FORMAT KUNJUNGAN RUMAH PASIEN GANGGUAN JIWA

A. IDENTITAS
1. Nama : ...............................................................................................................................
2. Umur : ..............thn
3. Jenis kelamin :L/P
4. Agama : ...............................................................................................................................
5. Pendidikan : ...............................................................................................................................
6. Alamat : ...............................................................................................................................
7. Tanggal Kunjungan : ...............................................................................................................................
8. Dx Medis : ...............................................................................................................................

B. FAKTOR PREDISPOSISI
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C. FISIK
1. Kesadaran : ..................................................................................................................................................
2. Riwayat makan dan minum dirumah
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D. PSIKOLOGI DAN SPIRITUAL

1. Konsep diri
a. Gambaran diri
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b. Identitas diri
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c. Peran
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d. Ideal diri
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e. Harga diri
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2. Hubungan sosial
a. Orang dekat
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b. Peran serta dalam kegiatan kelompok/dimasyarakat
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3. Spiritual
a. Nilai dan keyakinan
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b. Kegiatan ibadah
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E. STATUS MENTAL
1. Penampilan
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2. Pembicaraan
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3. Aktivitas motoriK
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4. Alam perasaan
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5. Afek
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6. Interaksi selama wawancara
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7. Persepsi
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8. Proses pikir
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9. Isi pikir
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10. Memori
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11. Tingkat konsentrasi dan berhitung
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12. Kemampuan penilaian
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13. Daya tilik diri
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Noebana,....................................20
Petugas

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