
1 6/60 2 1 6/9.5 3/60 6/40 4/60 -1.25
1 6/9 1 1 6/9 6/7.5 6/6 6/6 -0.50
1 6/15 1 1 6/15 6/12 6/10 6/10 +1.25
1 6/9 1 1 6/9 6/7.5
1 6/15 1 1 6/30 6/20 +3.25
1 6/9 1 1 6/15 6/7.5 6/7.5 6/10 +1.25
1 6/15 1 1 6/9 6/12
1 6/15 1 1 6/12 6/15 6/6 6/6 +0.50
2 6/15 1 1 6/30 6/12 6/40 6/30 +2.75
1 6/15 1 1 6/6 6/7.5
1 6/20 2 1 6/15 6/18 6/15 6/15 +1.50
1 6/15 1 1 6/9 6/12 6/20 6/20 -0.25
1 6/15 1 1 6/9 6/9 6/15 6/15 +1.25
1 6/9 1 1 6/9 6/9
1 6/9 1 1 6/7.5 6/9.5
1 6/20 2 1 6/19 6/30 6/15 6/20 +1.50
1 6/9 1 1 6/12 6/9
1 6/15 1 1 6/15 6/9 -0.50
1 6/9 1 1 6/6 6/7.5
1 6/15 1 1 6/7.5 6/9.5
1 6/15 1 1 6/7.5 6/9
2 6/30 2 2 6/30 6/36 6/40 5/60 +3.50
4 1/60 4 4 1/60 1/60 1/60 1/60 +12.25
0 6/6 0 0 6/6 6/6
1 6/9 1 1 6/7.5 6/7.5
1 6/15 1 1 6/9.5 6/12 +0.25
4 6/9 1 1 1/60 6/9.5 1/60 6/10 +10.25
1 6/15 1 1 6/24 6/12 +1.75
4 NLP 4 4 1/300 NLP
1 6/15 1 1 6/7.5 6/12 +0.50
2 6/20 2 2 6/30 6/18 6/40 6/30 -1.50
1 6/9 1 1 6/7.5 6/15
2 6/30 2 1 6/18 6/19 4/60 5/60 -4.00
1 6/15 1 1 6/12 6/9 +2.00
1 6/15 1 1 6/15 6/15 +1.50
4 6/20 2 2 NLP 6/18 NLP 6/20
2 6/30 2 2 6/48 6/18 6/40 6/40 -2.00
3 6/9 1 1 6/48 6/7.5 4/60 6/15 -2.00
1 6/20 2 1 6/6 6/19 -0.00
2 6/20 2 1 6/24 6/18 6/30 6/20 +2.00
1 6/15 1 1 6/6 6/12
1 6/20 2 1 6/6 6/15 6/6 6/15 -0.25
4 6/15 1 1 1/300 6/12 0.5/60 6/12
1 6/9 1 1 6/9.5 6/12
1 6/9 1 1 6/9 6/7.5
4 1/300 4 4 1/60 1/300

2 2/60 4 2 6/36 3/60 6/60 2/60

1 6/9 1 1 6/6 6/6
2 6/30 2 2 6/20 6/20 6/30 6/30 +3.00
1 6/60 2 1 6/9 3/60 6/15 3/60 +0.75
2 6/20 2 2 6/15 6/15 6/30 6/20 -1.00
2 6/60 2 2 6/60 6/30 5/60 6/60 +4.25
3 4/60 3 3 6/60 3/60 4/60 3/60 -0.25
2 LP 4 2 6/18 LP 6/40 1/300 +0.5
1 6/9 1 1 6/9.5 6/9.5
1 6/15 1 1 6/18 6/12 6/15 6/15 +2.00
2 6/15 1 1 6/24 6/15 6/20 6/15 +6/50
4 6/60 2 2 1/60 6/36 2/60 6/60 -9.75
1 6/9 1 1 6/6 6/12
3 2/60 4 3 3/60 3/60 3/60 3/60 -6.50
2 6/30 2 2 6/19 6/12
2 6/30 2 2 6/15 6/30 6/20 6/30 +0.75
2 6/30 2 2 3/60 6/20 3/60 5/60 -5.25
1 6/15 1 1 6/12 6/9.5
4 6/15 1 1 1/60 6/12 0.5/60 6/75
1 LP 4 1 6/24 LP 6/20 LP +0.50
1 6/15 1 1 6/7.5 6/7.5 +0.50
2 LP 4 2 6/19 LP 6/30 LP -1.75
1 6/15 1 1 6/15 6/24 +3.75
2 6/30 2 2 6/15 6/24 6/15 6/15 +1.25
1 6/15 1 1 6/9 6/9
4 6/15 1 1 1/60 6/9 1/60 6/15
1 6/20 2 1 6/18 6/24 6/20 6/40 +3.00
1 6/9 1 1 6/9 6/7.5
2 6/30 2 2 6/30 6/24 6/30 6/30 -2.50
4 6/60 2 2 LP 6/30 1/300 6/60 +11.75
1 6/15 1 1 6/12 6/12
2 1/60 4 2 6/24 1/60 6/20 1/60 +1.50
4 4/60 3 3 LP 6/60 LP 5/60
1 1/300PB 4 1 6/12 1/300 6/15 1/300 +0.75
1 6/15 1 1 6/9 6/18
1 6/30 2 1 6/7.5 6/24 6/15 6/20 -0.25
3 6/20 2 2 3/60 6/24 3/60 6/30 +0.75
1 6/20 2 1 6/15 6/15 6/15 6/15 -0.50
4 1/300 4 4 1/60 1/60 1/60 05/60
2 6/20 2 2 6/15 6/18 6/20 6/20 +1.75
4 6/20 2 2 1/60 6/7.5 0.5/60 6/15
1 6/9 1 1 6/6 6/9
0 6/6 0 0 6/5 6/5
1 6/9 1 1 6/6 6/7.5
2 6/60 2 2 3/60 3/60 3/60 3/60 -2.75
1 1/300 4 1 6/75 1/60 +0.50
1 3/60 3 1 6/12 3/60
1 6/15 1 1 6/7.5 6/7.5
1 6/9 1 1 6/12 6/12
1 6/15 1 1 6/7.5 6/9
4 6/30 2 2 6/30 6/24 6/60 6/40 -2.25
2 3/60 3 2 6/60 2/60 -5.00
1 6/9 1 1 6/7.5 6/6
4 1/60 4 4 1/60 1/60 -5.00
2 6/15 1 1 6/15 6/12 6/15 6/10 +1.00
1 6/15 1 1 6/24 6/24 6/20 6/20 +1.25
2 1/60 4 2 6/19 6/15 1/300
4 1/60 4 4 3/60 3/60 1/60 1.5/60
2 6/60 2 2 3/60 6/30 5/60 5/60 -0.25
4 6/9 1 1 LP 6/12
2 6/20 2 2 6/18 6/20 6/30 6/30 +3.00
1 6/15 1 1 6/12 6/12
4 2/60 4 4 6/30 6/30 5/60 4/60 -3.50
2 6/60 2 2 6/12 6/24 6/20 6/40 +4.50
4 3/60 3 3 -3.50
0 6/6 0 0 6/6 6/6
2 6/20 2 2 6/18 6/24 6/15 6/20 +1.75
4 LP 4 4 1/60 6/60 LP
1 6/15 1 1 6/9.5 6/15
1 6/9 1 1 6/6 6/6
1 6/9 1 1 6/6 6/6
1 6/9 1 1 6/12 6/6
1 6/9 1 1 6/7.5 6/6
1 6/15 1 1 6/12 6/12 6/10 6/10 +1.00
1 6/6 0 0 6/6 6/6
1 6/15 1 1 6/15 6/18 +2.50
2 6/30 2 2 6/30 6/15 6/60 6/60 -2.50
1 6/9 1 1 6/12 6/7.5
1 6/15 1 1 6/7.5 6/12
1 6/9 1 1 6/6 6/6
2 2/60 4 2 6/36 3/60 5/60 3/60 -2.00
2 4/60 3 2 6/7.5 3/60 6/15 5/60 +1.25
1 6/9 1 1 6/9 6/7.5
2 6/20 2 2 6/24 6/24 5/60 4/60
1 6/15 1 1 6/12 6/15
1 6/15 1 1 6/12 6/9
1 6/15 1 1 6/15 6/24 -0.25
4 1/60 4 4 6/48 1/60 0.5/60 0.5/60
3 3/60 3 2 6/18 6/15 6/60 6/60 -6.25
1 6/15 1 1 6/9 6/12
2 6/20 2 2 6/15 6/12 +2.00
2 6/60 2 2 6/60 6/60 +1.25
2 6/30 2 2 6/24 6/30 6/30 6/40 -0.75
1 6/15 1 1 6/7.5 6/9
1 6/9 1 1 6/9 6/7.5
1 6/15 1 1 6/12 6/6 +1.75
2 6/15 1 1 3/60 6/15 -3.00
1 6/20 2 1 6/12 6/15 6/20 6/30 -1.00
1 6/15 1 1 6/20 6/15 6/20 6/15 +1.50
2 6/15 1 1 6/36 6/18 6/40 6/20 -1.75
1 6/15 1 1 6/12 6/12
4 3/60 3 3 3/60 6/15 2/60 4/60
2 6/20 2 2 6/24 6/12 6/20 6/20 +1.75
1 6/6 0 0 6/9 6/5
2 6/30 2 2 6/48 6/30 6/60 6/20
1 6/9 1 1 6/9 6/7.5
2 6/20 2 2 6/15 6/15 6/15 6/15 +1.50
3 5/60 3 3 3/60 6/30 3/60 6/60 +2.75
2 6/30 2 2 6/18 6/30 6/30 5/60 -2.00
1 6/6 0 0 6/6 6/6
0 6/6 0 0 6/6 6/6
2 6/30 2 2 6/30 6/30 6/60 5/60 +3.50
2 6/15 1 1 3/60 6/19 4/60 6/25 +4.50
2 6/30 2 2 6/30 6/30 6/60 6/60 -0.75
1 6/15 1 1 6/7.5 6/9.5
2 6/30 2 2 3/60 6/20 6/60 6/30 -3.25
1 6/9 1 1 6/6 6/6
1 6/15 1 1 6/9 6/12
1 6/15 1 1 6/7.5 6/6 6/6E 6/6E
1 3/60 3 1 6/9 3/60 6/15 3/60 +0.25
2 6/30 2 2 6/30 6/34 6/40 6/40 -2.50
1 6/9 1 1 6/6 6/7.5
2 6/15 1 1 6/24 6/18 6/20 6/7.5 -1.00
2 6/20 2 2 6/30 6/30 6/30 6/20 +1.00
4 6/30 2 2 1/300 6/15 1/300 6/15 +1.75
1 6/15 1 1 6/9 6/15 +0.25
1 6/9 1 1 6/9 6/9
4 6/30 2 2 3/60 6/24 4/60 6/30
1 6/15 1 1 6/15 6/24 6/15 6/20 +1.75
1 6/9 1 1 6/7.5 6/7.5
2 6/30 2 2 6/30 6/24 6/40 6/30 +0.50
 PEMERIKSAAN VISUS, TIO DAN REFRAKSI
AUTOREF SUBJECTIVE VISUS (TRIAL LENSE)
OD OS OD OS
C A S C A S C A S
-4.75 80 +1.00 -3.75 86 0 -3.50 20 0
-1.75 83 -0.50 -1.00 89 +0,50 -1.00 90 -0.75
-1.50 74 +1.50 -0.75 107 +0.75 -0.75 75 +0.75
-3.50 87 +0.25 -3.25 91 0.00 -3.00 90 0.00
-3.50 88 +4.75 -4.50 163 0.00 -3.00 85 TTK addisi +3.
-1.25 74 +1.50 -1.00 84 +0.75 0 0 +0.75

+14.50 -2.00 156 TTK TTK TTK +13.00

addisi +1.50 addisi +1.50

addisi +1.50 addisi +1.50
-0.75 83 -1.75 -2.25 41 TTK TTK TTK TTK

-2.50 97 +1.00 -2.50 76 addisi +1.50 Addisi +1.50

-0.25 57 -0.00 -0.25 85 Addisi +2.75 Addisi +2.75
-1.00 59 TDK TDK TDK -6.00 0 0 -6.00
-1.50 77 +1.75 -1.50 82
-0.50 100 +1.00 -1.00 77 addisi +2.00 Addisi +2.00
0 0 +1.25 -0.25 88
-2.75 69 +0.50 -2.50 100 +0.50 -1.50 70 0
-0.75 87 -3.50 -0.75 105 -5.50 0 0 -3.00
-1.00 127 +0.25 -1.75 57
-1.50 94 +1.00 -0.50 105

TTK Addisi +2.50 TTK TTKTTK Addisi +2.50 PD 60/58

-1.75 102 +0.25 -1.75 93TTK addisi S +3.00 PD 63/61

TTK TTK addisi S +3.00
-1.00 164 TTK TTK TTK TTK TTK TTK TTK

-0.25 55 -0.25 -0.25 22 addisi +3.00 addisi +3.00

-1.25 64 -2.75 -1.50 91 TTK TTK TTK -2.50

-1.50 83 +3.00 -1.25 39 +2.50 -0.75 90 +2.50 add +2.75 PD 63/61
-3.00 78 +0.50 -2.00 96 -2.00 80

add +2.00 PD 62/60

-1.25 150 -1.25 -1.50 116 -1.50

-0.50 102 -1.00 -0.50 73 -1.50 -1.50

-0.50 87 +0.50 -0.75 77 ADD +2.25 PD66/64

-0.50 86 +0.50 ADD +2.25

-0.75 127 +0.75 -0.25 43
-0.75 -4.50 77 TTK
-0.25 34 +1.00 -0.50 107 ADD +2.00 PD 63/61

+0.75 -2.00 163 TTK

-0.50 79 +1.00 -0.25 113

-1.50 85 -4.75 -3.50 75 -5.50 -4.00

-0.50 55 +2.25 -1.00 91 +1.50 +1.50 ADD +2.50 PD 63/61

-1.75 84 +1.75 -1.00 93 +1.25 -1.25 90 TTK ADD +3.00 PD 64/62
-0.75 -2.75 86 -0.50

-0.75 107 -1.25 -1.25 65 -1.50 -0.50 105 -1.25

-2.00 -2.75 72 -2.00

+0.25 -2.50 146 ADD + 2.00 PD 62/60

-2.25 84 +0.75 -1.50 90 -2.25 90 +0.50
-2.50 114 +2.00 -0.50 68 +1.50 -1.50 110 +1.50 ADD +2.75 PD 64/62
-2.75 87 TTK NLP

-9.25 2
-0.50 127 -2.50 -0.75 56 -1.50 -3.00 ADD +3.00 PD 67/65
-0.25 -0.25 101 ADD +1.75 PD 56/54
-0.50 83 +1.50 -0.50 69 +0.75 +0.75 ADD +2.25 PD 60/58
-1.50 73 +2.00 -1.00 108 +1.50 +1.00 ADD +2.75
-0.50 72 +1.00 -0.25 100 +0.50 +0.75 ADD +1.75 PD 61/59

-1.00 2 +1.00 -0.50 170 ADD +.200 PD 64/62

-1.00 167 +3.25 -1.25 11 +2.00 +2.50 ADD +2.25 PD 63/61

-0.50 61 +1.00 -0.75 67 TTK TTK ADD +2.75 PD 68/66

-0.50 61 +1.50 -0.50 115 TTK TTK ADD +2.50 PD 65/63
-0.50 41 +1.25 -0.75 101 TTK TTK ADD +2.25 PD 59/57

-2.75 83 +1.00 -2.75 92 TTK TTK

-0.50 67 +0.50 -1.25 82

-0.75 109 +4.25 -1.50 79 +2.50 +3.75

-0.50 120 +12.25 -2.50 156 +12.00 +12.50

-1.25 73 +0.50 -1.00 89

-0.25 169 +0.25 -0.75 26 +10.00 TTK ADD +3.00 PD 60/58
-0.75 82 +1.50 -0.75 98

-0.50 92 +0.75 -1.50 74

-1.00 98 -1.25 -0.25 5 -0.75 90 -1.25 ADD +1.25 PD 63/61
-2.00 105 -2.00 -1.25 81 -3.50 -1.75
-0.50 82 +2.00 -0.50 103
-0.25 136 +2.00 -0.50 160
+0.75 -2.50 76 +0.50
-1.25 89 -1.25 -1.00 89 -1.50 -1.00 90 -1.00
-1.00 78 -0.00 -0.75 111 -1.75 -1.00 75 +3.00
-1.00 165 -1.00 -2.50 180
-0.50 58 +1.50

-0.25 134 -0.00 -0.25 36

-0.50 -1.25 154

-1.25 152
-1.50 70 -7.50 -2.25 51 -1.00 75 -7.00
-1.00 167 -0.00 -1.75 94
-0.25 120 +2.75 -1.25 19
-5.75 87 -2.50 -1.75 82
+2.25 118 -2.00 120

-0.50 18 +1.50 -0.50 35 ADD +3.00

-7.00 141 +3.25 -3.25 19
-3.00 80 -2.75 -1.75 68 -1.00 -1.50 75 -3.00

-5.50 -0.50 51 -6.00 -5.50

-1.00 79
-1.50 66 -1.50 -3.00 122

-0.25 -0.50 146 ADD +3.00

-1.25 82 +3.00 -4.00 91
-1.25 89 +0.50 -1.25 75
-1.25 179 -1.75 ADD +3.00
-0.25 95 +4.25 -0.75 84
-1.00 60 +1.75 -1.25 86

+1.00 -0.50 41 +0.75 ADD +2.25

-2.00 92 +3.75 -1.75 77 +2.25 -1.25 90 +2.00 ADD +2.50

-2.75 73 +1.25 -3.25 95 -1.50

-0.75 73 +0.50 -1.50 66 +12.00 +0.75

-2.75 104 +1.50 -2.00 69

-1.25 -4.25 101
-1.00 75

-1.25 91 -1.00 -0.50 85 ADD +2.50

-1.25 87
-1.00 97 -0.00 -1.00 98 ADD +2.50 PD 62/60

-0.75 18 +2.50 -0.75 11 +1.00 0 0 +1.00 ADD +3.

-1.00 -0.25 33 -1.00 ADD +3.00 PD 62/60
-1.00 137 -3.50 -1.0 162 -3.00 0 0 -3.00
-0.75 80 +12.00 -1.25 171 +12.00 ADD +3

-1.25 6 -1.50 -0.75 50 -2.50 -1.00 -1.50 ADD +3.00 PD 65/63

-3.75 80

-1.50 106 -7.25 -1.75 114

-2.25 91 +0.25 -1.50 90 TTK TTK TTK TTK ADD +3.00
-0.25 53 +1.50 -0.25 110 +1.25 0 0 +1.25 ADD +2.
TTK TTK TTK ADD +3.00

-1.25 94 -0.50 -1.50 92 TTK TTK TTK TTK

-1.00 92 +3.25 -1.00 88 +2.50 -1.00 90 +3.00 ADD +2.

