LAPORAN HASIL KUNJUNGAN RUMAH

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A. Identitas Pasien
Nama : Umur :
Jenis Kelamin : Pekerjaan :
Pendididkan : Agama :
Status Perkawinan : Alamat :
Diagnosis :

B. Identitas Keluarga / Penanggung Jawab

Nama :
Jenis Kelamin :
Pendididkan :
Status Perkawinan :
Status Hubungan :
Alamat :

C. Maksud Kunjungan Rumah

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D. Latar Belakang Keadaan Sosial dan Ekonomi Keluarga

1. Status Rumah Tinggal : ............................................................................

2. Kondisi rumah : ............................................................................
3. Kebersihan Rumah
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4. Kerapihan Rumah : ............................................................................
5. Kamar untuk Pasien
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6. Ekonomi Keluarga
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7. Biaya Hidup Ditanggung Oleh : ............................................................................
8. Jumlah Tanggungan Kelurga
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9. Sikap Pasien Terhadap Keluarga : ............................................................................

10. Sikap Keluarga Terhadap Pasien

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11. Hubungan pasien dengan Tetangga (Saat dirumah)

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12. Hubungan Tetangga dengan Pasien (Saat dirumah)

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E. Kondisi Fisik Pasien ( TB, BB, Bentuk Fisik, Kondisi Fisik, Penampilan )
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F. Gejala Psikiatrik Pasien ( Cacat gejala Psikiatrik yang masih ada secara
singkat )
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G. Kondisi Disabiltas Pasien ( Actifity Of Day Living, Tingkah Laku Sosial,

Tingkah Laku Okupasional )
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H. Pengobatan Jenis Dan Dosisnya

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I. Lain- Lain
1. Kesukaran yang dihadapi
Pasien : ...................................................................................................
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 Keluarga : ...................................................................................................

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2. Sikap Keluarga Terhadap Petugas Kunjungan Rumah

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3. Pendidikan/Penyuluhan Kesehatan yang Telah diajarkan/diberikan(Termasuk

Persiapan Pasien Kembali Kerumah/Kekeluarga, dan Persiapan keluarga
menerima kembali Pasien dalam Lingkungan keluarga/ Masyarakat.

a. Pasien
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b. Keluarga
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 c. Masyarakat
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J. Kesimpulan
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Pekanbaru, ............................

Keluarga / Penanggung Jawab Petugas Kunjungan Rumah

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