RUMAH SAKIT UMUM

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PATIENT HISTORY
Riwayat Pasien
IDENTIFIC ATION
Identifikasi

Name : Date : ….... / …….. / …… (dd/mm/yy)

Tanggal (tgl/bln/thn)
Date : ……./………/…….. (dd/mm/yy)
Doctor’s :……………………………………..
Isi atau tempelkan stiker identitas pasien disini
Package : ……………………………..
Paket

Tujuan : ......................................………………………………
Keluhan : ..........................................................................................................................................................

MEDICAL HISTORY
Riwayat Penyakit

Yes No Yes No Yes No

Sinus trouble   Gall bladder disease   Any blood disease  
Sinusitis Gangguan kandung empedu Gangguan kelainan darah
Neck swelling/glands   Marked change in bowel habits   Kidney disease  
Pembesaran kelenjar getah bening Gangguan pencernaan Penyakitt Ginjal
Vision Problem   Change in weight   Painful passage of urine  
Gangguan Penglihatan Perubahan Berat Badan Nyeri saat kencing
Hearing problem   Varicose veins   Blood in urine  
Gangguan Pendengaran Gangguan pembuluh darah perifer Kencing ber darah
Asthma/bronchitis   Lump in breast   Diabetes Mellitus  
Asma Benjolan di payudara Kencing Manis
Hayfever/other allergy   Cancer   Headaches/migraine  
Alregi Kanker Sakit Kepala
Skin Problem   Heart disease   Dizziness/fainting  
Masalah kulit Sakit Jantung Pusing berputar / pingsan
Tuberculosis   Rheumatic fever   Epilepsy  
Tuberkulosis Demam Reumatik Epilepsi
Shortness of breath   Abnormal heartbeat   Surgical operation  
Sesak Gangguan irama jantung Tindakan operasi
Coughed blood   High blood pressure   Accident/fracture  
Batuk Darah Tekanan darah tinggi Kecelakaan/ patah tulang
Abdominal pain   Stroke   Tropical disease  
Nyeri Perut Stroke Penyakit Infeksi Tropik
Stomach ulcer   Serious chest pain   Fear of heights  
Gastritis/Maag Nyeri Dada yang serius Takut ketinggian
Jaundice/hepatitis  
Hepatitis/ Sakit Kuning
HAVE YOU EVER BEEN Yes No Yes No Yes No
Apakah anda sedang melakukan Treated for a mental Toxic chemicals  
Reject for employment condition   Bahan kimia berbahaya
on insurance for medical   Mendapat terapi untuk Excess noise  
reasons gangguan mental Bising (Melebihi batas ambang dengar)
Gagal untuk test kesehatan Treated for drinking
calon karyawan karena problem/drug abuse  
alasan kesehatan
FOR WOMEN ONLY
Mendapat terapi oleh karena Hanya untuk wanita
Awarded benefits for penyalahgunaan obat/ HAVE YOU EVER HAD/Apakah anda pernah
industrial injury   minuman beralkohol
An abnormal smear  
Mendapat ganti rugi Exposed to : Hasil PAP Smear Abnormal
dikarenakan kecelakaan kerja
Mercury / Merkuri   A gynecological treatment  
Radioactivity / Radioaktif   terapi ginekologis
Are you pregnant  
Sedang hamil

RSU Kasih Bunda Cimahi -1- Medical Check Up

 RUMAH SAKIT UMUM
umUMuUMUUMUUMU

Medication taken regularly : tidak / ya *)…………………………………………

Mengikuti pengobatan yang rutin
Allergies to medication : tidak / ya *)…………..…………………………………
Alergi obat
DATES OF LAST VACCINATIONS: (day/month/year)
Tanggal terakhir vaksinasi : (tgl/bln/thn)
POLIO : ........./........../......... Hepatitis B : ......../........./........... Hepatitis A : ......../.........../...........
Tetanus : ........./.........../.......... Yellow fever : ........./........./........... Typhoid : ........./........../...........
Alcohol consumption : Number of glasses per day : tidak / ya *)……………………gelas/hari
Mengkonsumsi Alkohol: Berapa gelas sehari
Tobacco : Number of cigarettes per day : tidak / ya *)…………………………………batang/hari
Merokok : Berapa batang sehari
Coffee consumption : Number og glasses per day : tidak / ya *) …………………….gelas/hari
Mengkonsumsi kopi : berapa gelas sehari