-2.25 35 -5.00 -4.00 89 -3.00 -2.00 40 -5.50 PD 58

-4.00 92 TTK TTK TTK TTK
-0.75 50

-0.50 110 +2.50 -0.50 18 +1.00 0 0 +1.50 ADD +2.

TTK TTK TTK
-0.25 147 +1.00 -0.50 6 +0.50 0 0 +0.50 ADD +2.

-1.75 84 +2.75 -1.50 94

-0.25 38 -2.50 -0.25 112 -2.25 0 0 -2.25 PD 62

-0.75 3 -5.75 -0.25 171 -2.25 -0.50 180 -5.55 ADD 2.5
0.25 59 +0,75 0 0 TTK ADD +2.25

-5.00 -0.50 29 TTK TTK TTK -4.00

-1.00 120 +0.75 -2.00 77

-4.25 136 -0.25 -1.25 45 TTK TTK TTK TTK

-0.50 90 +1.25 -0.25 84

-3.75 88 -1.25 -2.75 84
-2.25 93 -0.50 -3.75 88 -0.75 -2.00 95 -0.50

-1.25 96 +1.25 -0.75 92

-4.00 9 -1.25 -0.50 96
-1.00 72 -2.25 -0.75 164 -1.25 0 0 -1.75 PD 68
-0.75 44 +1.00 -1.00 91 TTK TTK TTK TTK
-2.00 91 +0.75 -3.00 88 -1.50 -1.50 90 -2.00
 -2.50 -4.25 91 TTK TTK TTK TTK
-2.75 87 +1.00 -2.00 72 TTK TTK TTK TTK

+1.25 -0.50 17 +1.50 +1.00 ADD +2.25 PD 62/60

-1.75 92 +1.00 -1.50 70 TTK TTK TTK ADD +2.00

-0.75 114 +2.25 -1.00 63 +2.00 +2.00
-1.75 3 -5.50 -2.25 138 TTK TTK TTK -4.00

-0.50 84 +3.50 -0.25 91 +2.50 +2.50 ADD +2.50 PD 64/62

-0.75 72 +2.75 -1.00 102 +3.00 +2.00 ADD +2.50
-2.00 79 -1.75 -1.00 4 TTK TTK TTK -1.50

-0.25 126 -0.25 -2.00 85 -3.00 ADD +2.00 PD

ADD +1.75 PD 59/57

-0.50 39 -5.00 -1.00 126 TTK TTK TTK -5.00
-1.50 103 -1.00 -1.75 81 -2.00 -1.50

-0.25 32 +0.25 -0.25 55 -0.50 TTK ADD +2.25 PD 67/65

-2.75 85 +0.25 -1.50 94 TTK TTK
-0.50 122 +1.75 -1.25 55 TTK
-0.50 126

+1.75 -2.25 51 TTK TTK

-0.50 87 +2.25 -1.25 101 +1.00 +1.25 ADD +2.25 PD 63/61
-2.00 81 -0.00 -0.75 90 TTK TTK
 SENSIBILITAS KORNEA
(TRIAL LENSE) BCVA TIO
MATA KANAN
OD OS OD OS Superior Nasal Inferior
C A
-2.0 90 6/20 6/10 14 15 60 60 60
-1.00 90 6/10 6/7.5 16 13 55 55 60
-0.75 100 6/10 6/7.5 12 13 60 60 60
-3.00 90 6/7.5 6/6 13 15 60 60 60
TTK TTK 6/20 TTK 11 14 60 60 60
0 0 6/6 6/6 15 21 60 60 60
14 17 60 60 60
-1.50 160 TTK 6/7.5 13 error 60 60 60
14 14 60 60 60
11 11 60 60 60
15 14 60 45 45
TTK TTK TTK TTK 12 14 60 60 60
14 15 60 60 60
14 14 60 60 60
16 15 60 60 60
14 14 60 60 60
14 13 60 60 60
0 0 6/60 6/60 20 22 60 60 60
16 14 50 50 50
15 19 60 60 60
13 12 60 60 60
-1.75 105 6/7.5 6/6 14 14 60 60 60
0 0 6/30 6/30 13 13 60 60 60
10 11 60 55 50
 16 18 60 60 60
13 12 55 60 60
13 15 60 60 60
16 16 60 60 60
TTK TTK TTK TTK 21 18 60 60 60
14 14 60 60 60
-1.50 90 TTK 6/15 14 16 60 50 60
TTK TTK TTK TTK 16 14 50 55 60
11 11 55 60 60
TDK 14 14 60 60 60
10 12 60 60 60
0 0 TTK 6/30 15 30 50 60 55
.50 add +2.75 PD 63/61 6/7.5 6/7.5 16 19 55 60 60
-1.25110 add +2.25 PD 62/60 6/6 6/6 12 14 60 60 60
18 16 60 60 60
14 15 50 60 60
d +2.00 PD 62/60 12 12 55 45 60
14 12 55 60 60
13 ERR 60 60 60
12 12 60 60 60
TTK 6/30 12 11 60 60 55
18 17 60 60 60
ADD +1.75 PD 63/61 6/6 6/6 14 14 60 60 60
19 18 55 50 60
DD +2.25 PD66/64 16 16 60 60 60
13 13 60 60 60
20 21 60 60 60
16 14 60 60 60
6/6 14 6 60 60 60
 13 13 55 60 55
TTK TTK TTK TTK 11 9 50 30 45
DD +2.00 PD 63/61 13 12 55 60 60
N/P 45 40 40
TTK TTK TTK TTK ERR 19 60 60 60
14 17 60 60 60
15 15 60 60 60
-2.00 75 3/60 6/15 13 16 60 60 60
16 17 60 60 60
17 17 60 60 60
14 13 45 40 50
.50 ADD +2.50 PD 63/61 6/15 6/15 19 17 50 60 60
K ADD +3.00 PD 64/62 6/15 14 13 55 55 60
-2.5090 ADD +3.00 PD 62/60 6/6F 11 12 60 55 55
23 16 60 60 60
-1.0070 ADD +1.25 PD 61/59 6/6 6/6 11 13 60 60 60
15 15 60 45 55
-1.50 75 6/30 12 13 60 60 60
17 17 55 55 60
60 (PTISIS BULBI) NYERI -
DD + 2.00 PD 62/60 17 PTISIS BULBI
-1.5090 ADD +2.75 PD 61/59 6/6 6/6 15 15 60 60 55
.50 ADD +2.75 PD 64/62 6/6 6/6 13 13 55 45 50
TTK TTK 15 55 60 55
12 12 60 60 60
28 6 60 60 60
00 ADD +3.00 PD 67/65 6/7.5 6/20 13 14 55 60 60
DD +1.75 PD 56/54 16 13 60 60 60
.75 ADD +2.25 PD 60/58 6/6 6/6 14 13 60 50 60
 15 13 OS MENOLAK
.00 ADD +2.75 6/15 6/15 14 13 60 60 60
.75 ADD +1.75 PD 61/59 6/6 6/6 12 15 60 60 60
15 16 60 60 60
DD +.200 PD 64/62 15 14 60 60 60
.50 ADD +2.25 PD 63/61 6/30 6/15 14 15 60 60 60
22 20 60 60 60
K ADD +2.75 PD 68/66 TTK TTK 11 13 55 60 55
K ADD +2.50 PD 65/63 TTK TTK 12 13 60 60 60
K ADD +2.25 PD 59/57 TTK TTK 14 14 60 60 60
14 15 60 60 60
15 17 60 60 60
13 13 60 60 60
9 11 55 60 60
19 18 60 60 60
14 14 60 60 50
14 14 60 60 60
17 14 60 60 60
-1.0080 ADD +2.50 PD 70/686/7.5 6/20 17 16 60 60 60
-1.50160 ADD +3.00 PD 63/616/6 6/15 17 17 60 60 60
13 12 60 60 60
16 17 60 60 60
16 18 60 60 60
K ADD +3.00 PD 60/58 6/6 17 15 60 60 60
14 14 35 30 40
14 30 40 50
14 14 60 60 60
25 ADD +1.25 PD 63/61 6/6 6/6 15 12 50 60 60
15 17 60 55 60
 6/20 6/15 17 15 60 60 60
19 17 60 60 60
15 15 60 60 60
-1.75 75 6/6 12 13 60 50 60
-1.00 90 6/6 6/6 13 12 60 60 60
-1.00 105 6/15 6/15 17 17 60 60 60
17 16 55 55 55
6/10 18 17 60 60 60
20 15 60 60 60
14 12 60 60 60
10 11 60 60 60
17 17 60 60 60
12 12 60 60 60
tdk dapat diperiksa
dk dapat ecdiperiksa
ulkus ornea
ecOD+leukoma
pasien
ulkus kesakitan
ornea OS tidak dilakukan
OD+leukoma OS

