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Nama :

usia :
No.RM :

STATUS PASIEN MATA


Data Awal
Tanggal :
DATA MEDIS :
ANAMNESA
1. Keluhan Utama : ...............................................................................................................
2. Keluhan Tambahan : ...............................................................................................................
3. Riwayat Penyakit :................................................................................................................
4. Riwayat Penggunaan Obat :................................................................................................................
5. Riwayat Alergi Obat : ya............................................................ tidak
zPEMERIKSAAN FISIK
Status Mata :
A.V.O.D :............... A.V.O.S :........................
kor Sph.........Cyl........ Ax..... Menjadi............... Kor Sph.........Cyl........ Ax...... Menjadi...............
T.O.D : T.O.S :
STATUS OFTALMIKUS

Hirschberg

Posisi : Posisi :
O.D O.S
Palp. sup :..................................................... Palp. sup :.....................................................
Palp. inf :..................................................... Palp. inf :.....................................................
Konj. tars. sup :..................................................... Konj. tars. sup :.....................................................
Konj. tars. Inf :..................................................... Konj. tars. Inf :.....................................................
Kornea :..................................................... Kornea :.....................................................
Bilik mata depan:.................................................... Bilik mata depan:....................................................
Pupil :..................................................... Pupil :.....................................................
Iris :..................................................... Iris :.....................................................
Lensa :..................................................... Lensa :.....................................................
Fundus okuli :..................................................... Fundus okuli :.....................................................
- Media :..................................................... - Media :.....................................................
- Papil :..................................................... - Papil :.....................................................
- Retina :..................................................... - Retina :.....................................................
- Makula :..................................................... - Makula :.....................................................

PEMERIKSAAN PENUNJANG
....................................................................................................................................................................................

DIAGNOSA
.....................................................................................................................................................................................
TERAPI/TINDAKAN :
 ...............................................................................................................................................................................
 ...............................................................................................................................................................................
 ...............................................................................................................................................................................
 ...............................................................................................................................................................................
 ...............................................................................................................................................................................

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