RM RJ 05.

01
No.RM :
Nama :
ASESMEN FISIOTERAPI Tanggal Lahir :
Jenis Kelamin :
Tanggal Asesmen : ........................ Jam : ........................................
Anamnese : Autoanamnese Heteroanamnese
Keluhan Utama : .............................................................................................................................................................................
.............................................................................................................................................................................
Riwayat Penyakit Sekarang : ...............................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
Riwayat Penyakit Dahulu, Penyerta, dan Keluarga
: ............................................................................................................................
................................................................................................................................................................................................
..............................................................................................................................................................................................
.
Riwayat Imunisasi (khusus pediatrik) : .................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................

Pemeriksaan Fisik
1. Tanda Vital : 3. Nutrisi
TD : mmHg, Nadi : x/menit BB : kg, TB : cm
0
Suhu : C, RR : x/menit IMT : kg/m2, LK (khusus pediatrik) : cm
2. Alergi : Tidak Ya,...................................................... 4. Psikologis :
Nyeri : NIPS FLACC CPOT
Senang Tenang
Wong Baker/Numeric Pain Scale
Skor : .......... Sedih Tegang
Kategori : Tak nyeri Nyeri ringan
Takut Depresi
Nyeri sedang Nyeri berat
P(Provocating) :.............................................................................. Lainnya,................................
Q(Quality) :................................................................................... 5. Alat bantu : Tidak Ya,..........................................
. 6. ADL : Mandiri Dibantu,..................................
R(Region) :................................................................................... 7. Prothesa : Tidak Ya,..........................................
. 8. Riwayat jatuh dalam 3 bulan terakhir :
S(Scale) :................................................................................... Tidak Ya,................................................................
.
T(Timing) :...................................................................................
.
Kanan Kiri Kiri Kanan
 Gb. Belakang
Gb. Depan

1. Pemeriksaan Umum:
(Inspeksi, palpasi, perkusi, auskultasi, pemeriksaan fungsi gerak dasar dan spesifik)
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
.....................................................................................................................................................................................
......................................................................................................................................................................................
2. Pengukuran Khusus :
(MMT, LGS, SDC, Anthopometri, Spirometri, dll)
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
3. Data Penunjang
(laboratorium, radiologi, EMG, EKG, lain-lain)
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................
4. Diagnosis Fisioterapi :
a. Impairment :
......................................................................................................................................................................... .......................
......................................................................................................................................................................... ........................
b. Functional Limitation :
......................................................................................................................................................................... ........................
 RM RJ 05.01
......................................................................................................................................................................... ........................
c. Participation Restriction :
......................................................................................................................................................................... ........................
......................................................................................................................................................................... ........................
5. Program/ Rencana Terapi :
(Tujuan, modalitas, frekuensi)
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
Fisioterapis,

(______________________)
Tanda tangan dan nama terang