60 60 60
13 16 55 60 60
14 13 55 60 60
-1.00 50 6/6 6/20 15 16 60 60 60
16 14 60 60 60
17 16 60 60 60
14 12 40 60 60
+3.00 6/15 62/60 15 12 45 50 60
15 15 60 60 60
TTK TTK 14 14 60 60 60
TTK TTK 15 13 60 60 60
-1.00 70 6/30 6/30 14 18 50 55 60
12 12 60 55 60
6/6 6/6 15 16 60 60 60
 14 11 60 60 60
TTK TTK 12 13 60 60 60
12 10 45 60 60
13 14 60 60 60
TTK TTK 13 13 20 30 60
TTK 18 15 50 45 60
16 16 60 60 60
6/15 LP 7 14 50 60 50
15 13 55 55 55
TTK TTK 14 13 50 60 60
18 19 60 60 60
.75 ADD +2.25 TTK 6/6 14 14 60 60 60
.00 ADD +2.50 6/6 6/20 15 19 60 60 60
13 14 60 60 60
6/20 TTK 15 14 50 50 60
-1.50 70 1/60 6/15 12 11 55 55 60
12 14 60 60 60
TTK TTK 11 13 60 60 60
16 60 60 60
TTK 13 13 60 60 60
12 12 60 60 60
TTK TTK 12 12 45 60 50
TTK TTK 14 17 50 50 60
DD +2.50 PD 62/60 TTK TTK 23 21 60 60 60
16 15 35 40 50
0 0 6/7.5 6/10 17 16 60 60 60
00 ADD +3.00 PD 62/60 6/6 17 12 60 60 60
14 13 60 60 60
12 13 60 60 60
 13 15 55 60 60
0 0 6/60 6/60 13 13 60 60 60
-1.00 180 6/15 16 16 60 60 60
15 13 55 60 60
19 18 60 55 60
15 14 60 60 60
17 17 60 60 60
50 ADD +3.00 PD 65/63 6/10 6/20 11 11 50 50 50
17 19 55 40 60
13 14 50 50 60
14 13 60 55 60
TTK TTK 18 17 30 60 60
0 0 6/6 6/6 12 12 60 60 60
13 14 60 55 60
14 15 55 50 55
TTK TTK 13 14 60 60 60
13 14 50 50 55
-1.00 90 6/6 6/6 15 15 60 60 60
18 18 60 60 60
-2.50 90 6/15 6/15 13 13 55 60 60
TTK TTK 14 13 60 60 60
60 60 60
16 14 60 60 60
0 0 6/6 6/6 14 12 30 60 60
14 60 60 60
13 14 60 60 60
17 17 60 60 60
14 14 60 60 60
15 15 60 60 60
 16 16 60 60 60
0 0 6/6 6/6 14 14 60 60 60
13 12 60 60 60
15 14 55 55 60
0 0 6/6 6/6 10 11 55 55 60
17 16 60 60 60
18 15 60 60 60
12 10 60 60 60
0 0 6/7.5 6/20 19 21 55 60 55
TTK TTK 6/6 13 14 60 50 60
18 17 60 60 60
0 0 6/40 14 17 60 60 60
14 16 60 60 60
15 16 60 60 60
23 18 50 60 55
17 60 60 60
TTK TTK 16 14 60 55 60
13 11 60 60 60
15 14 60 60 60
15 18 40 60 60
-3.00 90 6/6 6/7.5 14 14 15 55 55
15 14 60 60 60
14 14 60 60 60
16 16 60 60 60
12 15 60 55 60
0 0 6/6 6/6 10 13 55 50 60
TTK TTK 19 16 55 60 60
0 90 6/7.5 6/7.5 15 15 60 60 60
13 13 55 45 60
 TTK TTK TTK TTK 13 13 50 60 60
TTK TTK TTK TTK 14 16 60 60 60
15 15 50 55 60
.00 ADD +2.25 PD 62/60 6/15 6/6 14 14 60 60 60
11 12 45 60 60
TTK TTK TTK TTK 13 10 60 60 60
-1.00 75 6/20 6/15 10 11 45 45 55
TTK TTK TTK 6/60 16 13 20 55 60
17 18 55 60 40
12 12 60 60 60
.50 ADD +2.50 PD 64/62 6/6 6/6 15 14 60 60 60
.00 ADD +2.50 6/15 6/75 17 14 60 55 60
TTK 6/20 17 16 60 60 60
13 13 60 60 60
-2.00 90 6/75 6/6 15 17 60 60 60
14 13 60 60 60
18 18 60 55 60
DD +1.75 PD 59/57 11 10 60 60 60
TTK 6/40 14 21 60 60 60
-1.00 85 6/20 6/15 13 13 50 50 60
14 14 60 60 60
K ADD +2.25 PD 67/65 6/6 15 14 30 60 60
12 12 35 35 60
12 14 40 60 35
12 13 55 60 60
13 12 60 60 60
15 55 60 55
.25 ADD +2.25 PD 63/61 6/6 6/6 19 17 60 60 60
16 17 60 60 60
11 11 40 60 60
 SENSIBILITAS KORNEA
NAN MATA KIRI MADAROSIS TRIKIASIS
Temporal Superior Nasal Inferior Temporal OD OS OD OS
60 60 60 60 60 1 1 0 0
55 55 60 60 55 1 1 1 1
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
55 60 60 60 55 1 1 1 1
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 40 40 60 0 0 0 0
55 55 60 60 60 0 1 1 0
60 60 60 60 60 0 0 1 1
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 1
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
50 60 60 55 55 0 0 1 1
60 60 40 60 55 0 0 0 0
60 60 60 60 60 0 0 0 1
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
50 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 1 1
60 55 60 60 60 0 0 0 1
60 60 60 60 60 1 1 1 1
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 55 60 60 35 1 1 1 1
55 60 55 60 60 0 0 0 0
60 60 60 60 60 1 1 1 1
60 60 60 60 60 0 0 1 1
60 60 60 60 60 0 0 0 0
60 55 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 40 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 45 60 55 55 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 30 50 50 35 0 0 0 0
 60 45 60 55 60 1 1 0 0
60 55 60 60 60 1 1 0 0
60 60 60 55 55 1 1 1 0
45 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
55 60 50 55 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 55 60 60 60 1 1 0 0
55 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 55 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
BI) NYERI - 60 60 60 60 0 0 0 0
ULBI 60 60 60 60 1 1 9 0
60 60 60 60 60 1 1 1 0
60 55 60 60 60 1 1 0 0
60 60 (KERATOPATHY) 1 1 0 0
60 60 60 55 60 0 0 0 0
60 30 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 55 60 1 1 0 0
 OS MENOLAK 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 0 1 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
55 60 60 60 60 1 1 1 1
60 60 60 60 60 1 0 0 0
60 60 50 55 60 1 1 1 1
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 1 1
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 55 55 60 1 1 0 0
60 55 50 60 60 1 1 0 0
60 55 60 60 55 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 1 1
60 60 60 60 60 0 0 0 0
45 30 40 40 40 1 1 0 0
50 40 5 10 10 1 1 1 1
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 55 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
55 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 1 1
60 60 60 60 60 1 1 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 1 1 1 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
9 1 1 1
0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 55 60 60 1 1 0 0
60 60 60 60 60 0 0 1 1
60 60 60 60 60 1 1 0 1
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 35 60 60 60 1 1 0 0
60 60 60 60 60 1 1 1 1
60 60 60 60 60 1 1 0 0
60 60 50 60 60 1 1 0 0
60 60 60 60 60 1 1 1 0
60 60 60 60 60 0 0 1 0
60 55 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 1 1
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 1 1
60 50 55 60 60 1 1 0 0
60 10 50 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
50 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 1
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 1 1
60 60 60 60 60 0 0 0 0
55 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 1 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 55 60 55 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
50 40 45 45 45 0 0 0 0
60 60 55 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 50 45 10 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 55 60 60 60 1 1 1 1
60 60 40 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
50 50 50 50 50 1 1 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 55 55 60 60 1 1 1 0
60 60 60 60 60 1 1 0 0
60 55 55 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 40 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 50 60 55 50 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 45 60 60 60 0 0 1 (INFERIOR) 1 (INFERIOR)
60 55 55 55 55 0 9 0 9
60 60 55 60 60 1 1 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 55 0 0 0 1
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 55 60 50 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 1 1
60 30 60 60 60 1 1 0 1
60 60 60 60 60 0 0 0 0
55 50 60 60 60 1 1 1 0
60 30 40 20 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 55 60 60 60 0 0 0 0
60 55 60 60 60 1 1 0 0
60 40 60 60 60 0 0 1 1
60 45 55 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 1
60 60 60 60 60 0 0 0 0
60 50 60 50 60 1 1 0 0
60 60 60 60 60 1 1 0 1
60 60 60 60 60 0 0 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 0 0 1 1
60 55 60 60 60 0 0 0 0
60 60 60 55 60 1 1 0 0
60 55 60 60 55 0 0 0 0
60 60 60 60 60 0 0 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 45 60 50 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 55 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 25 60 60 60 0 0 0 0
60 60 60 55 60 1 1 1 1
55 60 60 60 60 1 1 0 0
60 55 60 45 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 0 0 0 0
60 60 60 60 60 1 1 0 0
60 60 60 60 60 0 0 0 0
60 45 60 55 55 1 1 0 0
 ADNEKSA ANTERIOR
EKTROPION ENTROPION LAGOFTALMOS OBSTRUKSI LAKRIMAL EPIFORA
OD OS OD OS OD OS OD OS OD
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 1 1 1 0 0 1
0 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
1 1 0 0 1 1 0 0 1
0 0 0 0 1 0 0 0 0
0 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 1 1 1 0 0 0
0 0 0 0 0 1 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 1 1 0 0 0
0 0 0 0 1 0 0 0 1
1 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
1 0 1 0 1 1 0 0 0
9 0 9 0 9 0 9 0 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0
0 0 1 1 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 1 1 0 0 0 0 1
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 1 1 0 0 0
0 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 (4MM) 1(4MM) 0 0 0
0 9 0 9 0 9 0 9 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 (5MM) 1 (7MM) 0 0 0
0 0 0 0 1 (1MM) 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 0 1 (3.5 MM) 1 (6.5 MM) 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 (2 MM) 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 1 (SUP) 1 0 0 0 0 0
0 0 1 1 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 1 (SUP) 0 0 1 (6 MM) 0 0 0
0 1 (INF NASAL) 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 (8MM) 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 1 (0.5 MM) 0 0 0 0
0 0 0 0 1 (1 MM ) 1 (1 MM) 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 1 1 0
1 1 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0
EPIFORA DAKRIOSISTITIS LAIN-LAIN MGD
OD OS
OS OD OS OD OS
KODE KET KODE KET
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOKALASIS 1 DERMATOKALASIS 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 1 1
0 0 0 1 DERMATOKALASIS 1 DERMATOKALASIS 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOKALASIS 1 DERMATOKALASIS 0 0
0 0 0 0 0 0 0 1 1
0 0 0 1 DERMATOKALASIS 1 DERMATOKALASIS 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 3 3
0 0 0 0 0 1 BLEFARITIS ANTERIOR 0 0
0 0 0 1 HORDEOLUM SUP 0 0 2 2
0 0 0 0 0 0 0 0 0
1 1 0 CORNEAL1 EXPOSURE (+), LAGOFTALMOS
CORNEAL 0 EXPOSURE
7mm (-), LAGOFTALMOS
0 6mm 0
0 0 0 CORNEAL EXPOSURE
1 (+) 5mm,
CORNEAL
LAGOFTALMOS
EXPOSURE
1 10mm
(+) 4mm, LAGOFTALMOS
0 10mm 0
0 0 0 0 0 0 0 0 0
0 0 0 CORNEAL
1 EXPOSURE + 2mm,CORNEAL
LAGOF 1 1 mm
ESPOSURE + 2 mm. LAGOF 0 8mm 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
1 0 0 1 DERMATOKALASIA 0 0 0 0
0 0 0 LAGOFTALMUS
1 + CORNEAL EXPOSURE
0 0 0 0
0 0 0 0 0 0 0 2 2
0 0 0 1 nevus palp sup + inf 0 0 0 0
0 0 0 0 0 0 0 3 3
0 0 0 1papiloma palpebra superior0 0 0 0
0 0 0 0 0 1 DERMATOKALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 CORNEAL EXPOSURE 1 CORNEAL EXPOSURE 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 0 0 0 0 2 2
0 0 0 1 CORNEAL EXPOSURE - 1 CORNEAL EXPOSURE - 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 PTOSIS INVOLUTIONAL 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 CORNEAL EXPOSURE + 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 9 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 1 1
0 0 0 1 DERMATOKALASIA 1 PTISIS BULBI 0 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 1 1
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 1 DERMATOKALASIA 1 NEVUS PALP SUPERIOR 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 NEVUS PALP SUP 0 0 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOKALASIA
DERMATOKALASIA
1 + CORNEAL EXPOSURE
0 1 MM 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 1 DERMATOKALASIA 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 2
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 FOAMY TEAR 1ANKILOBLEPHARON MEDIA0 0
0 0 0 1 LAGOFTALMOS 1.5MM 1 HEMIFLACID SPASM 0 0
0 0 0 1 TIC FACIALIS 0 0 0
0 0 0 1 DERMATOCHALASIS 1 DERMATOCHALASIS 0 0
1 0 0 0 0 LAGOFTALMOS
1 7mm, corneal exposure
0 3mm 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 lagoftalmos > 3 mm 1 lagoftalmos > 3mm 0 0
0 0 0 1 foam dermatochalasis 0 dermatochalasi foam 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 ptosis 1 ptosis 0 0
0 0 0 0 1 trikiasis superior 0 0
0 0 0 1 dermatocalasia 1 dermatocalasia 0 0
0 0 0 0 0 0 0 2 2
0 0 0 0 0 0 0 3 3
0 0 0 1 dermatochalasis 1 dermatochalasis 0 0
0 0 0 0 0 0 0 3 3
0 0 0 1 dermatochalasis 1 dermatochalasis 0 0
0 0 0 1 dermatochalasis 1 dermatchalasis 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 3 3
0 0 0 0 0 0 0 3 3
0 0 0 0 0 1 lagoftalmos 1mm 0 0
1 0 0 1 dermatochalasis 1 dermatochalasis 0 0
0 0 0 1 dermatochalasis 1 dermatochalasis 3 3
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 dermatochalasis 0 0
0 0 0 1 dermatochalasis 1 dermatochalasis 3 3
0 0 0 1 dermatochalasis 0 0 0 0
0 0 0 1 ptosis, dermatochalasis 1 dermatochalasis 0 0
0 0 0 1 dermatochalasis 1 dermatochalasis 0 0
0 0 0 0 0 0 0 3 3
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 3 3
0 0 0 1 dermatochalasis 1 dermatochalasis 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 3 3
0 0 0 0 0 0 0 2 2
0 0 0 1 dermatochalasis 1 dermatochalasis 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1ptosis, sulcus suspek dalam1 sulkus suspek dalam 0 0
0 0 0 1 dermatochalasis 1 dermatochalasis 0 0
0 0 0 1 dermatochalasis 1 dermatochalasis 2 2
0 0 0 0 0 0 0 2 2
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIS 1 DERMATOCHALAASIS 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIS 1 DERMATOCHALASIS 0 0
1 0 0 0 0 1 ENTROPION SUP 0 0
0 0 0 1 DERMATOCHALASIS 1 DERMATOCHALASIS 0 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIS 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 0 0 1 DERMATOCHALASIS 0 0
0 0 0 1 BLEFARITIS ANT 1 BLEFARITIS ANT 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 0 0 0 0
0 0 0 0 0 1 DERMATOCHALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1CORENAL EXPOSURE 1 MM0 0
0 0 0 0 0 0 0 2 2
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 2 2
0 0 0 0 0 0 0 0 0
0 0 0 1CORNEAL EXPOSURE 1 MM1CORNEAL EXPOSURE 1 MM0 0
9 0 9 0 0 ULKUS1TEREPITALISASI DESCEMETOCELE
0 + 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 KORNEA EXPOSURE 1 MM 1 KORNEA EXPOSURE 1 MM 2 2
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 CORNEAL EXPOSURE
1 0.2 MM, HEMIFACIAL
1CORNEAL
SPASMEXPOSURE
+ 0.2 MM0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 3 3
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 KORNEA EXPOSURE 1 MM 2 2
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 1 DERMATOCHALASIA
DERMATOCHALASIA,
1 CORNEAL EXPOSURE
0 4.5 MM 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 2 2
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASI 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIA 1 DERMATOCHALASIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 2 2
0 0 0 0 0 1LAGOFTALMOS 1MM, CE (-)0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 BAGGY
1 EYELIDS, LAGOFTALMOS
BAGGY
11MM
EYELIDS, LAGOFTALMOS 1.5MM
0 0
0 0 0 0 0 0 0 0 0
0 0 0 DERMATOCHALASIA,
1 LAGOFTALMOS
DERMATOCHALASIS,
1 1MM LAGOFTALMOS 0 4MM 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOCHALASIS 1 DERMATOCHALASIS 0 0
0 0 0 KISTA
1 KANTUS LATERAL, PINGUECULA
1 PINGUECULA
0 0 0 0 0 0 0 4 4
0 0 0 0 0 0 0 2 2
0 0 0 1 DERMATOCHALASIS 1 DERMATOCHALASIS 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1
0 0 0 Nevus palpebra
1 superior dan nasal, dermatochalasis
1 dermatochalasis 0 0
0 0 0 1 DERMATOCHALASIS 1 DERMATOCHALASIS 2 1
0 0 0 0 0 0 0 0 0
0 0 0 DERMATOKALASIA
1 + XANTHELASMA
DERMATOKALASIA
1 + XANTHELASMA
0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 0 0
0 0 0 1DERMATOKALASIA + PTOSIS1DERMATOKALASIA + PTOSIS0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 DERMATOKALASIA 1 DERMATOKALASIA 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 PTOSIS + 0 0
 KONJUNGTIVA
INJEKSI KONJUNGTIVITIS PTERIGIUM NODUL LAIN-LAIN
OD OS OD OS OD OS OD OS OD
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 1 1 0 0 pterigium gr III
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 pterigium gr I
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 pterigium gr I
0 0 0 0 0 0 0 0 0
1 0 0 0 1 1 0 0 pterigium gr I
1 1 0 0 0 0 0 0 0
1 1 0 0 1 1 0 0 pterigium gr I
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 pinguekula
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 1 1 pterigium II
0 0 0 0 0 0 0 0 konjungtivalisasi di inferior
0 0 0 0 0 0 0 0 pinguecula
0 0 0 0 1 1 0 0 pterigium gr I
0 0 0 0 0 0 0 0 0
1 1 0 0 1 1 0 0 pterigium gr II
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 pterigium gr I
0 0 0 0 0 0 0 0 0
1 0 0 0 1 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 1 0 0 0 NEVUS KONJ
1 1 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 0 9 0 9 0 9 0 9
0 0 0 0 0 0 0 0 PINGUEKULA
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 PINGUEKULA
0 1 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 SIKATRIKS
0 DI TEMP POST AVULSI
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 PINGUEKULA
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0
1 1 0 0 1 1 0 0 NEVUS KONJ
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 PINGUEKULA
0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
1 1 0 0 0 0 0 0 KONJUNGTIVALISASI
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 PINGUECULA
0 DI NASAL DAN BILATERAL
0 0 0 0 1 0 0 0 PTERIGIUM GR II
1 1 0 0 1 1 0 0
vasodilatasi pemb. darah, pterigium gr II
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 Pterigium GR II
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 PINGUECULA
0 DI NASAL DAN BILATERAL
1 1 0 0 0 0 0 0 pinguecula
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 1 1 0 0 pterigium gr II
0 0 0 0 1 1 0 0 Pterigium gr I
0 0 0 0 0 0 0 0 pinguekula lateral
0 0 0 0 0 1 0 0 0
1 0 0 0 1 1 0 inflamed
0 conjunctival, pterigium gr III
0 0 0 0 1 0 0 0 pterigium gr II
0 0 0 0 0 0 0 0 pinguecula di nasal
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 pinguecula di nasal
0 0 0 0 0 0 0 0 pinguecula di nasal
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 pterigium gr I
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 1 1 0 0 pterigium gr II
0 0 0 0 1 1 0 0 pterigium gr I
0 0 0 0 0 0 0 0 pinguecula di nasal
0 0 0 0 1 1 0 k0ornea kips (+), pterigium gr II
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 pterigium gr III
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 pinguecula di nasal
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 00 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 (GR.II) 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 PINGUEKULA NASAL LAT
0 0 0 0 1 (GR II)
1 (GR II) DOUBLE HEAD 0 0 0
0 0 0 0 1 (GR II) 1 (GR II) 0 0 DERMATOCALASIS
0 1 0 0 0 1 (GR I) 0 0 0
1 1 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 LENSA
LAIN-LAIN KEKERUHAN NUCLEAR KEKERUHAN SUBCAPSULAR ANT KEKERUHAN SUBCAPSULAR POST KATARAK MATUR
OS
OD OS OD OS OD OS OD
KODE KETERANGAN
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 sinekia post jam 3-6 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 1 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
fibrin
1 peripupil, koeppe nodul1+ 1 0 0 0 0 0
1 iris flocculi + 0 0 0 0 0 0 0
1 koeppe + 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 9 9 9 9 9 9 9
0 0 9 1 9 0 9 0 9
0 0 0 0 0 0 0 0 0
1 KOEPPE + 1 0 0 0 1 1 0
9 9 1 9 0 9 0 9 0
0 0 0 0 0 0 0 0 0
1MIDDILATASI, SINEKIA POST +0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 1 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 ATROFI IRIS 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 iris atropi di superior 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 1
0 0 0 0 0 0 0 1 0
0 0 1 1 0 0 0 0 0
1 COA dangkal 1 1 0 0 0 0 0
1 iris atropi 0 0 0 0 0 0 0
0 0 1 9 0 9 0 9 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 1 1 0 0 0 0 0
1 atrofi iris (+) 1 0 0 0 0 0 0
0 0 1 0 0 0 1 0 0
0 0 0 0 0 0 1 1 0
membran
1 fibrin (+) di belakang pupil 0 0 1 0 1 0
0 0 1 1 1 1 0 0 0
0 0 0 0 0 0 1 1 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 1 1 0
1 iris atrofi 1 1 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 0 1 1 0 0 1 1 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 1 1 0 0 0 1 0
1 iris atrofi 0 1 0 0 0 0 1
1 nodul uoppe(+), fibrin (+) 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 1 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 (GR III) 1 (GR III) 0 0 0 0 0
0 0 1 (GR II) 1 (GR. I-II) 0 0 0 0 0
0 0 1 (GR III-IV) 1 (GR II-III) 0 0 0 0 0
0 0 1 (GR II-III) 1 (GR II-III) 0 0 0 0 0
0 0 0 0 0 0 1 1 0
0 0 1 1 0 0 0 0 0
0 0 1 (GR II) 1 (GR II) 0 0 0 0 0
0 0 1 (GR I) 0 0 0 0 0 0
0 0 1 (GR I) 1 (GR I) 0 0 0 0 0
0 0 1 (GR II) 1 (GR II) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR II) 1 (GR II) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR III) 1 0 0 0 0 0
0 0 1 (GR I) 0 0 0 0 0 0
0 0 1 (GR II) 1 (GR II) 0 0 0 0 0
0 0 1 (GR I) 1 (GR I) 0 0 0 0 0
0 0 1 (GR I) 1 (GR I) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR III) 1 (GR III) 0 0 0 0 0
0 0 1 (GR III) 1 0 0 0 0 0
0 0 0 1 (GR II) 0 0 0 0 1
0 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR II) 1 (GR II) 0 0 0 0 0
0 0 1 (GR III) 1 (GR IV) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 0 0 0 9 0 9 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 (GR I) 1 (GR 1) 0 0 0 0 0
0 0 1 (GR I) 1 (GR I) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 (GR I) 1 (GR 1) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR I) 1(GR I) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 1 (GR II) 1 (GR II) 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR III) 1 (GR II) 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 1 (GR II) 1 (GR II) 0 0 0
0 0 0 1 (GR III) 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 (GR III) 1 (GRIII) 0 0 0 0 0
0 0 1 ( GR I) 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR II) 1 (GR II) 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 (GR I) 1 (GR I) 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
1 ATROFI IRIS 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 1 1 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR III) 1 (GR II) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 (GR II) 1 (GR II) 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 (GR I) 1 (GR I) 0 0 0 0 0
 LENSA SE
KATARAK MATUR KEKERUHAN KORTIKAL LAIN-LAIN PAPILEDEMA
OD OS
OS OD OS OD OS
KODE KET KODE KET
0 0 0 1 gr II 1 gr II 0 0
0 0 0 1 gr III 1 gr III 0 0
0 1 1 1 gr I 1 gr I 0 0
0 1 1 1 gr I-II 1 gr I-II 0 0
0 0 0 1 gr I-II 1 gr I-II 0 0
0 0 0 0 0 0 0 0 0
1 0 0 1 gr I 1 gr I 0 0
0 0 0 1 imatur OD gr III 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr III 1 katarak gr III 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr III 1 katarak gr III 0 0
0 1 1 1 katarak gr I 1 katarak gr I 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr I 1 katarak gr I 0 0
0 0 0 1 katarak OD>OS 1 katarak OD>OS 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr I 1 katarak gr I 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 Katarak gr II 1 Katarak gr II 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr I 1 katarak gr I 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 LENS PRECIPITATE? 1 LENS PRECIPITATE 0 0
0 0 0 0 0 0 0 0 0
0 1 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 KATARAK
1 GR I, LENS PRESIPITAT
0 0 0 0
1 0 1 1 KATARAK MATUR 0 IMATUR GR II 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 1PIGMEN IRIS DI KAPSUL ANT0 0 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 PSEUDOFAKIA DGN PCO 0 0
1 0 0 iris1 tremulans + katarak morgagni
0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 PSEUDOFAKIA DGN PCO 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 9 0 9 9 0 0 9 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 0 9 0 0 0 9 0 9
0 0 0 0 0 0 0 0 0
0 0 0 1 IOL + 1 AFAKIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 LENS PRECIPITATE
1 (PIGMEN IRIS DI KAP
0 ANT) 0 0 0
0 0 0 0 0 1 KATARAK MATUR 0 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 PSEUDOFAKIA 1 PSEUDOFAKIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 AFAKIA 1 AFAKIA 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 AFAKIA 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 membran1fibrin +, riw op katarak&retina
0 di rscm IOL + 9 0
0 0 0 0 0 0 0 0 0
0 0 0 1 KATARAK GR I-II 1 KATARAK GR 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 KATARAK GR I-II 1 KATARAK GR II 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak 1 katarak gr II-III 9 0
0 0 0 0 0 0 0 0 0
0 0 0 1 KATARAK GR I 1 KATARAK GR I 0 0
0 0 0 1 lens precipitaite 1 katarak gr IV 9 9
0 0 0 0 0 0 0 0 0
9 0 9 0 0 1 9 0 9
0 0 0 0 0 0 0 0 0
0 0 0 1 KATARAKAK GR II 1 KATARAK GR II 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr II 1 katarak gr II 0 0
0 0 0 1 katarak gr IV 1 katarak gr IV 0 0
0 0 0 1 katarak gr III 1 katarak gr III 0 0
1 0 0 1IOL (1 hoptic di sulcus) PCO +1 KATARAK MATUR 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr II 1 katarak gr III 0 0
0 0 0 1 katarak gr II 1 katarak gr II-III 0 0
0 0 0 1 katarak gr I 1 katarak gr I 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr I 0 0 0 0
0 0 0 1 katarak gr III 1 katarak gr III 0 0
1 0 0 1 katarak gr IV 1 lensa brown gr IV 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 keruh gr IV 0 Psudoafakia 0 0
0 0 0 1 keruh gr II-III 1 IOL (+), PCO(+) 0 0
0 0 0 0 0 0 0 0 0
1 0 0 1 IOL capture di nasal 0 0 0 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 keruh gr IV 1 keruh gr III 0 0
0 0 0 1 katarak gr I 1 katarak gr I 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 afakia 0 0 0 0
0 0 0 0 0 1 katarak gr I 0 0
0 0 0 1 katarak keruh gr II 1 keruh gr III 0 0
0 0 0 0 0 1 katarak gr III 9 0
0 0 0 1 katarak gr II 1 katarak gr IV brown 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 katarak gr II 1 katarak gr III 0 0
0 0 0 1 keruh gr II-III 0 0 0 0
0 0 0 1 keruh gr II 1 keruh gr II 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 PSEUDOFAKIA 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 ANGLE SUPPROT 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 IOL 1 IOL 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 0 9 0 9 0 9 0 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 LENSE PRECIPITAT + 0 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 IOL 1 IOL 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 GR III 1 GR III 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 GR I 1 GR I 0 0
0 0 0 1 IOL 1 IOL 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 GR II 1 GR III 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 GR I 1 GR I 0 0
0 0 0 1 GR I 0 0 0 0
0 0 0 1 GR II 1 GR II 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 GR III 1 GR III 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 GR II 1 GR II 0 0
0 0 0 1 GR III 1 GR III 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 SEGMEN POSTERIOR PAPIL SARAF OPTIK
PULSASI VENA EKSTRAVASASI PAPIL SARAF ATROFI LAIN-LAIN PERDARAHAN SUBHIALOID

