FORMAT PENGKAJIAN KESEHATAN REPRODUKSI

Hari / Tanggal :
Pukul :
Tempat Pengkajian :
Nomor Rekam Medik :

A. IDENTITAS/BIODATA

Nama Ibu : Nama Suami :

Umur : Umur :
Suku/Bangsa : Suku/Bangsa :
Agama : Agama :
Pendidikan : Pendidikan :
Pekerjaan : Pekerjaan :
Alamat Rumah : Alamat rumah :
Telepon : Telepon :

B. Alasan kunjungan & Keluhan

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C. Riwayat KB sekarang
Alat kontrasepsi yang digunakan :............................................................................
Lama pemakaian :....................................................................................................
Keluhan yang dirasakan :.........................................................................................

D. Riwayat kesehatan
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E. Riwayat kesehatan keluarga
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F. Riwayat perkawinan
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G. Riwayat obstetri
1. Haid
Menarche : .......................................
Lamanya : .......................................
Siklusnya : .......................................

2. Riwayat kehamilan dan persalinan : G............ P........... A.........

H. Riwayat KB yang lain

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I. Data psikologis
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J. Pola kebiasaan sehari-hari
1. Pola nutrisi
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2. Pola eliminasi
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3. Pola tidur dan istirahat

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 4. Pola personal hygiene
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5. Pola latihan dan aktivitas

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6. Pola seksualitas
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DATA OBJEKTIF
PEMERIKSAAN FISIK
1. Kesadaran umum
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2. Tanda-tanda Vital
Respirasi : .................x/menit Nadi : ................x/menit
Tekanan darah : .................mmHg Suhu : ................°C

3. BB sekarang : ...........kg
TB : ...........cm
IMT :

4. Mamae
Ada benjolan : ....................................................................................................

5. Abdomen
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6. Genitalia
Inspeksi : .........................................
Inspekulo : .........................................
VT : .........................................

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 7. Ekstremitas atas dan bawah
Oedema : ..........................................
Varises : ..........................................

PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium

Tanggal : ............................................

Darah
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Urine
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2. Pemeriksaan penunjang lainnya

Pap Smear :
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USG/Rongent :
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Mamogravi :
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Lain-lainya :
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Palangka Raya,............................

Mahasiswa
Pembimbing lahan praktik

(…………………………….)
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NIM…………………………….
NIP..........................................

Mengetahui
Pembimbing Institusi

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NIP...........................................

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