PT.

KALIMANTAN MEDIKA NUSANTARA

RS PARINDU
FORMULIR PEMERIKSAAN RONTGEN
RS Parindu, ............................... 20...

NAMA PASIEN : ................................................................................................

NO MEDICAL RECORD : ................................................................................................
TANGGAL : ................................................................................................ JAWABAN DOKTER :
UMUR : ................................................................................................
JENIS KELAMIN : ................................................................................................ ____________________________________________________________________________
ALAMAT : ................................................................................................ ____________________________________________________________________________
DOKTER PENGIRIM : ................................................................................................ ____________________________________________________________________________
DIAGNOSIS KLINIS : ................................................................................................ ____________________________________________________________________________
____________________________________________________________________________

JENIS PEMERIKSAAN ( Centang yang diperiksa ) : ____________________________________________________________________________

____________________________________________________________________________
 SCHEDEL SCHEDEL AP/LAT ____________________________________________________________________________
 SCHEDEL WATER’S CERVICAL ____________________________________________________________________________
 CERVICAL AP/LAT THORAX ____________________________________________________________________________
 THORAX PA/LAT THORACOLUMBAL
 THORACOLUMBAL AP/LAT LUMBAL ____________________________________________________________________________
____________________________________________________________________________
 LUMBAL AP/LAT PELVIS
____________________________________________________________________________
 FEMUR GENUE
____________________________________________________________________________
 GENUE AP/LAT CRURIS
____________________________________________________________________________
 CRURIS AP/LAT ANKLE JOINT
 ANKLE JOINT AP/LAT PEDIS
 PEDIS AP/LAT CLAVICULA
 SCAPULA HUMERUS
 ELBOW JOINT ELBOW JOINT AP/LAT
Salam Sejawat,
 ANTEBRACHII ANTEBRACHII AP/LAT
 WRIST JOINT WRIST JOIN AP/LAT
 MANUS MANUS AP/OBLIQUE
 LAIN-LAIN ……………………

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PT. KALIMANTAN MEDIKA NUSANTARA
RS PARINDU
PT. KALIMANTAN MEDIKA NUSANTARA
RS PARINDU