WORK HISTORY
Riwayat Pekerjaan
Yes No
1. Noisy  
Kebisingan
How Long Exposure a day __________________________________________
Sehari terpapar berapa lama?
2. High Temperature  
Suhu sangat panas
How Long Exposure a day __________________________________________
Sehari terpapar berapa lama?
3. Low Temperature  
Suhu sangat dingin
How Long Exposure a day __________________________________________
Sehari terpapar berapa lama?
4. Routine Vibrate / Continuity  
Getaran rutin
5. Dust or smoke  
Debu atau asap
6. Danger medicine  
Bahan kimia beracun
7. Operate hard equipment  
Mengoperasikan alat berat
8. Round active machine  
Sekitar mesin bergerak
9. Pay attantion color  
Perlu ketelitian warna
10. On higher  
Pada ketinggian
11. Staff Office  
Pekerjaan Kantor
12. Pantry manager  
Mengelola Makanan
13. Other _______________________________________
Lain-lain
FAM ILY HI STORY
Riwayat Keluarga
Does the parents or close family has one of these diseases ?
Apakah orangtua, saudara atau keluarga dekat menderita salah satu penyakit di bawah ini?
 Hypertension ……………………………  Stroke …………………………………….
Hipertensi stroke
 Cancer…………………………………….  Diabetes ………………………………….
Kanker Penyakit Gula
 Haemorrhoid……………………………..  Mental Problem…………………………
Hemoroid Masalah kejiwaan
 Asthma ………………………………….  Alergic…………………………………….
Asma Alergi
 Heart ………………………………………  Hepatitis / Jaundice……………………
Jantung Hepatitis
 TBC ……………………………………….
Tuberkulosis

RSU Kasih Bunda Cimahi -2- Medical Check Up

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PHYSICAL EXAMINATION
Pemeriksaan Fisik
MEDICAL EXAMINATION Normal Abnormal IF ABNORMAL, PLEASE DETAIL
Pemeriksaan Medis Jika hasilnya abnormal, mohon dijelaskan
1. Eyes and pupils (Mata)   ...................................................................................
2. Ear/Nose/Throat (THT)   ....................................................................................
3. Teeth and mouth (Gigi & Mulut)   ....................................................................................
4. Lungs and chest (Paru-paru dan dada)   ....................................................................................
5. Cardiovascular (Jantung)   ....................................................................................
6. Abdo. Viscera (Perut)   ....................................................................................
7. Hernial orifices (Hernia)   ....................................................................................
8. Anus and rectum (Anus dan usus)   ....................................................................................
9. Genito-urinary (Genital-Saluran kencing)   ....................................................................................
10. Extremities (Ekstremitas)   ....................................................................................
11. Musculo-skeletal (Otot)   ....................................................................................
12. Skin/Varicose vns (Kulit)   ....................................................................................
13. Neurological (Syaraf)   ....................................................................................
14. Breast (Payudara)   ....................................................................................

Blood Pressure (supine) ………/…… mmHg Pulse …….. x/mnt Respiration ………. x/mmt Temp. …………… oC
Weight (W) ………… kg Height (H) ………. cm BMI (*) …………… Waist ………… cm
2
(*) BMI = W / H (Underweight = <18, Normal 18-25, Overweight 25-30, Obese > 30)

PARA CLINICAL EXAMINATION

 COLOR BLINDNESS TEST TIDAK BUTA WARNA / BUTA WARNA PARSIAL / BUTA WARNA TOTAL *)

 CHEST X-RAY (Foto Thorak/Dada) terlampir

 BLOOD ANALYSIS (Analisa Darah) terlampir

Note : *) : coret yang tidak terpakai/salah

RSU Kasih Bunda Cimahi -3- Medical Check Up

 RUMAH SAKIT UMUM
umUMuUMUUMUUMU

RESUME DAN ADVISE

Kesimpulan dan Saran

…………………………………………………………, after you have following Medical Check Up examination

, Setelah anda melakukan serangkaian pemeriksaan Medical Check Up
on …../……../……. at Kasih Bunda General Hospital, so we gave you the result of physical
pada tanggal ……………………………………………… di RSU Kasih Bunda , maka dengan ini kami sampaikan hasil pemeriksaan fisik
examination and support examination :
dan pemeriksaan lainnya sebagai berikut :

Resume :
Kesimpulan
1. Pemeriksaan Fisik :
2. Lab :

3. RO Thorax :
4. Tes Buta Warna :

Advise :
Saran

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

Medical Check Up Team

RSU Kasih Bunda

dr......................................

RSU Kasih Bunda Cimahi -4- Medical Check Up