FORMULIR PEMERIKSAAN KESEHATAN JEMAAH HAJI KEDUA

Puskesmas : ............................................... KBIH : ..............................................

FORMULIR PEMERIKSAAN KESEHATAN JEMAAH HAJI PERTAMA

Nama : Nama Dokter Pemeriksa : .............................................

(Name) (Physician's Name)
No. Porsi : Nama Sarana Kesehatan : .............................................
(Number Porsi) (Clinic/Hospital)
Umur Alamat Sarana Kesehatan : .............................................
(Age) : (Clinic/Hospital Address)
Jeni Kelamin Tanggal Pemeriksaan : .............................................
(Sex) (Examination Date)
Alamat :
(Address)

Pemeriksaan Kesehatan yang dilakukan meliputi :

The medical examination include :

Beri Tanda (√) ada (Yes) Beri Tanda (x) Tidak Ada/NO
Put mark Put mark

I. ANAMNESA
Anamnesa
1. Keluhan medis saat ini : …………………………………………………………………………………………………………………………..
Medical Complains

2. Riwayat Penyakit
Medical History

Hypertention [ ] Stroke [ ] Heart Dissease [ ]

Chronic Cough [ ] Hemoptoe [ ] Asthma [ ]
Hypertyroid [ ] Diabetes Melitus [ ] Gastritis [ ]
Appendicitis [ ] Hematuria [ ] Urolitiasis [ ]
Piouri [ ] Eczema [ ] Allergic [ ]
Hematochezia [ ] Haemoroid [ ] Leprosy [ ]
Malaria [ ] Epilepsi [ ] Malignancy [ ]
Psychiatric Disorder [ ] Tumor [ ] Cronoc Kidbey Dosease (CKD) [ ]

3. Riwayat Kebiasaan
Addiction

Meroko
(Smoking)
Minum Alkohol
(Alcohol)
Menyalahgunakan
Narkoba (Drugs)

4. Riwayat Penyakit Keluarga/Orang Tua :

Family/Parents Medical History

Tekanan Darah Tinggi Eksem

(Hypertention) (Eczema)
Stroke Alergi
(Stroke) (Allergic)
Sakit Jantung Kusta
(Heart Diesease) (Leprosy)
Batuk Lama HIV/AIDS
(Chronic Cough) (HIV/AIDS)
Batuk Lama Berdarah Gangguan Jiwa
(Chronic Hemaptoe) Psychiatric Disorder
Asma Keganasan
Asthma Malignancy
Hipertiroid Kencing Manis
Hypertyroid Diabetes Melitus
Gagal Ginjal
Cronoc Kidbey Dosease (CKD)

II. PEMERIKSAAN FISIK

(Physical Examination)

Nadi (Pulse) : ……………….Kali/Menit Tinggi Bandan (Height) : ……………….CM

Pernafasan (Respiration Rate) : ……………….Kali/Menit Berat Badang (Weight) : ……………….KG
Tekanan Darah (Blood Pressure) : ……………….mmHg Lingkar Pinggang : ……………….CM
Suhu (Temperature) : ……………….◦C Kekuatan Otot : ………... (pilihan 5,4,3,2,1)
IMT : …………… kg/m2
Reflek : …………...(positif/negatif)

Pemeriksaan Normal Abnormal Keterangan

(Examination) (Normal) (Abnormal) (Desciption)
leher (Neck) .........................................................................................................
Kepala (Head) .........................................................................................................
Mata (Eye) .........................................................................................................
Hidung (Nose) .........................................................................................................
Tenggorokan (Throat) .........................................................................................................
Gigi (Dental) .........................................................................................................
Leher (Neck) .........................................................................................................
Dada (Chest) .........................................................................................................
Paru (Lung) .........................................................................................................
Jantung (Cor) .........................................................................................................
Perut (Abdomen) .........................................................................................................
Anus/Rektum (Anal/Rectum) .........................................................................................................
Genetalia Ekterna .........................................................................................................
(External genitalia) .........................................................................................................
Ektrimitas Atas .........................................................................................................
(Upper extremity)
Kelenjar getah bening .........................................................................................................
(Lymph nodes)
Kulit & integumen .........................................................................................................
(dermal & integumentum)
Kuku (Nail) .........................................................................................................

