FORMULIR

PELACAKAN KASUS TERSANGKA/ PENDERITA DBD

BIODATA PENDERITA

Nama tersangka/ Penderita : .................................................................................................

Jenis Kelamin : .................................................................................................
Umur : .................................................................................................
Nema Kepala Keluarga : .................................................................................................
Alamat : RT ........ RW......
Desa/ Kelurahan .....................................................................
Jalan ........................................................................................
Kecamatan Parungpanjang Kabupaten Bogor
RIWAYAT PENYAKIT

1. Tanggal Mula sakit : .................................................................................................

2. Sblm Sakit Pergi kmn : .................................................................................................
3. Kapan ? : .................................................................................................
4. Pernah lihat yg spt ini : .................................................................................................
5. Jika Ya, dmn ? : .................................................................................................
6. Kapan? : .................................................................................................
7. Namanya siapa? : .................................................................................................

KEADAAN TERSANGKA/ PENDERITA

Panas ............ hari

Tourniquest

Bintik bintik merah

Gusi berdarah

Preshock

Shock

HASIL PEMERIKSAAN LABOLATORIUM

Uraian I II III IV
Trombosit
Hematokrit

Masuk Rumah Sakit Tanggal : .................................................................................................

Nama Rumah Sakit : .................................................................................................
Keluar Rumah Sakit : .................................................................................................
1. Sembuh
2. Masih Sakit
3. Meninggal : .................................................................................................

Bogor, ..................... 20.......

Petugas yang melacak

Sukmawan. P
NIP. 197010221993031005