OD OS OD OS OD OS OD OS OD
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 9 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 CWS PERIPAPILCWS PERIPAPIL 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
9 0 9 0 9 0 9 0 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 9 0 9 0 9 0 9 0
0 0 0 0 0 0 0 0 0
0 0 1 0 1 1 ATROFI PAPIL TOTAL RD + 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 9 0 9 0 9 0 9 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 0 9 0 9 0 9 0 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 VITRUS STRAND
VITREUS STRAND 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 RETINA
ERDARAHAN SUBHIALOID PERDARAHAN INTRARETINA EDEMA RETINA EDEMA MACULA LAIN-LAIN
OD
OS OD OS OD OS OD OS
KODE KETERANGAN
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 pigmentary changes
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 9 0 9 0 9 0 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 0 9 0 9 0 9 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 ATROFI MAKULA, PPA +
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 0 9 0 9 0 9 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 VITR. STRAND +
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 VITR.STRAND +
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 VITR.STRAND +
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 9 0 9 0 9 0 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 9 0 9 0 9 0 9 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
9 0 9 0 9 0 9 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 9 0 9 0 9 0 1 9
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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9 0 9 0 9 0 9 0 9
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 VITREUS STRANDS
VITERUS
+ STRANDS +
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 PEMBULUH DARAH RETINA
LAIN-LAIN RASIO ARTERI VENA PERDARAHAN MIKROANEURISMA LAIN-LAIN
OS
OD OS OD OS OD OS OD
KODE KETERANGAN
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 rasio arteri vena 2/2
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 rasio arteri vena 2/3
0 0 1 1 0 0 0 0 0
9 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
9 9 9 9 9 9 9 9 9
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 9 1 9 0 9 0 9
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 0 1 9 0 9 0 9 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 9 0 9 0 9 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
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0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
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0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 VITR. STRAND+ 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 1 1 0 0 0 0 0
1 VITR. STRAND + 1 1 0 0 0 0 0
1 VITR. STRAND + 1 1 0 0 0 0 0
 0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 9 0 9 0 9 0 9
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 1 9 0 9 0 9 0 9
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 1 1 0 0 0 0 0
0 9 1 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 9 0 9
strand vitreous (+) 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 vitreous penuh 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 9 1 9 0 9 0 9 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 1 1 0 0 0 0 0
0 0 9 1 9 0 9 0 9
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0 0 0 0 0 0 0 0 0
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0 0 1 1 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 9 0 9 0 9 0 9 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
9 9 9 9 9 9 9 9 9
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
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0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 1 1 0 0 0 0 0
 STABILITAS AIR MATA PRODUKSI AIR MATA
LAIN-LAIN TBUT SCHIRMER I SCHIRMER 2
OS OD OS OD OS OD OS

0 15 6 9 4 13 13
0 4 5 8 6 15 20 madarosis,
0 6 7 24 23 15 15
0 11 13 4 3 9 8
0 5 6 5 1 8 6 madaro
0 10 10 9 5 17 15
0 15 7 15 21 16 24
0 5 5 6 6 3 4 pte
0 15 16 6 7 >35 30
0 7 3 9 5 13 11
0 10 12 15 30 13 18
0 10 4 10 11 15 20 entropion ODS, pterigium gr I ODS, ma
0 16 14 4 5 20 28
0 9 11 3 8 14 20
0 13 15 5 3 12 10
0 10 5 1 10 14 9 pterigi
0 10 6 8 6 8 9
0 5 5 16 13 10 9 pterigi
0 11 8 10 25 15 30 entropion
0 12 7 3 4 12 15
0 17 8 10 13 19 20 trichias
0 1 1 1 5 25 15 MG
0 4 5 5 7 15 18 blefari
0 10 8 9 4 20 15
 0 10 10 24 30 30 26
0 2 2 20 26 27 32 lagoftalmo
rasio arteri vena 2/3 7 3 10 20 25 31 lagoftalmos dgn Corneal Expo
0 10 7 1 3 4 4 Pter
0 10 2 10 4 10 7
rasio arteri vena 2/3 7 8 3 5 5 10 M
0 4 4 14 10 19 11 pterigi
9 12 12 28 27 20 16 MGD gr I OS, sikatrik
0 7 8 35 35 17 14 pterigium gr II O
0 10 10 9 7 21 19
0 6 7 16 6 23 14 lago
0 3 1 9 17 17 27 uveitis anterior sarata
0 11 12 20 25 20 26 nevus pa
0 1 2 9 1 10 14
0 >10 >10 22 20 14 14
0 8 5 7 8 8 14
0 10 7 >35 >35 20 16
0 10 10 17 18 14 10
0 <5 <5 20 18 10 22 EKTROPION ODS, ENTR
0 10 10 14 35 23 24
0 14 13 4 8 17 29 PTERIGIUM GR II OD, GR III OS
0 10 10 16 30 14 22
0 10 6 16 9 10 10
0 10 7 9 8 2 4
0 10 10 23 2 20 20
0 <10 <10 4 1 35 14 MGD GR I O
0 10 5 15 4 17 11
0 8 8 9 14 6 5 PTERI
0 8 8 6 4 1 8 SIKATRIKS KORNE
0 10 10 11 14 14 7
0 10 8 1 5 5 14 KATARAK MATUR
0 1 1 10 21 10 7 MADAROSIS DER
9 9 9 5 2 7 5
9 1 1 16 22 10 15 MADAROSIS ODS, MGD ODS, PINGUEK
0 10 10 6 11 9 7
0 6 7 14 12 8 14
0 6 7 25 10 29 10 ENTROPION ODS, KATARAK
0 >10 >10 12 16 10 8
0 7 8 18 16 3 14 LAGOFTALM
0 4 10 11 28 13 10
0 <5 10 35 8 25 15 LAG
0 1 1 22 17 11 9 MADAR
0 5 8 1 8 8 9 PTOSIS INVOLUSIONAL OD, MGD
0 >10 >10 8 15 15 23 KA
0 3 3 5 4 10 13
0 >10 >10 5 8 15 20
0 1 2 15 7 12 6 KATARA
0 4 3 8 17 8 13 LAG
9 <5 <5 5 11 3 3 PTISIS BULBI ODS, ENTROP
0 - >10 <1 25 31 >35 PTISIS BULBI OD,
0 8 9 3 3 10 6 MGD
0 1 1 20 5 10 MADAROSIS ODS, MG
9 7 <5 2 30 4 17 PTISIS BULBI O
0 >10 >10 20 5 30 30
0 2 4 2 1 6 3 GLAUKOMA SEKUNDER OD, PAP
0 10 10 35 35 12 10 ENT
0 4 4 1 14 1 1 MG
9 2 3 3 3 8 10
0 >10 >10 PASIEN MENOLAK
0 4 >10 7 12 10 10 MADAROSIS ODS, ENTROPION ODS, DERMATOKALASIA
0 8 10 3 2 20 19
0 3 1 23 4 35 22 KATARAK IMATUR ODS, UV ANT SONATA
0 >10 >10 35 20 35 20
0 2 1 35 30 35 20 KATARAK IMATUR ODS, SIKATRIK
0 >10 >10 10 2 11 11
0 >10 >10 3 4 2 4 DE
0 >10 6 14 12 15 20 MADAROSIS OD,
0 3 3 4 <1 7 2 DRY EYES , MADAROSIS O
0 7 10 6 6 6 6
0 <5 <5 3 <1 2 6 TRIKIASIS O
0 2 2 3 9 14 22 NEVUS PALP SUP OD, S
0 7 7 6 2 3 5 DERMATOKALASIA
0 3 3 9 8 7 3 MADAROSIS ODS, LAGOFTALMUS O
0 5 8 9 <1 5 5
0 7 4 4 8 15 12 LAGOFTALMUS OS DE
0 6 7 20 13 15 9
0 >10 >10 >35 14 13 10
0 10 10 28 9 19 12 AFAKIA
0 3 5 5 8 9 5
0 1 1 24 22 35 27 UVEITIS ANT SANATA ODS, KATARAK I
0 >10 >10 4 15 8 8 ENTROPION OS, TRIKIA
0 10 7 2 4 7 4 ENTROPIO
0 4 8 4 13 8 8 MADAROSIS + DERMATO
9 <5 <5 20 22 23 12 SIKATRIKS KORNEA ODS (LEUKOMA
0 10 8 13 3 26 22
0 2 2 1 3 <1 <1
0 2 2 21 22 8 22
0 >10 >10 29 23 21 15 AN
0 <5 10 4 4 1 0
0 >10 >10 9 21 20 30
0 >10 >10 20 10 20 17 koagulum + imbibisi kornea OD (n
0 >10 >10 4 15 9 17
0 6 > 10 7 24 17 26 madarosis OD
0 > 10 >10 6 6 4 7 lagoftalmo
0 > 10 7 5 9 4 5 lagoftalmos ODS, entropion ODS, madar
0 > 10 > 10 4 9 15 21
0 10 3 4 13 5 7 lagofta
0 4 4 3 2 29 11 madarosis IDS, trikiasi OD, leukoma adheren+ep
0 2 4 8 9 20 20 pi
0 4 3 15 14 10 12
9 9 9 >35 >35 33 9
0 9 9 9 9 9 9 ektrop
9 <5 <5 8 7 8 9 pterigium
0 >10 >10 30 22 32 30
0 > 10 4 2 2 12 20 trichiasis ODS, entropion
0 3 3 9 19 14 15
0 5 5 2 1 7 4 d
0 6 7 19 17 14 19 katarak matu
0 1 1 15 18 21 14 pterig
0 >10 >10 12 10 9 7 entropion + madarosis+ trikiasis
0 2 4 7 4 4 8 vitre
0 4 4 13 13 5 4 dermatokalasis, mada
0 4 8 10 5 10 8 madarosis ODS, trikiasis OD, dermatoch
0 >10 6 2 9 1 5 Katarak i
0 1 3 6 4 5 4
0 2 2 6 21 15 19
0 3 3 >35 >35 >35 >35 Katara
0 <5 <5 7 17 13 10 entropion involu
0 4 5 13 13 15 7 oftalmople
0 8 8 10 8 10 13 madarosis
0 5 7 13 9 19 11 uveitis s
0 3 2 8 23 24 24 pseudofakia OS, katara
0 1 1 33 26 30 32 mak
9 4 1 7 10 10 10 ptosis ODS, ektropion inferior ods, entropion superior ods,
0 3 4 10 15 7 12 dermathalasi
0 3 4 3 4 17 18 ka
0 > 10 > 10 7 8 4 9 madarosis
0 3 3 9 4 12 8
0 3 5 5 4 9 6 pterigium, entropion, ka
0 3 2 5 5 13 10
0 3 4 7 4 18 16 pin
0 3 2 8 9 19 10 uveitis OD, afakia O
0 >10 >10 15 14 15 18
0 2 3 35 15 17 7 lagoftalmos OD
0 7 3 10 6 7 9 ptosis, entropion OD, mad
0 5 7 5 20 19 35
0 7 7 5 3 14 16
0 5 8 8 7 3 10
0 6 6 6 17 21 16 kata
0 10 7 5 8 9 8
0 3 4 15 6 14 17
0 4 10 15 10 12 12 madarosis
0 8 4 35 30 30 34 dermatochalasis + madaro
0 4 4 15 15 5 10
0 2 4 10 8 15 12 Mada
0 >10 >10 12 10 10 11 pterigium O
0 2 2 14 14 15 16 entropion sup O
0 10 10 2 3 3 <1 Afa
0 7 9 10 3 9 4 madarosis, tric
0 3 5 9 17 11 19
0 7 8 1 4 8 12
0 3 3 2 2 4 5 Dermatochalas
0 7 4 4 3 pseudofakia
17 OD, katarak
20 imatur OS, dermatokalasis ODS, dry eye ODS
0 >10 >10 11 11 19 20 KSI ODS, de
0 7 3 8 10 4 10
0 2 4 35 35 22 23 madarosis
0 2 2 7 9 13 14
0 3 4 3 5 5 10
0 3 4 10 30 5 15 dermatochalasis ODS, pterygiu
0 5 4 12 17 35 25
0 7 4 2 3 8 6 d
0 8 4 35 5 35 30 dermato
0 4 4 25 10 13 5
0 10 5 10 20 20 33 lag
0 5 5 7 13 15 17 entropion OD
0 10 10 5 5 1 1
0 9 9 5 <1 3 3
0 10 10 <1 <1 4 1
0 4 3 6 13 6 7
9 10 9 10 14 12 15
0 6 7 4 3 8 9
0 10 10 1 1 3 4
0 2 4 18 18 5 3 dermatoc
0 8 4 30 20 19 14
0 >10 >10 26 20 35 30
0 10 10 8 2 25 12
0 8 9 5 5 15 8
9 9 9 14 19 24 30
0 4 3 <1 4 10 5 madarosis O
0 >10 .10 7 6 14 15
0 4 2 17 20 10 30 lagoftalmos + corneal
0 4 3 5 5 5 5
0 5 6 <1 <1 5 7 dry eye OD
0 >10 >10 10 8 4 3
0 6 7 5 4 11 14
0 3 3 <1 2 4 6 madarosis ODS, entrop
0 5 7 25 25 30 35 dermatochalasis, entropio
0 3 3 4 6 4 8
0 2 9 15 8 16 10 lagoftalmos
0 7 <5 15 34 19 32 ektropion, entropion, trikiasis
0 2 2 14 9 6 5 pterig
0 4 10 9 9 9 9 epite
0 7 5 35 23 32 32
0 3 4 13 15 11 26 dermatochalasis ODS, trichiasis ODS
0 >10 >10 4 10 16 12
0 >10 >10 30 35 26 35
0 4 4 30 1 18 19
0 3 3 4 2 4 2
0 3 3 10 4 8 7 dermatochalasos ODS, lagoftalmos O
0 9 9 14 30 35 >35
0 3 8 12 9 4 7 trichias
0 5 5 9 11 12 35
0 10 10 12 2 25 25
0 >10 >10 17 21 10 8 En
0 5 3 7 4 19 10
0 3 7 5 33 2 14
0 >10 5 22 25 23 20 d
0 >10 8 10 14 9 6
0 3 3 14 12 13 12 trikiasis ODS, pinguecula O
0 6 5 <1 <1 5 9
0 6 3 22 35 30 15 lagoftalmos
0 5 5 15 14 10 11
0 10 5 10 23 10 5
0 10 9 9 15 4 6 derm
0 6 8 1 1 12 9
0 5 3 10 25 22 3
0 3 6 5 3 9 8 madar
0 > 10 >10 29 24 17 11
0 10 10 13 7 5 5
0 10 10 3 4 30 17
0 6 5 3 1 15 23
0 >10 7 15 2 33 9 nevus palpebra O
0 6 7 <1 4 10 8
0 4 3 19 11 6 26 LAG
0 4 5 5 7 9 26 LAGOFTALMUS ODS,
0 >10 >10 23 32 17 25 DERMATOKALASIA OD
0 6 7 6 14 15 5 EKTROPION OD, DERMA
0 6 >10 16 13 20 12 DERMATOKALAS
0 5 6 13 15 18 17
0 10 10 15 35 35 35
0 6 7 1 1 <1 <1
0 >10 3 13 5 8 8
0 10 10 25 15 25 30 LA
 DIAGNOSIS

madarosis, katarak imatur

madarosis, entropion, trichiasis, dermatokalasis, katarak imatur
dry eye ODS, katarak ODS
dry eyes ODS
madarosis, trichiasis, entropia, dermatokalasis, kat.imatur
madarosis ODS
katarak imatur ODS
pterigium gr III OS, afakia OS, katarak imatur OD
dry eyes ODS
madarosis, presbyopia
sikatriks kornea OD
entropion ODS, pterigium gr I ODS, madarosis ODS, uvetis sanata OS, katarak senilis ODS, sikatriks kornea OS, dry eyes
pterygium grade I ODS
dry eye OD
mata tenang ODS
pterigium gr I ODS, katarak, entropion OS, trichiasis OS
dry eyes OS
pterigium ODS, dermatokalasia ODS, katarak gr III ODS
entropion ODS, lid retraction OS, dry eye ODS, lagoftalmos OS
pterygium gr I ODS, presbyopia
trichiasis OS, pigmentary changes makula OD, dry eye OS
MGD gr III ODS, katarak imatur ODS, dry eye ODS
blefaritis anterior OS, katarak imatur ODS, dry eye ODS
hordeolum OD
 lagoftalmos ODS, trikiasis, ektropion inferior ODS, entropion OS
lagoftalmos dgn Corneal Exposure ODS, keratitis punctata ODS, epiteliopati, trikiasis OS, dry eye ODS
Pterigium gr II ODS + Madarosis ODS + dry eyes OS
lagoftalmos ODS, corneal esposure ODS
MGD gr I ODS, pinguecela OD, dry eye ODS
pterigium ODS, dry eyes ODS, entropion + trikiasis ODS
MGD gr I OS, sikatriks kornea OS, katarak imatur ODS (DD/komplikata, dd/juvenile)
pterigium gr II ODS + entropion palp superior ODS + dermatokalasia ODS
lagoftalmus ODS, epiteliopati OD
lagoftalmus OD + corneal exposure, dry eyes ODS
uveitis anterior sarata ODS, madarosis ODS, lagoftalmus OD, MGD ODS, dry eye ODS
nevus palp sup+inf OD, iris flocculi ODS, pterigium OS gr III
uveitis sarata ODS, katarak imatur ODS
papiloma palp superior OD
dry eyes ODS + dermatokalasia OS
dry eyes OS
katarak matur ODS
EKTROPION ODS, ENTROPION OS, PTERIGIUM GR 4 ODS, KATARAK SENILIS IMATUR OD