III. PEMERIKSAAN JIWA

(Psycjiatric examination)

Item (Items)
Demensia .........................................................................................................
(Dementia)
Gejala2 Psikotik .........................................................................................................
(Psycotic)
Episode Depresi .........................................................................................................
(Defresission)
Episode Manic .........................................................................................................
(Manic)
Ganguan Ansietas .........................................................................................................
(Anxiety)

IV. PEMERIKSAAN PENUNJANG

1. Pemeriksaan Laboratotium
Laboratory Examination

Darah Lengkap Golongan Darah [ ] Hitung Trombosit [ ] Laju Endap Darah [ ]

Blood Blood Type Trombocytes Blood Sediment Rate
Kadar HB [ ] Hitung Eritrosit [ ] Nilai Hematokrit [ ]
Haemoglobin Eritrocyte Hematokrit
Hitung Leukosit [ ] Hitung Jenis Leukosit [ ]
Leucocytes Differiential Count

Urin Lengkap Warna, Bau, Kejernihan[ ] Darah Samar [ ] Protein [ ]

Urine Colour, Smell, Clarity Glukosa [ ] Urobilirubin [ ]
Bilirubin [ ] Glukose pH [ ]
Keton [ ] Berat Jenis [ ]
Sedimen [ ] Specific Grafity
Sediment

Kimia Klinik Glukosa Sewaktu [ ] SGOT [ ] Kolesterol [ ]

Clinical Chemistry Random Blood Glucose SGPT [ ] Kolesterol HDL [ ]
Kreatinin [ ] Asam Urat [ ] Trygliserida [ ]
Creatinin Uric Acid Ureum [ ]

PEMERIKSAAN LABORAORIUM TAMBAHAN *) Bila diperlukan

Serologi THPA [ ] VDRL [ ]

Serology HBsAg [ ] Anti HIV [ ]

NAPZA Opiat [ ] Canabis [ ]

Drug Abuse Lainya [ ]
Others

Bakteri Tahan Asam (BTA) [ ] Feses [ ]

Acid Fast Bacilli (AFB) Stool

2. Pemeriksaan Radiologi
Radiology Examination

X Ray Thorak [ ]

Pemeriksaan Lainnya (bila diperlukan)

Radiologi Lainya Normal Abnormal Keterangan

3. Pemeriksaan EKG
EKG/ECG [ ]
Pemeriksaan Lainnya (jika diperlukan)
Jenis Pemeriksaan Normal Abnormal Keterangan
CT scan
MRI
Treadmill

Pemeriksaan Kesehatan telah di selenggarakan pada (….,………………………….,……………) di (……………………...……………….)

Medical Check Up has been held on (….,………………………….,……………) in (…………………………...……………….)

V. HASIL DAN REKOMENDASI DOKTER SPESIALIS

(Jika diperlukan)*
……………………………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………………..

VI. KESIMPULAN HASIL PEMERIKSAAN

(Conclusion)
……………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………

VII. ICD-X DIAGNOSIS

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

HASIL TES KEBUGARAN : ………………………………………………….

VIII. PENETAPAN ISTITAAH KESEHATAN

ISTITHAAH KESEHATAN 1. MEMENUHI SARAT
2. MEMENUHI SYARAT DENGAN PENDAMPINGAN
3. TIDAK MEMENUHI SYARAT SEMENTARA
4. TIDAK MEMENUHI SYARAT

IX. SARAN
(Recommendation)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………

JEMAAH HAJI HARUS MENGIKUTI PEMBINAAN MASA TUNGGU

Tanda Tangan ………………………………………..

Signature

Nama Dokter ………………………………………..

Phisician Name

No. SIP ………………………………………..

License Number