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SIE KESEHATAN SIE KESEHATAN SIE KESEHATAN

BEDUG 2017 BEDUG 2017 BEDUG 2017


IKA SMANSA PAMEKASAN IKA SMANSA PAMEKASAN IKA SMANSA PAMEKASAN

Tempat : ___________________________________ Tempat : ___________________________________ Tempat : ___________________________________


Tanggal : ___________________________________ Tanggal : ___________________________________ Tanggal : ___________________________________
No. : ___________________________________ No. : ___________________________________ No. : ___________________________________

IDENTITAS IDENTITAS IDENTITAS


Nama : Tn/ Ny/ Nn/ An _____________________ Nama : Tn/ Ny/ Nn/ An _____________________ Nama : Tn/ Ny/ Nn/ An _____________________
Usia : _____________________________bln/thn Usia : _____________________________bln/thn Usia : _____________________________bln/thn

ANAMNESA ANAMNESA ANAMNESA


Keluhan utama : ____________________________________ Keluhan utama : ____________________________________ Keluhan utama : ____________________________________
____________________________________ ____________________________________ ____________________________________
____________________________________ ____________________________________ ____________________________________
RPS : ____________________________________ RPS : ____________________________________ RPS : ____________________________________
____________________________________ ____________________________________ ____________________________________
RPD : ____________________________________ RPD : ____________________________________ RPD : ____________________________________
____________________________________ ____________________________________ ____________________________________
RPK : ____________________________________ RPK : ____________________________________ RPK : ____________________________________
____________________________________ ____________________________________ ____________________________________

PEMERIKSAAN FISIK DAN VITAL SIGN PEMERIKSAAN FISIK DAN VITAL SIGN PEMERIKSAAN FISIK DAN VITAL SIGN
TENSI : ______________________________mm/Hg TENSI : ______________________________mm/Hg TENSI : ______________________________mm/Hg
NADI : ______________________________ x/menit NADI : ______________________________ x/menit NADI : ______________________________ x/menit
RR : ______________________________ x/menit RR : ______________________________ x/menit RR : ______________________________ x/menit
BB : ______________________________ kg BB : ______________________________ kg BB : ______________________________ kg
TEMERATUR : ______________________________ C TEMERATUR : ______________________________ C TEMERATUR : ______________________________ C
GULA DARAH : ______________________________ mg/dl GULA DARAH : ______________________________ mg/dl GULA DARAH : ______________________________ mg/dl
Dx : ___________________________________ Dx : ___________________________________ Dx : ___________________________________
___________________________________ ___________________________________ ___________________________________
INJEKSI : ___________________________________ INJEKSI : ___________________________________ INJEKSI : ___________________________________
___________________________________ ___________________________________ ___________________________________
___________________________________ ___________________________________ ___________________________________

dr. ___________________ dr. ___________________ dr. ___________________

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