Format Askeb Kespro
Format Askeb Kespro
RIWAYAT KESEHATAN
1. Kunjungan saat ini
[ ] Kunjungan pertama
[ ] Kunjungan ulang
Keluhan Utama :
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2. Riwayat Perkawinan
Kawin : ............................... kali
Kawin pertama umur : ............................... tahun
Dengan suami sekarang : ............................... tahun
3. Riwayat Menstruasi
Menarche : ............................... tahun
Siklus : Teratur / Tidak, ............................... hari
Lamanya : ............................... hari
Sifat Darah : Encer / Beku
Fluor Albus : Ya / Tidak
Dismenorhoe : Ya / Tidak
Masalah Lain :
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Haid terakhir :
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c. Pola aktivitas
Kegiatan sehari-hari :
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Istirahat / tidur :
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d. Seksualitas : Frekuensi
Keluhan :
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e. Personal Hygiene
Kebiasaan mandi ………….. kali/hari
Kebiasaan membersihkan alat kelamin
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Kebiasaan mengganti pakaian dalam
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Jenis pakaian dalam yang digunakan
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B. DATA OBJEKTIF
1. Pemeriksaan Fisik
a. Keadaan umum ………….. kesadara ………………….
b. Tanda vital
Tekanan darah : ………………. mmHg
Nadi : ………………. Kali per menit
Pernafasan : ………………. Kali per menit
Suhu : ………………. 0C
c. TB : ……………….cm
BB : ……………….kg
d. Kepala dan leher
Hiperpigmentasi :
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Mata :
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Mulut :
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Leher :
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e. Payudara
Bentuk :
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Putting susu :
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Massa/tumor :
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f. Abdomen
Bentuk :
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Bekas luka :
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Massa/tumor :
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g. Ekstremitas
Edema :
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Varices :
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Reflek patela :
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h. Genetalia luar
Tanda chadwich :
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Varices :
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Bekas luka :
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Kelenjar bartholini :
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Pengeluaran :
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i. Anus hemoroid :
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2. Pemeriksaan Dalam/Ginekologis
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3. Pemeriksaan Penunjang
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II. ANALISIS
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III. PENATALAKSANAAN
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Pontianak, ..........................................
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Mahasiswa Pembimbing
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