KLINIK DOKTER KELUARGA

FAKULTAS KEDOKTERAN
UNIV. MUHAMMADIYAH PALEMBANG

KARTU BEROBAT
CATATAN MEDIS UMUM/DEWASA

No. ..... / ..... / ..... / 20...

Nama Pasien : .................................................................................................................(L/P)

Umur :

Nama Kepala Keluarga : Amri..............................................................................................

Alamat : Jl. Seiko/Akbar RT/RW 2/2 Nomor. 389 -Pakjo Palembang
Sumatra Selatan ...............................................................................
.......................................................................................................

Kunjungan I :  Umum  Gigi  KIA/KB  Tindakan  Lab  Lansia

INFORMASI PERSONAL

Status perkawinan :
 Lajang
 Menikah
 Cerai Mati
 Cerai Hidup
 Pisah

Pendidikan :
 Buta huruf
 Tidak Tamat SD  Tamat SD
 Tidak Tamat SMP  Tamat SMP
 Tidak Tamat SMA  Tamat SMA
 Perguruan Tinggi

Pekerjaan:
 Tidak Bekerja  Pegawai Swasta  Pegawai Negeri
 Pelajar/Mahasiswa  Pegawai BUMN  Pensiunan
 Buruh  Polri/ABRI  Lainnya -...................
Agama :
 Islam
 Katolik
 Prostestan
 Hindu
 Budha
 Lainnya ..................................................................

Suku bangsa :
 Melayu  Sunda
 Batak  Jawa
 Minang Lainnya Palembang

CATATAN KHUSUS

Riwayat penyakit dahulu :

 Di rawat di RS, Alasan :
 Tidak Pernah
Tanggal rawat : .....................................................................................................

 Di operasi, Alasan :
 Tidak Pernah
Tanggal operasi : ..................................................................................................

Riwayat penyakit keluarga :

1. Penyakit keturunan :
 DM
 Jantung
 Hipertensi
 Astma
 Lainnya .........................................................................................................................................

2. Penyakit tersering :
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Faktor risiko (alergi ) :

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Masalah sosial yang berat dalam keluarga :

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PEMERIKSAAN FISIK PERTAMA
BB : ....................... kg
TB : ....................... cm
TD : ....................... mmHg

Pemeriksa
No. Tanggal SOAP Diagnosis (ICD) Terapi
(TTD)
 Pemeriksa
No. Tanggal SOAP Diagnosis (ICD) Terapi
(TTD)