PTERIGIUM GR II OD, GR III OS, KATARAK ODS, SUSP. RETINOPATI HIPERTENSI ODS, CWS PERIPAPIL ODS

DRY OS
DRY EYES ODS
MATA TENANG ODS
MGD GR I ODS, PTERIGIUM GR I OS, KATARAK GR II OD, GR III OS
DRY EYES OS
PTERIGIUM GR I OD, NEVUS KONJ OD, DRY EYES ODS
SIKATRIKS KORNEA ODS, RIWAYAT POST RUPTUR KORNEA OS , PTERIGIUM OS
 MADAROSIS ODS + KATARAK ODS
KATARAK MATUR OD, KATARAK SENILIS IMATUR OS, DERMATOKALASIA ODS
MADAROSIS DERMATOKALASI ODS, DRY EYES ODS, KATARAK IMATUR ODS
PTISIS BULBI OD, LEUKOMA ADHEREN OS
MADAROSIS ODS, MGD ODS, PINGUEKULA ODS, UVEITIS ANT SANATA ODS, KATARAK KOMPLIKATA ODS, DRY EYES ODS

MADAROSIS ODS, DRY EYES ODS

ENTROPION ODS, KATARAK ODS, DERMATOKALASIA ODS, PTERIGIUM GR I ODS, DRY EYES ODS
MGD GR II ODS
LAGOFTALMUS ODS TANPA CORNEAL EXPOSURE, DRY EYES ODS
EPIFORA OD, LAGOFTALMUS OD
LAGOFTALMUS OD, EKTROPION OD, DRY EYES OD
MADAROSIS ODS, DRY EYES ODS, KATARAK IMATUR ODS
PTOSIS INVOLUSIONAL OD, MGD GR II ODS, KATARAK MATUR OD, PSEUDOFAKIA OS + PCO OS, DRY EYES ODS
KATARAK MORGAGNI OD, KATARAK MATUR OS
DRY EYES ODS, MGD ODS
SIKATRIKS KORNEA OS
KATARAK MATUR OD, NEAR MATUR OS, MADAROSIS ODS
LAGOFTALMUS OS DENGAN CORNEAL EXPOSURE
PTISIS BULBI ODS, ENTROPION OD EKTROPION OD LAGOFTALMUS ODS SIKATRIKS KORNEA ODS
PTISIS BULBI OD, KATARAK IMATUR OS, MADAROSIS ODS CORNEA SCAR OS
MGD GR I ODS, PTERIGIUM GR I ODS, DRY EYES ODS
MADAROSIS ODS, MGD ODS, SIKATRIKS KORNEA OD, UVEITIS ANT OD, DRY EYES ODS
PTISIS BULBI OS, DERMATOKALASIA OD, PTERIGIUM OD, DRY EYES ODS
MGD GR I OD
GLAUKOMA SEKUNDER OD, PAPIL ATROFI OD, TOTAL RD OS, PSEUDOFAKIA OD, AFAKIA OS, DRY EYES ODS
ENTROPION ODS, KATARAK ODS, MADAROSIS ODS
MGD ODS, SIKATRIKS KORNEA OS, DRY EYES ODS
KATARAK SENILIS IMATUR
 DERMATOKALASIA ODS
DAROSIS ODS, ENTROPION ODS, DERMATOKALASIA ODS, BAGGY EYELID, PTERIGIUM ODS, KATARAK IMATUR ODS, EPITELIOPATI ODS, DRY EYES OD
MATA TENANG ODS
KATARAK IMATUR ODS, UV ANT SONATA OD, PTERIGIUM GR III OD, MGD ODS, MADAROSIS + TRIKIASIS OD, DRY EYES ODS
MADAROSIS ODS
KATARAK IMATUR ODS, SIKATRIK KORNEA OD, PINGUEKULA 0S, PTERIGIUM OS, MGD ODS, DRY EYES ODS
DERMATOKALASIA ODS
DERMATOKALASIA, MADAROSIS, TRIKIASIS ODS
MADAROSIS OD, DERMATOKALASIA OD, NEVUS PALP SUP OS, DRY EYES OS
DRY EYES , MADAROSIS ODS, KATARAK IMATUR ODS, ENTROPION + TRIKIASIS PALP SUP ODS
PTERIGIUM GR II OD, DRY EYES OD
TRIKIASIS ODS, PTERIGIUM ODS, DRY EYES ODS, NEVUS KONJ OD
NEVUS PALP SUP OD, SIKATRIKS KORNEA OS, SUSP GANG REFRAKSI ODS, DRY EYES ODS
DERMATOKALASIA ODS, PSEUDOFAKIA ODS, ENTROPION ODS, DRY EYES ODS
MADAROSIS ODS, LAGOFTALMUS ODS, KATARAK IMATUR ODS, DRY EYES ODS, SIKATRIKS KORNEA OD, MGD ODS
DRY EYES ODS, MADAROSIS ODS
LAGOFTALMUS OS DENGAN CORNEAL EXPOSURE OS, EKTROPION OS, DRY EYES ODS
DRY EYES ODS
MATA TENANG ODS
AFAKIA ODS, PTERIGIUM GR I OD, PRO 2ND IMPLAN ODS
DRY EYES ODS
UVEITIS ANT SANATA ODS, KATARAK IMATUR ODS, MGD ODS, LAGOFTALMUS ODS, MADAROSIS ODS, DRY EYES ODS
ENTROPION OS, TRIKIASIS ODS, MADAROSIS ODS, DERMATOKALASIA OD, KATARAK OS
ENTROPION OS, AFAKIA OD, KATARAK GR III OD, DRY EYES OS
MADAROSIS + DERMATOKALASIA ODS, MGD OS, PTERIGIUM ODS, KSI ODS, DRY EYES ODS
SIKATRIKS KORNEA ODS (LEUKOMA ADHERENS ODS), ENTROPION ODS, DERMATOKALASIA ODS, DRY EYES ODS
MATA TENANG ODS, DRY EYES OS
SUSP. UVEITIS POST OS, MADAROSIS OS
DRY EYES ODS, SUSP UVEITIS POST ODS
 ANISOKORIA, PTERGIUM ODS, RIW UVEITIS OD
DRY EYES OD
MATA TENANG ODS
koagulum + imbibisi kornea OD (non functioned eye OD), pseudofakia OS, keratitis pungtata OD (epiteliopati)
MATA TENANG ODS
madarosis ODS, ankiloblepharon OS, katarak matur ODS, dry eye OD
lagoftalmos OD tanpa corneal exposure, hemiflacid spasm OS
lagoftalmos ODS, entropion ODS, madarosis+trikiasis ODS, scar cornea OS, epitelopati ODS, katarak senilis ODS, dry eye OS
madarosis ODS, dermatochalasis ODS
lagoftalmos + corneal exposure OS, sikatriks kornea OS
madarosis IDS, trikiasi OD, leukoma adheren+epitelopati OD, katarak komplikata OD, katarak imatur OS, leukoma kornea OS, dry eye ODS
pinguekula ODS, katarak skp os, drye eyes ods
pterigium OD, KSI ODS, drye eye ODS
ulkus kornea ODS+ uveitis (keratouveitis)
ektropion OD, dermatokalasis ODS, pseudophakia ODS
pterigium ODS, leukoma kornea ODS, KSI OD, dry eyes ODS
madarosis ods
trichiasis ODS, entropion OS, ptosis ODS, pterigium OS, corneal scar OS, KSI ODS, dry eyes OS
uveitis sarata OS, KSI ODS, dry eyes ODS
dermatokalasia ODS, KSI ODS, dry eyes ODS
katarak matur ODS, entropion palpebra superior ODS, Dry eyes ODS
pterigium gr II ODS, katarak imatur ODS, Dry eyes ODS
entropion + madarosis+ trikiasis ODS, pterigium ODS, corneal scar OD, pseudophakia OD, katarak matur OS
vitreous strand (uveitis posterior) OD, dry eyes ODS
dermatokalasis, madarosis ODS, pterigium OS, post uveitis OS, KSI ODS, dry eyes ODS
madarosis ODS, trikiasis OD, dermatochalasis ODS, pterigium gr III ODS, corneal scar OD, katarak imatur ODS, dry eye ODS
Katarak imatur ODS, trikiasis OD, pterigium OD, dry eye OS
makula kornea ODS
high myopia ODS, dry eyes ODS
 Katarak imatur ODS, ulkus kornea OD, lagoftalmos OS
entropion involusional ODS, pterigium gr II OD, katarak imatur senilis ODS
oftalmoplegi ODS total, dermatochalasia ODS, KSI ODS, dry eyes
madarosis, trikiasis ODS, scar cornea OD, KSI ODS, dry eye ODS
uveitis sarata OD, KSI OD, pseudoafakia OS, dry eyes ODS
pseudofakia OS, katarak imatur OD, pinguekula ODS, dry eyes ODS, dermatocalasia ODS
makula kornea OS, katarak SKP ODS, dry eyes ods
DS, ektropion inferior ods, entropion superior ods, madarosis ods, pseudofakia dgn iol capture od, epitelopati ods, katarak matur os, uveitis anterior os
dermathalasis ODS, katarak imatur ODS, pterigiumODS, dry eye ODS
katarak subkapsularis posterior, dry eyes ods
madarosis,entropion OS, KSI ODS, trikiasis OS, epiteliopati ODS
katarak imatur ODS, dry eyes ODS
pterigium, entropion, katarak imatur, iris atrofi, post uveitis dermatochalasis, dry eye ODS
pterigium ODS, KSI ODS, dry eye ODS
pinguecula ODS, katarak imatur ods, dry eye ods
uveitis OD, afakia OD, pseudophakia OS, pterigium OD gr II OS gr III, dry eye ODS
dermatochalasis ODS, KSI IS
lagoftalmos ODS, ekropion dan entropion OD, epiteliopati OD, KSI ODS
ptosis, entropion OD, madarosis ODS, pterigium OD, KSI ODS, sikatriks kornea OD, dry eye ODS
madarosis ODS, KSI ODS
pinguecula ODS, dry eyes ODS
KSI ODS, dry eyes ODS
katarak imatur ODS, entropion ODS, dry eyes ODS
KSI ODS, dry eyes OS
dermatokalasis katarak ODS, dry eye ODS
madarosis pterigium OS, KSI ODS, epiteliopati ODS, dry eye OD
dermatochalasis + madarosis ODS, katarak imatur ODS, uveitis anterior senata OD, dry eye ODS
KSI ODS, corneal scar OS, dry eye ODS
Madarosis ODS, pinguekula OD, KSI ODS, dry eye ODS
 pterigium ODS, KSI ODS, dermatochalasis ODS, post uveitis ODS
entropion sup OS, dermatokalasis ODS, katarak imatur ODS, dry eye ODS
Afakia OS, Katarak imatur OD, uveitis sanata OS
madarosis, trichiasis, entropion ODS, MGD ODS, KSI ODS, dry eye ODS
KSI ODS, dry eye ODS
KSI ODS
Dermatochalasis OD, katarak imatur ODS, epiteliopati ODS, dry eye ODS
r OS, dermatokalasis ODS, dry eye ODS
KSI ODS, dermatochalasis ODS, pterygium ODS, epiteliopati ODS
blefaritis ant ODS, KSI OD, dry eye ODS
madarosis ODS, trikiasis OS, pterigium OS, KSI ODS, dry eye ODS
Madarosis ODS, KSI ODS, dry eye ODS
pterygium, KSI ODS, dry eye ODS
dermatochalasis ODS, pterygium ODS, pseudofakia OD, katarak matur OS, iridodialisis OD, dry eye ODS
uveitis OD
dermatochalasis OD, KSI ODS, pterygium OS
dermatochalasis OS, katarak matur OD, KSi OS, dry eye ODS
KSI ODS, dry eye ODS
lagoftalmus + corneal exposure OS, dry eye OS
entropion OD, madarosis ODS, sikatriks kornea OD, pseufofakia ODS
katarak imatur ODS
KSI ODS, Dry eye ODS
mata tenang ODS
lagoftalmus + corneal exposure ODS
pre physical eye OS, uveitis sanata OD,
madarosis ODS, dry eye ODS
mata tenang ODS
dermatochalasis ODS, epiteliopati ODS, KSI ODS, dry eye ODS
KSI ODS, dry eye ODS
 KSI ODS
DERMATOCHALASIA ODS
DRY EYE ODS
lagoftalmus ODS, uveitis ODS
madarosis ODS, lagoftalmus OD, sikatriks kornea ODS, dry eye ODS
KSI ODS, entropion OS, madarosis ODS
lagoftalmos + corneal exposure ODS, trokiasis OS, hemifacial spasm OD, dry eye ODS
PTERIGIUM ODS, DRY EYE ODS
dry eye ODS, katarak subcapsularis posterior ODS, myopia ODS
pterigium ODS, epiteliopati OD, KSI ODS
mata tenang ODS, dry eye ODS
madarosis ODS, entropion ODS, trikiasis ODS, pterigium OD, KSI ODS, makula kornea OS
dermatochalasis, entropion, madarosis, trichiasis ODS, post uveitis ODS, KSI ODS< dry eye ODS
KSI ODS, DRY EYE ODS
lagoftalmos OS, pterigium ODS, katarak subcapsular ODS, dry eye
ektropion, entropion, trikiasis, corneal scar, KSI OS ; katarak matur OD ; epiteliopati ODS ; dry eye ODS
pterigium ODS, corneal scar OD, KSI ODS, dry eye ODS
epiteliopati ODS, katarak imatur ODS, dry eye ODS
madarosis ODS, KSI ODS
dermatochalasis ODS, trichiasis ODS, lagoftalmos + corneal exposure OS, corneal scar ODS, KSI ODS, dry eye ODS
mata tenang ODS
pterigium ODS
DRY EYES ODS
KSI ODS, dry eye ODS
dermatochalasos ODS, lagoftalmos OD, pinguecula OS, scar cornea OD, KSI ODS, dry eye ODS, ektropion OD palp inf
uveitis posterior ODS< KSI ODS
trichiasis OS, dermatochalais ODS, KSI ODS, dry eye ODS
pseudofakia ODS
dermatochalasis, madarosis
 Entropion trikiasis OS, madarosis ODS, KSI ODS
KSI IDS, pterigium ODS, dry eye ODS
lagoftalmos tanpa CE OS, dry eye ODS
dry eyes OS, KSI ODS, dermatochalasis ODS
pseudofakia ODS, dry eye OS
trikiasis ODS, pinguecula OD, cornea scar OD, KSI ODS, lagoftalmos tnpa CE ODS, dry eye ODS
pterigium gr II OD, gr I OS, dry eyes ODS
lagoftalmos ODS, entropion ODS, KSI ODS, ektropion, uveitis OD
dry eyes ODS
mata tenagn ODS, dry eyes ODS
dermatochalasis , pterigium, KSI ODS, dry eyes OS
KSI ODS, kista kantus lateral OD
MGD gr III-IV, KSI ODS, dry eye ODS
madarosis ODS, dry eyes ODS, pinguecula OD, KSI ODS
KSI ODS
mata tenang ODS
mata tenang ODS
pterigium ODS
nevus palpebra OD, dermatochalasis ODS, pterigium OD, KSI ODS, dry eye OS
KSI ODS, pterigium OS, dry eyes ODS
LAGOFTALMUS ODS TANPA CORNEAL EXPOSURE
LAGOFTALMUS ODS, EKTROPION ODS, DERMATOKALASIA ODS, XANTHELASMA ODS
DERMATOKALASIA ODS, PINGUEKULA ODS, MADAROSIS ODS, TRIKIASIS ODS, KSI ODS
EKTROPION OD, DERMATOKALASIA ODS, LAGOFTALMUS ODS TANPA CORNEAL EXPOSURE
DERMATOKALASIA + PTOSIS ODS, KSI ODS, EPITELIOPATI ODS, DRY EYES OD
KSI ODS
SIKATRIKS KORNEA OD
MADAROSIS ODS, DRY EYES ODS
MATA TENANG ODS, DRY EYES OS
LAGOFTALMUS OD, PTERIGIUM ODS, KSI ODS
 TERAPI

c.lyterrs 6 x ODS
lyters 6 x OS
lyters ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS, resep kacamata +2.00
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS, resep kacamata +1.50
resep kacamata addisi +1.50
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
c. lyterrs 6 x ODS, Kacamata +2.00
c.lyteers 6 x ODS, addisi +3.00
c.lyterrs 6 x ODS, addisi +3.00
c.lyteers 6 x ODS, addisi +2.00
c. lyteers 6 x ODS
c. lyteers 6 x ODS
c. lyteers 6 x ODS, addisi +1.50
c. lyteers 6 x ODS
lid hygiene OS, c. lyteers 6 x ODS
levoflox 6 x OD, c.lyteers 6 x ODS, resep kacamata S +1.50
 c. lyteers 6xODS, lid taping
c. lyteers 6xODS, lid taping, kacamata +2.00
c. lyteers 6x ODS, Kacamata +2.00
c. lyteers 6x ODS
c. lyteers 6x ODS, Kacamata +2.00
lyters 6xODS, kacamata S+3.00
lyters 6xODS
lyters 6xODS
C. lyters 6xODS, kacamata +3.00
lyters 6xODS
lyters 6xODS

lyters 6xODS
lyters 6xODS
lyters 6xODS
lyters 6xODS + kacamata +2.00
pro phaco +IOL ODS
lyters 6xODS, kacamata S+3.00

lyters 6xODS
lyters 6xODS, kacamata S+1.50
lyters 6xODS

lyters 6xODS, kacamata S+2.00

lyters 6xODS
lyters 6xODS
lyters 6xODS, kacamata S+3.00
lyters 6xODS
lyters 6xODS
lyters 6xODS
lyters 6xODS

lyters 6xODS
lyters 6xODS
lyters 6xODS
lyters 6xODS
lyters 6xODS
lyters 6xOD, KACAMATA +2.50
lyters 6xODS
lyters 6xODS
TIDAK ADA TERAPI
LYTERS 6XODS
TIDAK ADA TERAPI
LYTERS 6XODS
lyters 6xOS, KACAMATA +1.50
LYTERS 6XODS
lyters 6xOS, KACAMATA +2.00
LYTERS 6XODS
P.PRED 6XOD, LYTERS 6XODS
LYTERS 6XODS
LYTERS 6XODS
TIMOL 2XOD, LYTERS 6XODS
LYTERS 6XODS, KACAMATA +2.00
LYTERS 6XODS, P.PRED 4XODS
LYTERS 6XODS, KACAMATA +2.50
 LYTERS 6XODS + KACAMATA +3.00
LYTERS 6XODS
LYTERS 6XODS
TIDAK ADA TERAPI
LYTERS 6XODS + KACAMATA +2.50

LYTERS 6XODS
LYTERS 6XODS
LYTERS 6XODS + KACAMATA +2.50
LYTERS 6XODS
KACAMATA +2.50
LYTERS 6XODS + KACAMATA +3.00
LYTERS 6XODS + KACAMATA +3.00
LYTERS 6XODS
LYTERS 6XODS + KACAMATA +1.50
LYTERS 6XODS
LYTERS 6XODS

