Formulir Pemeriksaan Kesehatan Jemaah Haji Tahap Kedua dan

BeritaAcaraPenetapan IstithaahKesehatan Haji

FORMULIRPEMERIKSAANKESEHATANJEMAAHHAJITAHAPKEDUA
Nama : NamaDokterPemeriksa:.................................
(Name) (Physician'sname)
No.Porsi : NamaSaranaKesehatan:.................................
(NumberPorsi) (Clinic/Hospital)
Umur : AlamatSaranaKesehatan:.................................
(Age) (Clinic/HospitalAddress)
Jenis Kelamin : TanggalPemeriksaan :.................................
(Sex) (Examinationdate)
Alamat :
(Address)

PemeriksaanKesehatanyangdilakukanmeliputi:
Themedicalexaminationinclude:

BeriTanda (√)Ada(Yes) BeriTanda (X)TidakAda/No

Putmark Putmark

I.ANAMNESA
anamnesa
1.Keluhanmedissaatini :
(medicalcomplains)

2.RiwayatPenyakit
MedicalHistory

Hypertention [ ] Stroke [ ] HeartDisease [ ]

ChronicCough [ ] Hemoptoe [ ] Asthma [ ]
Hyperthyroid [ ] DiabetesMelitus [ ] Gastritis [ ]
Appendicitis [ ] Hematuria [ ] Urolitiasis [ ]
Piouri [ ] Eczema [ ] Allergic [ ]
Hematochezia [ ] Haemorroid [ ] Leprosy [ ]
Malaria [ ] Epilepsy [ ] Malignancy [ ]
PsychiatricDisorder [ ] Tumor [ ] CKD/GagalGinjal[ ]

3.Riwayat Kebiasaan :
(addiction)
Merokok □
(smoking)
minumalkohol □
(alcohol)
Menyalahgunakan □
narkoba(drugs)

4. RiwayatPenyakitKeluarga/OrangTua:
(family/parentsmedicalhistory)
TekanandarahTinggi □ Eksem □
(hypertention) (eczema)
Stroke □ Alergi □
(stroke) (allergic)
SakitJantung □ Kusta □
(heartdisease) (leprosy)
BatukLama □ HIV/AIDS □
(chroniccough) (HIV/AIDS)
Batuklamaberdarah □ GangguanJiwa □
(chronichemaptoe) (psychiatricdisorder)
Asma □ Keganasan □
(asthma) (malignancy)
Hipertiroid □ KencingManis □
(hyperthyroid) (diabetesmelitus)
CRF/GagalGinjal □
II.PEMERIKSAAN FISIK
(physicalexamination)

Nadi(pulse …………..kali/menit TinggiBadan...........................cm

(height)
Pernafasan …………..kali/menit Beratbadan..............................Kg
(respiration rate) (weight)
……………..mmhg LingkarPinggang....................cm
Tekanandarah
(blood pressure) KekuatanOtot …………..
Suhu(temperature) …………….⁰C IMT ……………..
Reflek ……………..

Pemeriksaan Normal Abnormal Keterangan

(examination) (normal) (abnormal) (explanation)
Kepala(head) □ □ ………………………………….……………………..……………………………
Mata(eyes) □ □ ………………………………….……………………..……………………………
Telinga(ear) □ □ ………………………………….……………………..……………………………
Hidung(nose) □ □ ………………………………….……………………..……………………………
Tenggorokan(throat) □ □ ………………………………….……………………..……………………………
Gigi(dental) □ □ ………………………………….……………………..……………………………
Leher(neck) □ □ ………………………………….……………………..……………………………
Dada(chest) □ □ ………………………………….……………………..……………………………
Paru(lung) □ □ ………………………………….……………………..……………………………
Jantung(cor) □ □ ………………………………….……………………..……………………………
Abdomen(abdomen) □ □ ………………………………….……………………..……………………………
Anus/Rektum
(anal/rectum) □ □ ………………………………….……………………..……………………………
GenitaliaExterna(external
genitalia) □ □ ………………………………….……………………..……………………………
Ektremitasatas(upper
extremity) □ □ ………………………………….……………………..……………………………
Ekstremitasbawah (lower
extremity) □ □ ………………………………….……………………..……………………………
KelenjarGetahBening
(lymphnodes) □ □ ………………………………….……………………..……………………………
Kulit danintegumentum
(dermal
andintegument □ □ ………………………………….……………………..……………………………
um)
Kuku(nail) □ □ ………………………………….……………………..……………………………

