FORMULIR PEMERIKSAAN KESEHATAN HAJI TAHAP KEDUA

DAN BERITA ACARA PENETAPAN ISTITHAAH KESEHATAN HAJI

FORMULIR PEMERIKSAAN KESEHATAN JEMAAH HAJI TAHAP KEDUA

Nama :.................................................. Nama Dokter :....................................................

BIN/BINTI :.................................................. Nama Puskesmas :....................................................
No.Porsi :.................................................. Alamat :.....................................................
NIK :.................................................. Tgl Pemeriksaan :....................................................
Umur :.................................................. Tgl Iminisasi MM :....................................................
J.Kelamin :.................................................. Tgl Imunisasi Flu :....................................................
Pendidikan :.................................................. No.Telp.JH/Anak :....................................................
Pekerjaan :.................................................. Jenis Jemaah Haji : KBIH / Mandiri
Merokok :.................................................. Nama KBIH :....................................................
Alamat :.................................................. Alat Bantu :....................................................
................................................... .....................................................

PEMERIKSAAN KESEHATAN YANG DILAKUKAN MELIPUTI :

Beri tanda (√ ) ada Beri Tanda ( x ) Tidak ada

I. ANAMNESIS

1. Keluhan medis saat ini :......................................................................................................

...............................................................................................................................................

2. Riwayat Penyakit :
Tekanan Darah Tinggi ( ) Stroke ( ) Sakit jantung ( )
Batuk lama ( ) Batuk Darah ( ) Asma ( )
Hipertiroid ( ) Kencing Manis ( ) Gastritis/sakit maagh ( )
Usus Buntu ( ) Kencing Darah ( ) Batu Saluran Kencing ( )
Kencing beranah ( ) Eksim ( ) Alergi ( )
Berak Darah ( ) Hemoroid ( ) Kusta ( )
Malaria ( ) Epilepsi/Ayan ( ) Tumor Ganas ( )
Gangguan Jiwa ( ) Tumor ( ) Gagal Ginjal ( )

3. Riwayat Kebiasaan
Merokok ( ) Minum Alkohol ( ) Menyalah gunakan Narkoba ( )

4. Riwayat Penyakit Keluarga / Orang Tua :

Tekanan Darah Tinggi ( ) Hipertiroid ( ) Keganasan ( )
Stroke ( ) Eksim ( ) Kencing Manis ( )
Sakit Jantung ( ) Alergi ( ) Gagal Ginjal ( )
Batuk Lama ( ) Kusta ( ) Gangguan Jiwa ( )
Batuk Lama Berdarah ( ) HIV/AIDS ( ) Asma ( )

II. PEMERIKSAAN FISIK

Tekanan Darah :..................mmHg Tinggi Badan :.................Cm
Nadi :..................Kali/menit Berat badan :.................Kg
Pernapasan :..................Kali/menit Lingkar Pinggang :.................Cm
Suhu :..................ºC Lingkar panggul :.................Cm
Kekuatan Otot :..................5/4/3/2/1/0 IMT :.................Kg/m2
Reflek Fisiologis :..................Pos/Neg
Reflek Patologis :..................Pos/Neg
 Pemeriksaan Normal Abnormal Keterangan
Kepala
Mata
Telinga
Hidung
Tenggorokan
Gigi
Leher
Dada
Paru
Jantung
Abdomen
Anus / Retum
Genitalia Externa
Extermitas Atas
Extremitas Bawah
Kelenjar Getah bening
Kulit dan
Integumentum
Kuku

III. PEMERIKSAAN JIWA

Item Ada Tidak ada Keterangan

Demensia
Gejala-gejala Psikotik
Episode Depresi
Episode Manik
Gangguan Ansietas

IV. PEMERIKSAAN PENUNJANG

1. PEMERIKSAAN LABORATORIUM

Darah Lengkap
Golongan darah :................................... Eritrosit :........................................
Kadar Hb :................................... Hitung Jenis leukosit :.......................................
Hitung Leukosit :................................... LED :........................................
Trombosit :................................... Hematokrit :........................................

Urine Lengkap
Warna, Bau, Kejernihan:................................. Urobilinogen :........................................
Bilirubin :................................. pH :........................................
Darah Samar :................................. Keton :........................................
Glukosa :................................. Sedimen :.........................................
Protein :.................................. Berat Jenis :.........................................

Kimia Klinik
Asam Urat :....................................... Kolesterol HDL :............................................
SGOT :....................................... GD2PP :............................................
SGPT :....................................... Kreatinin :............................................
Kolesterol LDL :....................................... Trigliserida :............................................
Glukosa Puasa :....................................... Kolesterol Total :............................................