LYTERS 6XODS
LYTERS 6XODS
LYTERS 6XODS, KACAMATA +1.50

LYTERS 6XODS, PRO SECONDARY IMPLAN OD

LYTERS 6XODS
LYTERS 6XODS
LYTERS 6XOS
LYTERS 6XODS
LYTERS 6XODS
 LYTERS 6XODS
LYTERS 6XODS, KACAMATA +2.00
TIDAK ADA TERAPI
lyters 6 x OD, kacamata addisi +3.0
lyters 6 x ODS, kacamata S +1.50
lyters 6x ODS, kacamata +2.50
lyters 6x ODS, kacamata +2.50
lyters 6x ODS
lyters 6x ods, kacamata +2.00
lyters 6c ODS
lfx 6xod, lyters 6x ods, kacamata +3.00
c lyters 6xods, kacamata +3.00
LYTERS 6XODS, Kacamata +2.50
LFX tiap jam ODS, lyters 6x ods
lyters 6xods, kacamata +3.00
lyters 6xods, kacamata +2.50
kacamata +2.00
lyters 6xods
lyters 6x ods, ppred 6x os
lyters 6x ods
lyters 6x ods, kacamata +2.50
lyters 6x ods
lyteers 6xODS, kacamata +2.00
lyters 6xods, kacamata +2.00
lyters 6xods, kacamata +2.50
lyters 6xods
lyters 6xODS
lyters 6xODS
lyters 6xods
 lyters 6xods, lfx 6xods
lyters 6x ods, kacamata +3.00, lfx 4xod
lyters 6xods
lyters 6xods
lyters 6XODS, kacamata S +2.50
lyters 6xods, kacamata +3.00
lyters 6xods
lyters 6xods, kacamata +3.00
Lyters 6xods, kacamata +3.00
lyters 6xods, kacamata +3.00
lyters 6xods
lyters 6xods
lyters 6xods, kacamata +3.00
lyters 6xods
lyters 6xods, kacamata S +2.50
Lyters 6x ods
kacamata +1.50
lyters 6xods
lyters 6xods, kacamata +2.50
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6 x ODS
lyters 6 x ODS, kacamata +2.50
lyters 6 x ODS, kacamata +3.00
lyters 6 x ODS, kacamata S +2.50
lyters 6 x ODS
 lyters 6 x ODS, kacamata +2.50
lyters 6 x ODS
lyters 6 x ODS, kacamata +2.50
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS, kacamata +3.00
lyteers 6 x ODS
lyteers 6 x ODS
lyteers 6 x ODS, kacamata +1.50
lyters 6 x ODS
lyters 6 x ODS, kacamata +2.50
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x OD, pred. 6 x OD
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS

lyters 6 x ODS
lyters 6 x ODS, kacamata S +2.50
lyters 6 x ODS, kacamata S +1.50
lyters 6 x ODS
kacamata S +1.50
lyters 6 x ODS, kacamata S +2.50
lyters 6 x ODS
 lyters 6 x ODS
lyters 6 x ODS

lyters 6 x ODS

lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS

lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS

lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
pred 6 x ODS, lyters 6 x ODS
lyters 6 x ODS
lyters 6 x ODS
tidak ada terapi
 tidak ada terapi
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
lyters 6xods
tidak ada terapi
tidak ada terapi
tidak ada terapi
lyters 6xods
lyters 6xods
lyters 6xods
LYTERS 6XODS
LYTERS 6XODS

LYTERS 6XODS
LYTERS 6XODS
LYTERS 6XODS
TIDAK ADA TERAPI
LYTERS 6XODS
LYTERS 6XODS
LYTERS 6XODS
PROYEK KATAMATAKU SINGKAWANG
20-Jul-19

IDENTITAS
NO URUT
NAMA

88 Winda Wati
89 Bang Sun Gi
90 Andi Musa
91 Ca Cin Cu
92 Dahari
93 Tjeng Bui Sun
94 Halimah
95 Tshi Klain Ngo
96 Alun Irianto
97 Tjin Fun Fa
98 Sut Suga
99 Ernami
 2. Telah memberikan persetujuan ikut penelitian yang te
3. Bersedia mengiku

1. Partisipan menderita gangguan jiwa berat atau kes

IDENTITAS

ALAMAT RUMAH NO TELEPON

RSK alverno Singkawang

RSK alverno Singkawang
Dusun Setogor, Desa Sobok
Jl Gunung Sari Singkawang Barat
Jl Veteran No.26 RT/RW 26/09, Singkawang
Jl Gunung Sari Singkawang Barat
RSK alverno Singkawang
Jl Gunung Sari Singkawang Barat
RSK Alverno Singkawang
RSK alverno Singkawang
Antam, Rayan
RSK alverno Singkawang
 KRITERIA INKLUSI
23-24 APRIL 2018
uan ikut penelitian yang terdokumentasikan sebelum dilakukan prosedur penelitian
3. Bersedia mengikuti prosedur penelitian

KRITERIA EKSKLUSI
ngguan jiwa berat atau kesulitan berkomunkasi berdasarkan penilaian tim peneliti

1= ya 1= ya 1= ya 1= ya 1 = hari 1
0 = tidak 0 = tidak 0 = tidak 0 = tidak 0 = hari 2

1. Pasien KRITERIA INKLUSI DAN EKSKLUSI

2. Telah
kusta yang memberika
KRITERIA INKLUSI
sedang/per n
nah persetujuan
menjalani ikut
pengobatan penelitian 3. Bersedia
mengikuti KRITERIA EKSKLUSI HARI PEREKRUTAN
TANGGAL LAHIR(DD/MM/YYYYY)
monoterapi yang prosedur
/MDT di terdokumen penelitian
Rumah Sakit tasikan
Sitanala sebelum
berdasarkan dilakukan
pengakuan1 prosedur 1 1 0 1
pasien 1 penelitian1 1 1 1
1 1 1 0 1
1 1 1 0 1
1 1 1 0 1
1 1 1 0 1
1 1 1 0 1
1 1 1 0 1
1 1 1 0 1
1 1 1 0 1
1 1 1 0 1
1 1 1 0 1
 1
1
1
1
1
1
1
1
1
1
1
1
1
1
1 1 1 0 1 20/07/2019
1 1 1 0 1 20/07/201 ###
1 1 1 0 1 20/07/201 15/04/19070
1 1 1 0 1 20/07/201 ###
1 1 1 0 1 20/07/202 ###
1 1 1 0 1 20/07/202 ###
1 1 1 0 1 20/07/202 ###
1 1 1 0 1 20/07/202 18/01/1950
1 1 1 0 1 20/07/2024
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
 PEKERJAAN UTAMA PENGHASILAN RT PENDIDIKAN

1 - Pelajar 1 - <1.5 juta 1 - Tidak Sekolah

2 - Buruh bangunan 2 - 1.5 - 3.5 juta 2 - Lulus SD
3 - Buruh Pabrik 3 - > 3.5 juta 3 - Lulus SMP
4 - Supir Ojek 4 - Tidak mau menjawab 4 5- Lulus SMA
- Sarjana/Magister/
5 - Tukang Masak Doktor
6 - IRT
7 - Guru/Pendidik
8 - Pegawai Kantor
9 - Mekanik
10 - Tidak Bekerja
1 = pria
11 - Tidak Berlaku (pasien anak)
2 = wanita 99 - Lainnya

DEMOGRAFI
PEKERJAAN UTAMA
TINGKAT
USIA JENIS KELAMIN PENGHASILAN/BLN PENDIDIKAN
KODE KETERANGAN

58 tahun 2 10 tidak bekerja 4 4

95 tahun 2 10 tidak bekerja 4 1
35 tahun 1 3 buruh pabrik 2 3
78 tahun 2 10 tidak bekerja 4 1
45 tahun 1 99 petani 4 2
67tahun 1 10 tidak bekerja 4 1
60 tahun 2 10 tidak bekerja 4 1
70 tahun 2 10 tidak bekerja 1 1
77 tahun 1 10 tidak bekerja 4 2
77 tahun 2 10 tidak bekerja 4 1
22 tahun 1 10 tidak bekerja 1 4
28 tahun 2 10 tidak bekerja 1 2
 2 99 Petani 1 3

60 1 99 Petani 1 1
49 1 99 Petani 4 2
49 1 99 Petani 1 2
57 2 99 Petani 1 1
40 2 6 4 2
65 2 6 1 1
64 1 99 Petani 1 2
69 1 99 Petani 1 2
71 1 99 Petani 1 2
ENDIDIKAN STATUS PERNIKAHAN SUKU JUMLAH TINGGAL JUMLAH PENDERITA
SERUMAH KUSTA SERUMAH
Tidak Sekolah 1 - Belum Menikah 1 - Jawa 1 - Tinggal sendiri 1 - Tidak ada
2 - Lulus SD 2 - Menikah 2 - Sunda 2 - 1 orang 2 - 1 orang
- Lulus SMP 3 - Cerai (mati/hidup) 3 - Bali 3 - 2 orang 3 - 2 orang
5- Lulus SMA 4 - Tidak mau menjawab
- Sarjana/Magister/ 4 - Betawi 4 - > 2 orang 4 - > 2 orang
Doktor 5 - Tidak berlaku 5 - Aceh 5 - Tidak mau menjawab 5 - Tidak mau menjawab
6 - Madura
7 - Lampung
8 - Lainnya

MOGRAFI

TINGKAT JUMLAH ORANG JUMLAH PENDERITA

STATUS PERNIKAHAN SUKU (DARI AYAH) TINGGAL
PENDIDIKAN SERUMAH KUSTA SERUMAH

1 1
2 8
2 1
2 1
2 1
1 8
2 3
3 8
3 8
1 8
1 8
1 8
4 2
3 2
2 1
2 1
1 1
5 1
2 2
1 1
1 2
1 1
4 2
1 1
2 8 Dayak 4 4

2 1 4 1
2 8 4 3
2 1 2 2
2 1 4 2
2 8 4 3
2 8 Melayu 3 2
2 1 4 2
2 8 China 2 2
2 1 4 2
 2. Saat ini, 6. Seberapa
apakah 4. Seberapa besar
menurut sakit atau kesulitan 9. Karena
Anda tidak yang anda 7. Karena penglihatan
1. Secara alami saat penglihata 8.
penglihatan nyaman 5. anda,
Seberapa pekerjaan n anda, Seberapa
umum, Anda jika yang pernah melakukan seberapa
3. Berapa
menurut menggunak Anda besar besar
an kedua
banyak rasakan di
besar atau hobi seberapa kesulitan kesulitan
Anda, yang
waktu dalam dan kesulitan mengharuska besar yang Anda yang anda
kesehatan mata
(dengan Anda sekitar mata yang Anda n anda untuk kesulitan alami saat
Anda kacamata merasa Anda (misal alami saat melihat baik yang anda alami berjalan
secara atau lena dari jarak alami saat membaca menuruni
khawatir rasa nyeri membaca dekat,
keseluruh kontak, jika seperti seperti rambu- undakan,
dengan terbakar, tulisan memasak, mencari rambu
an adalah anda di tangga atau
memakainy penglihata gatal atau biasa di menjahit, sesuatu di jalan atau trotoar
a) adalah n Anda? nyeri?) surat memperbaiki rak yang dalam
benda-benda nama
sempurna, Apakah kabar? disekitar penuk cahaya
baik, cukup, menurut toko? redup atau
rumah atau sesak?
bruuk atau anda rasa mengguanaka malam hari?
sangat itu? n alat-alat
buruk? tangan?

No 1 No 2 No 3 No 4 No 5 No 6 No 7 No 8 No 9

5 5 4 3 1 1 1 1 1
5 6 2 2 5 5 5 4 5
3 1 1 1 1 1 1 1 1
4 6 5 2 4 4 4 4 3
4 4 4 4 5 4 4 3 3
1 2 1 1 1 1 1 1 1
3 3 1 1 5 5 1 5 1
4 5 4 2 2 5 5 5 5
3 5 5 3 3 3 3 3 2
3 3 2 2 5 3 2 1 1
2 1 1 1 1 1 1 1 1
4 1 2 2 1 1 1 1 1
5 5 5 4 4 3 1 1 1

3 3 1 1 3 1 1 1 1
1 1 1 2 1 1 1 1 1
2 2 1 2 1 1 1 1 1
4 5 2 3 1 3 3 2 1
3 2 1 1 5 1 1 1 1
3 1 1 1 1 1 1 1 1
2 5 4 5 3 3 2 2 2
4 4 1 1 1 1 1 1 1
3 3 1 1 5 1 1 1 1
 PERTANYAAN NOMOR

10. 14.
12. 13. 15b. 15c. JIKA
Karena Karena 15. JIKA ANDA SAAT INI
Karena Karena penglihata Sekarang,
penglihata 11. Karena penglihata 15a. Jika BERHENTI
penglihata n Anda, saya ingin MASIH
n anda, penglihatan TIDAK, MENGEMU
anda, n anda, n anda, seberapa bertanya DI Apakah MENGEM
seberapa sebeapa seberapa seberapa TANYAKA
hal itu UDI
besar besar besar tentang N Apakah
besar besar terutama Seberapa
kesulitan kesulitan kesulitan kesulitan mengend Anda karena
kesulitan yang Anda banyak
yang anda yang anda yang anda yang arai belum penglihatan kesulitan
anda alami saat mobil.
alami saat alami saat
pernah Anda,
memperh bagaimana alami
melihat saat alami saat pergi terutama yang Anda
mengunju menonton Apakah mengemu
memilih karena alami saat
atikan orang-orang Anda dikan
dan ngi orang bioskop, mengemu suatu alasan mengemu
benda bereaksi mobil lain atau di di siang
yang jatuh terhadap memadan di rumah drama, di, atau Anda karena
hal-hal yang kan mereka, hari di
di atau sebaiknya sudah penglihatan
anda pakaian di pesta Anda dan tempat
samping katakan? pertandin sekali- berhenti
anda atau di alasan yang Anda
saat anda gan sekali?
sendiri? restoran? olahraga? lainnya itu? kenali?
berjalan?

INDEKS KUALITAS HIDUP OFTALMOLOGI

No 10 No 11 No 12 No 13 No 14 No 15 No 15a No 15b No 15c

1 1 1 1 2 1 0 0 1
3 3 5 3 5 2 1 0 0
1 1 1 1 1 1 0 0 1
4 4 4 4 4 2 1 0 0
3 3 2 2 3 2 1 2 0
1 1 1 1 1 1 0 0 0
1 1 5 5 1 2 1 0 0
5 3 1 5 5 2 0 0 0
3 3 2 2 2 2 2 1 0
1 1 1 2 2 2 0 0 0
1 1 1 1 1 1 0 0 1
1 1 1 1 1 2 1 0 0
1 1 1 1 1 2 1

1 1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1 1 1 2 1 2
1 1 1 1 1 2 1 2
1 1 1 1 1 2 1 2
1 2 1 1 1 2 1 3
3 1 1 1 2 2 2 1
2 1 1 1 1 1 1
1 1 1 1 1 2 1 2
 19.
18. Seberapa
berpengaru
Apakah h rasa sakit
16a.Seberap Anda atau tidak 22. 23.
a besar
17. terbatasi nyaman
16. kesulitan Kontrol Karena
dalam hal yang pernah 20. Saya 21. Saya
Seberapa yang Anda Apakah Anda saya penglihata
alami saat Anda berapa rasakan
besar mengemudi di sering kali sering terhadap n saya,
kesulitan di keadaan mencapai lama dalam dan tetap sekali apa yang saya
kurang Anda di sekitar tinggal di merasa
yang Anda yang sulit, dari saya terlalu
yang dapat mata Anda
alami saat seperti (misalnya, rumah frustasi lakukan banyak
mengemu dalam cuaca inginkan bekerja
Anda
rasa seperti karena karena hanya bergantun
buruk, pada atau
di di jam terbakar,
sibuk, di karena melakuka gatal atau penglihata penglihata sedikit, g kepada
malam jalan bebas penglihata n saya n saya karena apa yang
n kegiatan nyeri) dalam
hari? hambatan penglihata dikatakan
n Anda? lain mencegah
atau lalu Anda n saya orang lain
lintas kota? karena
penglihata melakukan
apa yang
n Anda? Anda ingin
lakukan?

