PEMERINTAH KABUPATEN SANGGAU

DINAS KESEHATAN
PUSKESMAS HARAPAN MAKMUR
Jalan Dusun Tapang Trimulya, Desa Harapan Makmur, Kecamatan Meliau(78571)
Email.Puskesmaskemangai17@gmail.com Kode Pos 78684

RM 02

DATA DASAR DAN PEMERIKSAAN FISIK

I. IDENTITAS
No. RM : ................................................. Riwayat Alergi :

Nama : .................................................
Umur : .................................................
Alamat : .................................................

II. ANAMNESIS
A. Keluhan utama : .....................................................................................................................................
B. Riwayat Penyakit Sekarang : .................................................................................................................
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C. Riwayat Penyakit Dahulu : ....................................................................................................................
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D. Riwayat Penyakit Keluarga : .................................................................................................................
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E. Riwayat Pekerjaan, Sosial Ekonomi dan Kebiasaan : ...........................................................................
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III. PEMERIKSAAN FISIK

A. Kondisi Umum dan Tanda – Tanda Vital
- Kesadaran : ....................................... - Keadaan Umum : Baik/Sedang/Buruk
- Tekanan Darah : ............................ mmHg - Keadaan Gizi : Baik/Sedang/Buruk
- Nadi : ............................ x/menit - Berat Badan : .............................. kg
- Napas : ............................ x/menit - Tinggi Badan : .............................. cm
- Suhu : ………℃

B. Status Generalis :
- Kepala : ...............................................
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- Mata : ...............................................
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- Hidung : ...............................................
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- Telinga : ................................................
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- Mulut : ................................................
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- Leher : ................................................
- Thoraks : ...........................................
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- Jantung : ...........................................
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- Paru : ...........................................
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- Abdomen : ...........................................
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- Genitalia : ...........................................
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- Ekstremitas : ...........................................
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C. Status Lokasi :
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IV. PEMERIKSAAN PENUNJANG

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V.DIAGNOSIS
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VI. TATALAKSANA
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VII. PROGNOSIS
- Vitam : ...............................................................................................................................
- Functionam : ...............................................................................................................................
- Sanactionam : ...............................................................................................................................

Harapan Makmur, ...........................................

Dokter Pemeriksa
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