LEMBAR DATA KLIEN

Nama : ..................................... Umur : ....................

Alamat : ..................................... Jenis kelamin : ....................
..................................... Tgl / Jam : ....................
Pekerjaan : ..................................... No. Peserta Ujian : ....................

I Pengamatan
1. Keadaan Jiwa ( Shen ) : ..........................................................................
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2. Warna dan kesegaran : ..........................................................................
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3. Sing Tay :
 Bentuk tubuh : ..........................................................................
 Gerak gerik : ..........................................................................
 Kulit : ..........................................................................
 Rambut : ..........................................................................
 Hidung : ..........................................................................
 Telinga : ..........................................................................
 Mata : ..........................................................................
 Mulut : ..........................................................................
 Lidah : ..........................................................................
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II Pendengaran / Penciuman : .......................................................................
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III Wawancara / Anamnesa
1. Keluhan utama : ..........................................................................
2. Keluhan tambahan : ..........................................................................
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3. Riwayat penyakit : ..........................................................................

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Hal - Hal Umum

1. Suka panas / dingin : ..........................................................................
2. Keringat : ..........................................................................
3. Keluhan bagian tubuh : ..........................................................................
4. Buang air besar : ..........................................................................
5. Buang air kecil : ..........................................................................
6. Kebiasaan makan / minum : ..........................................................................
7. Keadaan tidur : ..........................................................................
8. Dada / perut / angg. tubuh : ..........................................................................
9. Pendengaran : ..........................................................................
10. Ke - haus - an : ..........................................................................
11. Penyakit yg pernah diderita: ..........................................................................
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12. Khusus Wanita & anak: ...........................................................................
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Hal - Hal Khusus

1. Paru - Paru : ..........................................................................
2. Usus Besar : ..........................................................................
3. Lambung : ..........................................................................
4. Limpa : ..........................................................................
5. Jantung : ..........................................................................
6. Usus kecil : ..........................................................................

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 7. Kantung kemih : ..........................................................................
8. Ginjal : ..........................................................................
9. Pericardium : ..........................................................................
10. Tri Pemanas / San Jiao : ..........................................................................
11. Kantung empedu : ..........................................................................
12. Hati : ..........................................................................

IV Perabaan
1. Daerah keluhan : …...........................................................................
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2. Titik Khusus : …...........................................................................
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3. Nadi : ..........................................................................
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V Diagnosa / Kesimpulan :…….…….............................................................
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VI Terapi / Pengobatan : ..........................................................................

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