No 16 No 16a No 17 No 18 No 19 No 20 No 21 No 22 No 23

4 4 5 4 4 5 5 5 5
0 0 3 3 3 3 3 2 1
1 1 5 5 5 5 5 5 5
0 0 2 2 2 2 1 2 2
0 0 2 2 2 4 4 4 5
0 0 5 5 5 5 5 5 4
0 0 5 5 5 1 5 4 4
0 0 5 5 5 4 1 4 4
0 0 2 2 4 4 4 4 4
0 0 3 2 4 3 3 5 5
1 1 5 5 5 5 5 5 5
0 0 5 5 5 5 5 5 5
 5 4 4 5 2 5 5

2 1 5 5 5 5 5 5 5
2 2 5 5 4 5 5 5 5
5 5 4 5 5 5 5
5 5 3 3 2 5 5
5 5 5 5 5 5 5
5 5 5 5 5 4 5
2 1 1 4 3 4 4
4 2 5 4 5 3 4 4 5
5 5 5 5 5 5 5
 25. Saya
khawatir
24. Saya melakuka
membutu n hal-hal
hkan yang akan
banyak memper
bantuan malukan
dari orang diri
lain sendiri
karena atau
penglihata orang lain
n saya karena
penglihata
n saya

UCVA SNELLEN UPEEK

No 24 No 25
KLASIFIKA KLASIFIKA KLASIFIKA
OD OS SI OS SIMATA
KEDUA OD OS
SI OD

5 5 6/60 3 6/60 3 3 0 0
1 1 0 0 0 0 12/30 12/30
5 5 6/60 3 6/60 3 6/6 6/6
2 2 1/300 3 LP+ 4 3 12/30 12/30
5 5 4/60 3 4/60 3 3 6/24 6/24
5 4 6/60 3 6/60 3 3 1/60 6/24
4 4 6/30 2 6/30 2 2 1/60 LP
3 5 5/60 2 5/60 2 2 6/12 6/7.5
2 4 0 1 6/15 1 1 NLP 6/0.75
5 5 6/60 3 6/20 2 3 6/12 6/12
5 5 6/6 1 6/6 1 1 6/6 6/6
5 5 6/6 1 6/6 1 1 6/6 6/6
2 2 LP 4 6/9 1 1 Hand move 6/6

5 5 6/20 2 6/15 1 1 6/9 6/15

5 5 6/7.5 1 6/15 1 1 6/6 6/6
5 5 6/6 1 6/6 1 1 6/6 6/6
5 5 6/9 1 6/9 1 1 6/6 6/9
5 5 6/6 1 6/6 1 1 6/6 6/6
5 5 6/60 2 6/60 2 2 6/30 6/24
4 4 1/300 4 2/60 2 2 LP 6/30
5 5 1/60 2 1/60 2 2 1/300 1/60
5 5 6/30
 PEMERIKSAAN VISUS, TIO DAN REFRAKSI
UREFRAKSI AUTOREF
OD OS
OD OS
S C A S

0 0 225 -100 45 -150

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 - 3.75 - 1.75 80 +2.00
0 0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0
0 0 +11 0 0 +11.00
0 0 + 100 -2.75 80 +1.75
0 0 0 0 0 0
0 0 0 0 0 0
+0.75 -0.50 62 +0.50

-2.25 -2 91 +0.25
+4.25 -18.75 75 +0.00
+13.00 +13.00
DAN REFRAKSI
SUBJECTIVE VISUS (TRIAL LENSE)
OS OD OS

C A S C A S C A

-100 95 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 s-9.00 0 0 LP+ LP+ LP+
-2.75 140 0 0 0 0 0 0
0 0 s + 175 c- 200 95 s+400 c-300 90
0 0 0 0 0 0
0 0 0 -175 80 0 -150 150
-1.00 0 0 0 0 +10.00 0 0
-2.75 76 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
-0.25 101

-3.50 80 -2.25 addisi +3.00 -2.50 addisi +3.00 80

-3.25 63 +4.00 -3.00 63
+13.00 +13.00
 SENSIBILITAS KORNEA
BCVA TIO
MATA KANAN MATA K

OD OS OD OS Superior Nasal Inferior Temporal Superior

6/9 6/9 15 15 60 60 60 60 60
0 0 0 0 0 0 0 0
6/6 6/6 15 14 60 60 60 60 60
1/300 LP+ 19 20 60 60 60 60 60
6/24 6/24 15 3 <5 <5 <5 <5 <5
6/9 6/9 11 10 60 60 60 60 60
8 8 60 60 60 60 60
6/60 6/60 7 7 50 50 50 50 60
0 6/15 66 9 0 0 0 0 60
0 0 17 15 60 60 60 60 50
0 0 11 9 60 60 60 60 60
0 10 9 60 60 60 60 60
 tdp 12 sikatriks 60

12 10 60 60 60 60 60
7 8 60 55 60 60 25
6/6 6/6 10 9 60 60 60 60 60
8 9 60 60 60 60 60
14 15 60 60 60 60 60
6/9 6/9 22 9 60 60 60 60 60
1/60 6/24 8 8 20 sdn (pterig 15 20 60
6/30 6/20 9 7 50 50 60 60 60
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK

AS KORNEA
MATA KIRI MADAROSIS TRIKIASIS EKTROPION

Nasal Inferior Temporal OD OS OD OS OD OS

60 60 60 1 1 0 0 0 0
0 0 0 1 1 0 0 0 0
60 60 60 0 0 0 0 0 0
60 60 60 1 1 0 1 0 0
<5 <5 <5 1 1 0 0 1 1
60 60 55 0 0 0 0 0 0
60 60 60 1 1 0 0 0 0
60 60 60 0 0 0 0 1 1
40 50 35 1 1 0 0 0 0
50 50 50 0 0 0 0 0 1
60 60 60 0 0 0 0 0 0
60 60 60 0 0 0 0 0 0
 55 60 50 0 0 0 0 0 0

60 60 60 1 1 0 0 0 0
55 60 60 1 1 0 0 0 0
60 60 60 0 0 0 0 0 0
60 60 60 1 1 0 0 0 0
60 60 60 1 1 1 0 0 0
60 60 60 1 1 0 1 0 0
sdn(pterigi 60 50 1 1 1 0 0 0
60 60 60 0 0 0 1 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK

ADNEKSA ANTERIOR
ENTROPION LAGOFTALMOS OBSTRUKSI LAKRIMAL EPIFORA DAKRIOSISTITIS

OD OS OD OS OD OS OD OS OD

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 1 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0
 0 = grade 00 = grade 0
1= grade 1 1= grade 1
1 - ADA 1 - ADA 1 - ADA 2 = grade 22 = grade 2 1 - ADA 1 - ADA
3 = grade 33 = grade 3 0 -ADA
TIDAK 0 - TIDAK
0 - TIDAK 0 - TIDAK 0 - TIDAK ADA
4= grade 4 4= grade 4

MATA

DAKRIOSISTITIS LAIN-LAIN MGD INJEKSI

OD OS
OS OD OS OD OS
KODE KET KODE KET

0 0 0 0 0 1 2 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 2 2 0 0
0 0 0 0 0 2 2 0 0
0 0 0 0 0 3 3 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 2 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 1 1 1

0 1 Distichiasis 0 0 3 3 0 0
0 0 0 0 0 3 0 0 0
0 0 0 1 Distichiasis 1 2 0 0
0 1 Blefaritis 0 0 2 3 0 0
0 1 Trichiasis 0 0 2 2 0 0
0 0 0 0 0 0 0 0 0
0 1 lagoftalmos 1 pinguekula 2 2 0 0
0 0 0 1 epitheliop 4 4 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA ADA ADA

KONJUNGTIVA
KONJUNGTIVITIS PTERIGIUM NODUL LAIN-LAIN INJEKSI

OD OS OD OS OD OS OD OS OD

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 pinguekulapinguekula 0

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 PinguekulaPinguekula 0
0 0 0 0 0 0 0 Pinguekula 0
0 0 0 0 0 0 PinguekulaPinguekula 0
0 0 0 0 0 0 Pinguekula 0 0
0 0 0 0 0 0 Pterigium Pterigium 0
0 0 0 0 0 0 pterigium gr
pterigium 0
0 0 0 0 0 0 Pinguekula 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA ADA

SKLERA
INJEKSI EPISKLERITIS SKLERITIS STAFILOMA LAIN-LAIN
OD
OS OD OS OD OS OD OS
KODE KETERANGAN

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA ADA

PUPIL
LAIN-LAIN REFLEKS ANISOKORIA LAIN-LAIN KERATITIS
OS
OD OS OD OS OD OS OD
KODE KETERANGAN

0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 Sinekia pos 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 1 0 0 0 ireguler(?) 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA ADA ADA

SENSIBILITAS KORNEA, SEGMEN ANTERIOR-POSTERIOR, T

KORNEA
KERATITIS PANUS LEUKOMA KERATINISASI KERATIK PRESIPITAT

OS OD OS OD OS OD OS OD OS

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 0

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA ADA ADA

IOR-POSTERIOR, TEAR BREAK UP TIME DAN SCHIRMER

KERATITIS PUNGTATA ULKUS LAIN-LAIN IRIS PEARLS IRITIS

OD OS OD OS OD OS OD OS OD

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 N/A 0 N/A

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 Sikatrik ec 0 0 0 0
0 0 0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA

UVEA
IRITIS AQUEOUS FLARE AQUEOUS CELLS LAIN-LAIN
OD OS
OS OD OS OD OS
KODE KETERANGAN KODE KETERANGAN

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 N/A 0 N/A 0 N/A 0

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA ADA ADA

LENSA
KEKERUHAN NUCLEAR KEKERUHAN SUBCAPSULAR ANT KEKERUHAN SUBCAPSULAR POST KATARAK MATUR KEKERUHAN KORTIKAL

OD OS OD OS OD OS OD OS OD

1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
N/A 0 N/A 0 N/A 0 N/A 0 N/A

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA

SEGMEN POSTERIOR PA
KEKERUHAN KORTIKAL LAIN-LAIN PAPILEDEMA PULSASI VENA
OD OS
OS OD OS OD OS
KODE KET KODE KET

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 N/A 0 N/A 0 N/A 0

0 1 Katarak ima 1 Katarak ima 0 0 0 0

0 1 Katarak ins 1 Katarak ins 0 0 0 0
0 0 0 1 Katarak ima 0 0 0 0
0 1 Katarak ima 1 Katarak ima 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 Katarak len 1 Katarak ima 0 0 0 0
0 1 IOL (+) 1 IOL (-) aph 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA ADA ADA

SEGMEN POSTERIOR PAPIL SARAF OPTIK

EKSTRAVASASI PAPIL SARAF ATROFI LAIN-LAIN PERDARAHAN SUBHIALOID
PERDARAHAN INTRARETINA

OD OS OD OS OD OS OD OS OD

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
N/A 0 N/A 0 N/A 0 N/A 0 N/A

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA

RETINA
RDARAHAN INTRARETINA EDEMA RETINA EDEMA MACULA LAIN-LAIN
OD OS
OS OD OS OD OS
KODE KETERANGAN KODE KETERANGAN

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 N/A 0 N/A 0 N/A 0

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 geografik at 1 geographic
0 0 0 0 0 0 0 0 0
 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA 1 - ADA
0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK 0 - TIDAK
ADA ADA ADA ADA ADA ADA ADA ADA

PEMBULUH DARAH RETINA STABILITAS AIR MATA

RASIO ARTERI VENA PERDARAHAN MIKROANEURISMA LAIN-LAIN TBUT

OD OS OD OS OD OS OD OS OD

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
N/A 1 N/A 0 N/A 0 N/A 0

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
STABILITAS AIR MATA PRODUKSI AIR MATA
TBUT SCHIRMER I SCHIRMER 2

OS OD OS OD OS

0 3 6 0 0
0 0 0 0 0
0 >35 >35 0 0
0 13 12 0 0
0 0 0 0 0
0 4 5 0 0
0 16 0 0 0
0 10 2 0 0
0 7 6 0 0
0 9 9 0 0
0 12 15 0 0
0 4 7 0 0
 34 27

0 4 6
0 30 25
0 33 >35
0 11 1
0 7 16
0 >35 16
0 25 9
0 5 7
 DIAGNOSIS

Madarosis ODS + Katarak Imatur ODS

Madarosis ODS + Blefaritis ODS+ Afakia OD + Pseudofakia ODS
MGD ODS + Pingecuela ODS
Katarak Matur ODS, trichiasis OS, Corneal Scas OS
midrosis ODS + elektropion OD
Ektropiom OD + Pinguecela ODS+ katarak imatur OPD
Katarakimatur ODS + pteregium OD+ piinguecela OS
Ektropion ODS + Lagoftalmus ODS + Blefaritis ODS + Sikatrik OD + Katarak Imatur ODS
Madarosis ODS + Ektropion OS + Pinguecuela OS + Sikatrik OD
MGD ODS + Pinguecuela OS + Katarak Imatur+ektropion OS
Normal
Normal
Corneal Scar OD, Pterigium graede I OS, MGD grade I ODS

Madarosis ODS + Distichiasis OD + MGD gr III + Pinguekula OS + Katarak Imatur ODS

Pinguekula ODS
Districhiasis OS + MGD ODS + Pinguekula OS + Katarak imatur OS
Madarosis ODS + Blefaritis OD + Pinguekula ODS + Katarak Imatur ODS
Madarosis ODS + Trichiasis OD + MGD ODS + Pinguecula OD + Sinekia Posterior OD
Madarosis ODS + Trichiasis OS + pterigium ODS
Madarosis ODS + lagoftalmos OD + MGD gr II ODS + Hordeolum internum OS + sikatrik kornea ec pasca avulsi pte
 TERAPI

Cenfresh 3x1 ODS

Cenfresh 3x1 ODS
Cenfresh 3x1 ODS
Cenfresh 3x1 ODS
Cenfresh 4x1 ODS
Cenfresh 4x1 ODS
cenfersh 3x1 ODS
cenfresh 3x1 ODS
Cenfresh 3x1 ODS
Cenfresh 3x1 ODS
Tidak ada pengobatan
Tidak ada pengobatan
 Cenfresh 3 x 1 gtt ODS
Cenfresh 3 x 1 gtt ODS
Cenfresh 3 x 1 gtt ODS
Cenfresh 3 x 1 gtt ODS
Cenfresh 3 x 1 gtt ODS

kornea ec pasca avulsi pterigium OD + pterigium ODS

 0=
tidak/belu
m pernah
1= Pausi release
1= ya 1= ya
from
Basiler
2= Multi treatment
0= tidak 0= tidak
Basiler
98= Tidak 98 = tidak 98 = tidak
tahu tahu tahu

Tipe kusta
Lama berdasark
Lama
TERAPI keluhan an terapi
sakit Riwayat Riwayat
sebelum saat
kusta putus obat relaps
terdiagnos pertama
(bulan)
is kusta kali
diberikan
12 98 1 1 1
 RIWAYAT PENYAKIT KUSTA

0 = tidak 1= 0.25-
ada reaksi 2=6tab
6-10
1= tipe 1 1= 1= ya
ya/pernah tab
3 = > 10
2= tipe 2 0= tidak 1= ya
98 = tidak mendapat 98 = tidak 98 = tidak 98 = tidak 98 =tab
tidak 0= tidak
0 = tidak
modifikasi
tahu tahu tahu tahu tahu

Jika ada
reaksi, RIWAYAT PENYAKIT KUSTA Apakah
apakah pernah
Bila Ya,
Riwayat 1 ada
Jikadiya Bila Ya, lama
Bila iya, mengalam
wajah?
0 Jika Bila Ya, Riwayat dosis i neuritis
reaksi Riwayat jenis pemberian
tidak lama pemberian kortikoste (nyeri
kusta modifikasi terapi kortikoste
modifikasi kortikoste roid/hari menjalar
(jawaban terapi yang roid
terapi roid yang di siku,
dapat >1) diberikan (dalam
didapat: lutut, dan
bulan)
mata
kaki)?
0 0 98 98 98
 1=
1=
2 = 0-6 belum/ak
sebelum an 1= ya 1= ya
3bulan
pengobat
= 6-12 1
sesudah 2 == 2= dalam 2=tidak
mendapat 2=tidak
4 =an
bulan
> 12
pengobat instruksi
instruksi 3terapi
=terapi
dalamPB
sesudah
bulan 1= ya 3= 1= ya
an dan terapi MB
4 = 5putus
pengobat
sesudah 0= tidak imobilisas =
latihan 0= tidak obaat
98 =an
tidak 98 = tidak
pengobat 98 = itidak 98 = tidak release
tahu
an tahu tahu tahu 98from= tidak
treatment
tahu

Pasangan Apakah
pasien
pasien
memiliki Komo
Onset (MH/tidak) keturunan?
terjadinya 1 Ya 1 Ya
Apakah Jenis Status
neuritis Riwayat 0 Tidak 0 Tidak pengobat
pernah fisioterapi imunisasi
(Jika YA
pernah
mendapat yang BCG an kusta
Diabetes melitus
Hipertensi
mengalam
fisioterapi diterima saat ini
i neuritis)
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak
99 = lainnya

RIWAYAT PENYAKIT KUSTA SAAT INI DAN KOMORBIDITAS

Komorbiditas dan ko-infeksi Pengobatan lain sela
Lainnya
Tuberkulosis HIV Hepatitis B/C
Infeksi cacing
Keganasan Prednison anti nyeri
Kode Keterangan
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak
99 = lainnya

IDITAS
Pengobatan lain selain MDT yang diresepkan oleh dokter Keluhan pad
Lainnya
Alis/bulu Penglihatan Penglihatan
Anti depressan
Antibiotik
Anti hipertensi
Anti diabetes mata rontok silau buram
Kode Keterangan
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 0=tidak 0=tidak

IDENTIFIKASI KELUH
Keluhan pada mata
Bercak/infiltrate/plak Kontraktur lemas
Mata tidak yang mati rasa (clawing)
Riwayat
Mata kering Mata berair Mata merah dapat operasi
menutup mata
rapat Ya / Tidak Lokasi Ya / Tidak Lokasi
 1= ya 1= ya 1= ya 1= ya 1= ya
0=tidak 0=tidak 0=tidak 0=tidak 0=tidak

IDENTIFIKASI KELUHAN SUBJEKIF

Keluhan pada ekstremitas
Kontraktur kaku tangan Tangan lunglai (drop
Kontraktur kaku kaki Luka/borok Kaki semper (drop foot)
(stiffness) hand)

Ya / Tidak Lokasi Ya / Tidak Lokasi Ya / Tidak Lokasi Ya / Tidak Lokasi Ya / Tidak

 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
0=tidak 0=tidak 2=tidak 2=tidak 2=tidak 2=tidak

Inspeksi pada
Hilang jari-jari atau Susutnya jari-jari atau Bercak/makula
Kaki semper (drop foot)
anggota gerak anggota gerak

Dahi Pipi kanan Pipi kiri Dagu

Lokasi Ya / Tidak Lokasi Ya / Tidak Lokasi
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

Inspeksi pada wajah

a Bintil/nodulus
Bercak/Makula bintil/nodulus
Lainnya Dahi Pipi kanan Pipi kiri Dagu Lainnya
Ya/Tidak Keterangan Ya/Tidak
 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak

Inspeksi pada ek
Inspeksi pada tangan
bintil/nodulus jaringan parut kulit keriput penebalan kulit ulkus ekstremitas

Keterangan Ya/Tidak Keterangan Ya/Tidak Keterangan Ya/Tidak Keterangan Ya/Tidak Keterangan

 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

Inspeksi pada ekstremitas

Inspeksi pada kaki
BCG scar Bercak/makula bintil/nodulus jaringan parut kulit keriput

Ya/Tidak Keterangan Ya/Tidak Keterangan Ya/Tidak Keterangan Ya/Tidak Keterangan Ya/Tidak

 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

KULIT
Pemeriksaan mata
pada kaki Lagoftalmus Atrofi otot
kulit keriput penebalan kulit ulkus ekstremitas
OD OS dextra sinistra
Keterangan Ya/Tidak Keterangan Ya/Tidak Keterangan
 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

KULIT
Pemeriksaan tangan
Kitting Lunglai Ulkus Pemendekan jari Atrofi otot

dextra sinistra dextra sinistra dextra sinistra dextra sinistra dextra

 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak

PEMERIKSAAN KLINIS KULIT

Pemeriksaan kaki
Atrofi otot Kitting Lunglai Ulkus Pemendekan jari

sinistra dextra sinistra dextra sinistra dextra sinistra dextra sinistra

 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1= ya 1=lunak 1= ya
2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2=tidak 2= keras 2= tidak

LIT
Palpasi
Anestesi pada lesi Anestesi pada tangan Anestesi pada kaki N. auricularis magnus
dextra
dextra sinistra dextra sinistra dextra sinistra
Ada/tidakkonsistensi nyeri
 1= ya 1=lunak 1= ya 1= ya 1=lunak 1= ya 1= ya 1=lunak 1= ya
2=tidak 2= keras 2= tidak 2=tidak 2= keras 2= tidak 2=tidak 2= keras 2= tidak