III.PEMERIKSAANJIWA
(psychiatricexamination)
Item(items) Ada Tidak Ada Keterangan
Yes No (explanation)
Demensia (Dementia) □ □ …………………..………………………………..………………………………
Gejala-gejalaPsikotik
(Psychotic) □ □ …………………..………………………………..………………………………
EpisodeDepresi
(Depression) □ □ …………………..………………………………..………………………………
EpisodeManik (Manic) □ □ …………………..………………………………..………………………………
GangguanAnsietas
(Anxiety) □ □ …………………..………………………………..………………………………

IV.PEMERIKSAANPENUNJANG

1.PemeriksaanLaboatorium
LaboratoryExamination

DarahLengkap GolonganDarah [ ] HitungTrombosit [ ] LajuEndapDarah [ ]

Blood BloodType Trombocytes BloodSedimentRate
KadarHb [ ] HitungEritrosit [ ] NilaiHematokrit [ ]
Haemoglobin Eritrocyte Hematokrit
HitungLeukosit [ ] HitungJenisLeukosit[ ]
LeucocytesCount DifferientialCount
UrinLengkap Warna,Bau Kejernihan[ ] Darah Samar [ ] Protein [ ]
Urine Colour,Smell,Clarity Glukosa [ ] Urobilinogen [ ]
Bilirubin [ ] BeratJenis [ ] pH [ ]
Keton [ ]
Sedimen [ ]

KimiaKlinik
ChemicalClinic
SGOT [ ] GlukosaPuasa [ ] GD2PP [ ]
SGPT [ ] Ureum [ ] Kreatinin [ ]
KolesterolLDL [ ] KolesterolHDL [ ] Trygliserida [ ]
PEMERIKSAANLABORATORIUMTAMBAHAN*) Biladiperlukan
Serologi :THPA[] VDRL []
SerologyHBsAg[] AntiHIV []

NAPZA: Opiat [] Canabis []

DrugAbuse

Pregnancytest []

Feses [] BTA []
Stool

2.PemeriksaanRadiologi
RadiologyExamination

XRayThorax []

PEMERIKSAANRADIOLOGILAINNYA*)Biladiperlukan

CTScan []

3. PemeriksaanEKG

EKG []

4.Pemeriksaanlainnya
PemeriksaanKesehatantelahdiselenggarakanpada(tanggal/bulan/tahun)di(tempatpemeriksaan)
Medical CheckUphasbeenheldon(day/month/year)in(healthfacility)

HASILDAN REKOMENDASIDOKTERSPESIALIS
(Jikadiperlukan)*
………………………………………………………………………………………………………………
…………………………………………………………………………………………………………….

KESIMPULANHASIL PEMERIKSAAN
(conclusion)
………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………….

VII.ICDX: DIAGNOSA:
1…………………………………………………………. 1………………………………………………………….
2………………………………………………………… 2…………………………………………………………
3……………………………………………………….. 3………………………………………………………..
4………………………………………………………… 4…………………………………………………………
5……………………………………………………….. 5………………………………………………………..

VIII.PENETAPANISTITHAAHKESEHATAN
ISTITHAAHKESEHATAN1Memenuhi Syarat
2Memenuhi Syarat Dengan Pendampingan3Tidak MemenuhiSyaratSementara
4TidakMemenuhi Syarat

IX.SARAN
(recommendation)
………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………….
JEMAAHHAJIHARUSMENGIKUTIPEMBINAANMASAKEBERANGKATAN

Tanda Tangan
Signature

NamaDokter
PhysicianName

No.SIP
LicenseNumber