2. Anamnesa
a. Keluhan Utama :
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b. Riwayat Menstruasi
1) Umur menarche : _____ tahun
2) Lamanya haid : _____ hari
3) Jumlah darah haid : _____ kali ganti pembalut
4) Haid terakhir : _____________________
5) Gangguan haid : _____________________
6) Flour Albous :______________________
c. Riwayat penyakit yang lalu/operasi
1) Pernah dirawat :__________,kapan :__________,dimana : __________
2) Pernah dioperasi : __________,kapan :__________,dimana : __________
d. Riwayat penyakit keluarga
1) Kanker : Ada/tidak
3. Pemeriksaan Penunjang
a. Laboratorium
1) Darah : _________
2) Urin : _________
b. Diagnostik
1) CTG : __________
2) USG : __________
c. Lain –Lain :_________
6. PELAKSANAAN ASUHAN
Tanggal :_______________, Pukul :__________
1. Memberitahu klien dan keluarga tentang hasil pemeriksaan
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2. Memberikan pendidikan kesehatan mengenai
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3. ____________________________________________________________________
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4. ____________________________________________________________________
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5. ____________________________________________________________________
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7. EVALUASI
Tanggal :_______________, Pukul :__________
1. Klien mengetahui tentang hasil pemeriksaan
2. Klien mengerti tentang pendidikan kesehatan yang telah diberikan
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ____________________________________________________________________
( )
NIM.
(_______________________________) (_______________________________)