Pembesaran saraf tepi

N. auricularis magnus N. ulnaris
sinistra dextra sinistra

Ada/tidakkonsistensi nyeri Ada/tidakkonsistensi nyeri Ada/tidakkonsistensi nyeri

 1= ya 1=lunak 1= ya 1= ya 1=lunak 1= ya 1= ya 1=lunak 1= ya
2=tidak 2= keras 2= tidak 2=tidak 2= keras 2= tidak 2=tidak 2= keras 2= tidak

Pembesaran saraf tepi

N. peroneus komunis N. tibialis posterior
dextra sinistra dextra

Ada/tidakkonsistensi nyeri Ada/tidakkonsistensi nyeri Ada/tidakkonsistensi nyeri

 1= ya 1=lunak 1= ya 1=normal 1=normal 1=normal 1=normal 1=normal 1=normal
2=tidak 2= keras 2= tidak 2=lemah 2=lemah 2=lemah 2=lemah 2=lemah 2=lemah
3= lumpuh3= lumpuh3= lumpuh3= lumpuh3= lumpuh3= lumpuh

Fungsi motorik
N. tibialis posterior N. radialis N. ulnaris N. medianus
sinistra
dextra sinistra dextra sinistra dextra sinistra
Ada/tidakkonsistensi nyeri
 1=normal 1=normal 1=normal 1=normal 1= normal 1= normal 1= normal 1= normal 1= normal
2=lemah 2=lemah 2=lemah 2=lemah 2= tidak 2= tidak 2= tidak 2= tidak 2= tidak
normal normal normal normal normal
3= lumpuh3= lumpuh3= lumpuh3= lumpuh

motorik Fungsi sensorik

N. peroneus komunis N. tibialis posterior N. radialis N. ulnaris N. medianus

dextra sinistra dextra sinistra dextra sinistra dextra sinistra dextra

 1= normal 1= normal 1= normal 1= normal 1= normal 1= pausi 1=0 1=0 1=0
basiler
2= tidak 2= tidak 2= tidak 2= tidak 2= tidak 2= 3multi = 2= 1 2= 1 2= 1
normal normal normal normal normal basiler
release 3= 2 3= 2 3= 2
4 =from
tidak
treatment
diketahui

Fungsi sensorik Derajat kecacatan (WHO)

N. medianus N. peroneus komunis N. tibialis posterior
Tipe kusta
Mata Tangan Kaki
sinistra dextra sinistra dextra sinistra
 0 = tidak,
jika
"tidak",
selama
seminggu
terakhir,
seberapa
1besar
= ya
kelainan
1= tidak sama1= tidak
sekalisama
1= tidak
sekalisama
1= tidak
sekalisama
1= tidak
sekalisama
1= tidak
sekalisama kulit
1= tidak andasekali 1= tidak sama sekali
sekalisama
menjadi
2= kecil 2= kecil 2= kecil 2= kecil 2= kecil 2= kecil masalah 2= kecil 2= kecil
3=besar= 86=NA
86=NA 3=besar= 86=NA
3=besar= 86=NA
3=besar= 86=NA
3=besar= 86=NA
3=besar= 86=NA
3=besar
ketika= 3=besar=
86=NA
4pertanyaa
= sangat 4pertanyaa
= sangat 4pertanyaa
= sangat 4pertanyaa
= sangat 4pertanyaa
= sangat 4pertanyaa
= sangat 4pertanyaa
=anda
sangat 4pertanyaa
= sangat
besar
n tidak besar
n tidak besar
n tidak besar
n tidak besar
n tidak besar
n tidak besar
bekerja
n tidak nbesar
tidak
sesuai sesuai sesuai sesuai sesuai sesuai atau
sesuai sesuai
untuk untuk untuk untuk untuk untuk belajar
untuk untuk
saya saya saya saya saya saya saya saya

Selama
Selama Selama seminggu
seminggu INDEKS
Selama KUALITASSelama
seminggu HIDUP DERMATOLOGI terakhir,
Selama Selama terakhir, terakhir, seminggu Selama seminggu
seminggu seberapa terakhir, apakah kelainan seberapa
seminggu seminggu seberapa terakhir,
terakhir, kulit anda besar
terakhir, terakhir, besar besar seberapa
seberapa mengakibatkan anda kelainan
seberapa seberapa kelainan kelainan besar
besar kulit anda
parah rasa malu atau kulit anda kulit anda kelainan tidak dapat bekerja atau
kelainan mempengar belajar? menyebabk
gatal, perih, tidak menggangg kulit anda
kulit anda uhi kegiatan menyulitka an masalah
nyeri, atau nyamankah u kegiatan mempernga social atai Ya / Tidak Jika Tidak dengan
tersengat anda karena berbelanja, n anda
pada kulit keliainan mengurus ruhi cara kegiatan di untuk pasangan,
anda teman
anda? kulit anda? rumah atau berpakaian? waktu berolahraga dekat, atau
pekarangan santai ? keluarga
? anda? anda?
1= tidak sama1= tidak
sekalisama sekali
1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
2= kecil 2= kecil 2 - tidak ada 2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
3=besar= 86=NA
86=NA 3=besar=
4pertanyaa
= sangat 4pertanyaa
= sangat
besar
n tidak nbesar
tidak
sesuai sesuai
untuk untuk
saya saya

Selama
seminggu Do you
Selama terakhir, wash your
seminggu seberapa Can you Do you Do you
whole
terakhir, menggangg see walk cut your
Do you body?
seberapa ukah (enough Do you sit Do you longer finger or
walk (using
besar pengobatan to carry or squat walk on distances toenails?
kelainan kulit anda, barefoot? soap,
out your on the uneven ? i.e. e.g. using
kulit anda misalnya e.g. most sponge,
daily ground? ground? longer scissors
menyebabk mengotori of the time jug;
activities) than 30 or
an masalah rumah atau standing
seksual? menghabisa ? minutes clippers...
or
kn waktu sitting....)
anda?
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada

Do you lift
Do you
SALSA SCALE
objects
Do you
Do you handle or
Do you work with above
carry Do you manipulat
hold a cup tools? i.e. your Do you Do you
heavy open/clos e small
or basin tools head? e.g. cook? i.e. open jars
objects or Do you e screw objects?
with hot which you to place prepare with
bags? e.g. pour hot capped e.g. coins,
contents? hold in on a shelf, food both screw-on
shopping, liquids? bottles? nails,
e.g. your on your hot and lids? e.g.
food, e.g. oil, small
drinks, hands to head, to cold jam...
water, water .. screws,
food… help you hang
wood ... grains and
work ... clothes to
seeds ...
dry ...
 1 - ada 21--tidak
ada 1 - ada 1 - ada 1 - ada 1 - ada
2 - tidak ada ada 0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada

Do you Do you Do you DEFORMITAS

use thread pick up CLAW HAND
Do you CLAW HAND ULNAR MEDIOULNAR
buttons? needles? pieces of
pick up Total
e.g. i.e. pass paper,
things SALSA
buttons thread handle
from the Score Dekstra Sinistra Dekstra Sinistra
on through paper or
floor?
clothing, the eye of put it in
bags... a needle order?
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada

DEFORMITAS AMPUTASI DIGITI

APE HAND DROP HAND DIGITI I DIGITI II DIGITI III

Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra

 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada

AMPUTASI DIGITI ROM (ISI

DIGITI III DIGITI IV DIGITI V WRIST FLEXI WRIST EXTENSI

Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra

 1 - ada 1 - ada 1 - ada
2 - tidak ada
2 - tidak ada 2 - tidak ada

PEMERIKSAAN FIS
ROM (ISI DENGAN ANGKA YANG TERTERA DLM FORM)
FINGER TO PALMOPPONENT TIP TO TIPOPPONENT
DIGITI II TIP TO TIPOPPONENT
DIGITI III TIP TO TIPOPPONENT
DIGITI IV TIP TO TIP DIGITI

Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra

 0- tidak ada0- tidak ada0- tidak ada0- tidak ada0- tidak ada0- tidak ada0- tidak ada0- tidak ada
1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang
2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 2 - ada

PEMERIKSAAN FISIK EKSTREMITAS ATAS

SENSIBILITAS LIGHT TOUCH SENSILIBILTAS P
ONENT TIP TO TIP DIGITINERVUS
V ULNARIS NERVUS MEDIANUS NERVUS RADIALIS NERVUS ULNARIS

Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra

0- tidak ada0- tidak ada0- tidak ada0- tidak ada
1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
2 - ada 2 - ada 2 - ada 2 - ada 2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada

SENSILIBILTAS PIN PRICK PINCH

NERVUS MEDIANUS NERVUS RADIALIS LATERAL PINCH TIP TO TIP THREE JAW CHUCK

Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra

 SENSIBILITAS MONIFILAMEN
ISI DENGAN :

1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada

2 - tidak ada 2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada
2 - tidak ada

CH GRASP
THREE JAW CHUCK POWER (IN KG) SILINDER HOOK SPHERIC

Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra Dekstra Sinistra

 MMT

2- lainnya
1 - steppage gait
- tidak ada 0 - normal 0 - tidak ada
tidak diisi - sulit din

USG NERVUS ULNARIS

POWER (IN KG)
CIRCUMFERENCE AREA POLA
POLA
KETERANGAN JALAN
JALAN
Dekstra Sinistra LAINNYA
Dekstra Sinistra Dekstra Sinistra
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada
tidak diisi - tidak
sulit dinilai
diisi - tidak
sulit dinilai
diisi - tidak
sulit dinilai
diisi - tidak
sulit dinilai
diisi - tidak
sulit dinilai
diisi - tidak
sulit dinilai
diisi - tidak
sulit dinilai
diisi - tidak
sulit dinilai
diisi - sulit dinilai

DEFORMITAS
CLAW TOE EQUINUS VALGUS ANKLE VARUS ANKLE EQUINOVARUS

Kanan Kiri Kanan Kiri Kanan Kiri Kanan Kiri Kanan

 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada 0 - tidak ada 0 - tidak ada 0 - tidak ada
0 - tidak ada
0 - tidak ada
tidak diisi - tidak
sulit dinilai
diisi - tidak
sulit dinilai
diisi - sulit dinilai

PEM
S A
EQUINOVARUS EQUINOVALGUS lainnya DIGITI I DIGITI II

Kiri Kanan Kiri Kanan Kiri Kanan Kiri Kanan

 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada

REHAB MEDIK
PEMERIKSAAN FISIK EKSTREMITAS BAWAH
AMPUTASI DIGITI ROM (DALAM DERAJAT)
DIGITI II DIGITI III DIGITI IV DIGITI V DORSOFLEXI

Kiri Kanan Kiri Kanan Kiri Kanan Kiri Kanan Kiri

 0- tidak ada0- tidak ada0- tidak ada0- tidak ada0- tidak ada0- tidak ada
1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - kurang 1 - ada
2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 2 - ada 0 - tidak ada

OM (DALAM DERAJAT) SENSIBILITAS MONOFILAMEN

PLANTAR FLEXI N. SAPHENUS MEDIAL N. PERONEAL SUP N. MEDIAL PLANTAR JINJIT 20X

Kanan Kiri Kanan Kiri Kanan Kiri Kanan Kiri Kanan

 KEMAMP
UAN
AMBULAS
I

1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada

0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada

MMT
JINJIT 20X QUADRICEPS TIBIALIS ANTERIOR HAMSTRING GASTROCNEMIUS

Kiri Kanan Kiri Kanan Kiri Kanan Kiri Kanan Kiri

 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada
- tidak ada 0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada

AMPUTASI TRANSFEMORAL AMPUTASI TRANSTIBIAL

ada ada
TANGGAL
KETERANGAN
AMPUTAS
tidak ada
<3 bulan >3 bulan - <3 bulan >3
I bulan -
1 tahun >1 tahun 1 tahun >1 tahun
 1 - ada 1 - ada 1 - ada 1 - ada 1 - ada 1 - YA
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada
0 - tidak ada2 - TIDAK

LOWER LIMB PROSTHETIC EVALUATION FORM

RANSTIBIAL AMPUTASI LISFRANC AMPUTASI CHOPARD
ada ada

tidak ada tidak ada tidak ada

<3 bulan >3 bulan - <3 bulan >3 bulan -
1 tahun >1 tahun 1 tahun >1 tahun
 1 - berjalan diluar rumah
2 - berjalan di rumah
1 - Ya 1 - FIT 3 - berjalan ke toilet
1 - silicone
0 - Tidak 2 - TIDAK FIT 4 - kursi roda
2 - polyetilen foam

UATION FORM
AMPUTASI DIGITI REKOMENDAS
USIA
ada MEMAKA CHECK PROTHESI KEMAMP
I OUT S (BILA UAN
tidak ada PROSTESI PROSTESI YA) *isi AMBULAS LINERS
<3 bulan >3 bulan -
1 tahun >1 tahun S S dalam I
tahun
 0 - tidak ada
1 - HT
2 - STROKE0 - Tidak Ada
2 - obat yang rutin
3 - JANTUNG1 - Multivitamin
diminum (sebutkan
5 - TBC
1 - silicone 1 - thigt belt
1 - endoskeleton1 - sach 4 - DM
(BATUK > di keterangan
polyetilen foam 2 - PTB2 - eksoskeleton
2 - multiaxis 3 BLN)
6 - ALERGI

REKOMENDASI PROSTHESIS BARU Obat-obatan yang

dikonsumsi
Riwayat
SUSPENSI K-LEVELS
KETERANGAN
penyakit Keteranga
SOCKET ON OF TYPE OF yang
TYPE PROTHESI SHANK Jenis n (Khusus
ANKLE diderita utk no 2)
S
 FORMULIR PEMERIKSAAN KARDIORESPIRASI
Tekanan darah Heart rate

TB BB BMI PCF PFR chest expans

Pre Post Pre
AAN KARDIORESPIRASI
Heart rate Respiratory rate BORG Scale SaO2

Jarak VO2 max

Post Pre Post Pre Post Pre Post tempuh
 1 - (20 = Mandiri)
1 - ( 0-12 = No significant restriction)
2 - (12 -19 = Ketergantungan 2 - Ringan)
(13-22 = Mild restriction)
3 - (9-11 = Ketergantungan
3 - (23-32
Sedang)
= Moderate restriction)
1 - Ya 4 - (5-8 = Ketergantungan 4 - Berat)
(33-52 = Severe restriction)
0 - Tidak 5 - ( 0-4 = Ketergantungan
5 - ( 53-90
Total) = Extreme restriction)

FORMULIR TIMED UP AND GO TEST

Berjalan dengan alat

Timed Up and Go Test bantu FORMULI FORMULI FORMULI
R
R INDEKS R DASH PARTISIPA
METs BARTHEL
SI
Bila Ya,
1 2 3 Ya / Tidak Sebutkan
o significant restriction)
2 = Mild restriction)
Moderate restriction)
= Severe restriction)
= Extreme restriction)

LEMBAR PREVENTION OF DISABILITY

Nyeri tekan n. Nyeri tekan n. Nyeri tekan n.

ulnaris peroneus peroneus lateralis Lagoftalm Nyeri
Nodul us baru 6 tekan
Kanan Kiri Kanan Kiri Kanan Kiri ulserasi bulan saraf
terakhir
 Subjektif

Kekuatan Rasa raba Mata

otot berkurang Alis/ bulu tidak
berkurang dalam 6 Bercak di mata Penglihat Penglihat dapat Mata Lain-lain
dalam 6 wajah rontok an buram an silau menutup merah
bulan
bulan terakhir rapat
terakhir
 DAFTAR TILIK PEMERIKSAAN MAT

Ada/Ya (1) mata

Kelopak Kelopak mata
Derajat kekuatan
Tidak ada/Tidak (0)m.
Alopesia alis/bulu (kekuatan (kekuatan m.
otot m. orbicularis Injeksi konjungtiva
mata orbicularis oculi) orbicularis oculi)
oculi
with force without force
Kanan Kiri Kanan Kiri Kanan Kiri Kanan Kiri Kanan
TILIK PEMERIKSAAN MATA (VANIA ET AL)
Objektif

Injeksi konjungtiva Injeksi silier Kekeruhan kornea Injeksi episklera Nodul sklera

Kiri Kanan Kiri Kanan Kiri Kanan Kiri Kanan Kiri

 Shadow test positif Abnormalitas pupil Abnormalitas
Kekeruhan lensa dan iris tekanan intraokular
Lain-lain
Kanan Kiri Kanan Kiri Kanan Kiri Kanan Kiri
 Family Relationship
1 The
2 3 4 5 6 7 8 9
There has important My
I have My My
been no members I am an spouse My family I use a
been spouse spouse
change in in my accepted thrown avoids all behaves members separate
had
my family family part of out of my divorced physical disrespec do not plate and
my family house tfully touch me
relationsh know I contact cup
me
ip have an with me
illness
ationship
10 11 Because
12 13 14 15 16 1 2
I Because
of my There has
personall My of me my been no I am
illness my I do not children My family relative’s/
I attend y avoid all satisfied
family touch my have been considers children’s change in with my
all family physical takes children me as a my
functions contact
special purposely separated burden future will vocationa occupatio
with from me be n
care for
others affected l situation
me
 ANANDARAJ DEHABILITATION SCALE
Vocational condition
3 4 5 6 7 8 9 10 11
Others at
I have no I am work I carry out Others at Others at
I have an occupatio I have lost Ibeen
have worried my work work
place my duties avoid
occupatio n because my job suspende about speak
n of my losing my know I well touching disrespec
d have a
disease job me tfully
disease
 Social interaction
12 13
I have 14 1 2 3 4 5 6
been My I have no I feel I am
At work I refused I might I spend friends
I have my one to a useful
avoid have to leisure invite me I avoid my share
jobs many time my member
making end up with friends feelings
friends friends to
because their of the
friends begging
of my homes with society
illness
tion Self-esteem
7 8 9 1 2 3 4 5 6
People I feel the have not I think of
are afraid society Ibeen I have felt I feel I
I am There is I sit idle my
able satisfied no use in like cannot do most of problem
of has to get ending anything the time most of
touching discarded marries with life living my life useful
me me the time
 Tambaha
Mata
Pemeriksaan Sensibilita
Kornea, Segmen Anterio
Self-esteem dan Posterior, Tear Brea
7 8 9 10 11 12I am Up Time,Kornea
dan Schirmer'
I feel Test
Begging is I ignore personall Total Dehabilita Sikatriks
I look for I would I feel the only all advices y score tion level
creative like to be guilty and way to for responsibl
activities active ashamed make a improvem e for my OD
living ent misfortun
e 0
0
0
0
1
0
0
1
1
0
0
0
1

0
0
0
0
0
0
0
0
0
0
0
0
 Tambahan
Mata
emeriksaan Sensibilitas
ornea, Segmen Anterior
an Posterior, Tear Break
Up Time,Kornea
dan Schirmer's
Test
Sikatriks

OS

0
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