No. Reg. RS:………………..

Nama Lengkap :
Tanggal lahir : Umur : tahun Jenis Kelamin : L/P
Alamat : Nomor telepon:

Pekerjaan : Status : Belum menikah/ Menikah/ Janda/ Duda

Pendidikan: Etnis/Suku: Agama:

Dokter : _______________________
Tanggal:_____________Jam:______
ANAMNESIS
 Autoanamnesis
 Alloanamnesis
RIWAYAT PENYAKIT SEKARANG
Keluhan Utama : _____________________________________________________________
Riwayat perjalanan penyakit :
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ANAMNESIS UMUM (review of system)
berilah tanda bila abnormal dan berikan deskripsi
 Umum
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 Kulit
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 Kepala dan Leher
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 Mata
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 Telinga
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 Hudung
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 Mulut dan Tenggorokan
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 Pernapasan
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 Payudara
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 Jantung
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 Vaskuler
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 Abdomen
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 Ginekologi
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 Alat kelamin laki-laki
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 Ginjal dan saluran kemih
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 Hematologi
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 Endokrin/Metabolik
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 Muskuloskeletal
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 Sistem saraf
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 Emosi/Status psikologi
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RIWAYAT PENYAKIT DAHULU

Tanggal Penyakit Tempat perawatan Pengobatan/operasi

RIWAYAT KELUARGA Laki-laki Perempuan

X : Meninggal (sebutkan sebab meninggal dan umur saat meninggal)

kakek-nenek

Ayah-Ibu

Pasien

Anak

RIWAYAT PRIBADI

Riwayat Alergi Riwayat imunisasi

Tahun Bahan/obat Gejala Tahun Jenis Imunisasi

Hobi :
Olahraga :
Kebiasaan makan :
Merokok :
Minum Alkohol :
Hubungan Seks :
Penggunaan obat-obat :
DESKRIPSI UMUM
Kesan Sakit : Ringan/sedang/berat
Gizi :
Berat Badan : ………..kg Tinggi Badan : …………..cm, IMT : ………………kg/m2

TANDA VITAL
Kesadaran :
Nadi Frekuensi : ……………./menit Deskripsi :
Tekanan darah Berbaring Duduk
mmHg Lengan kanan : Lengan kanan :
Lengan Kiri : Lengan Kiri :
Temperatur Aksila : Rektal :
Pernafasan Frekuensi : Deskripsi :
Kulit
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Kepala dan leher
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Telinga
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Hidung
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Rongga mulut dan tenggorokan
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Mata
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Thorax kiri Kanan
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Janting
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Paru-paru
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Abdomen
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Ekstremitas
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Alat kelamin laki-laki
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Perampuan
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Rektum
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Neurologi
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Labolatorium
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DIAGNOSIS
- DX Kerja :

- DX Banding :

TATALAKSANA (PLANING)
- Planing Diagnosis :

- Planing Terapi :

- Planing Monitoring

PROGNOSIS