VI.

Riwayat Penggunaan Obat

..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
VII. Riwayat Tempat Tinggal
a. Jumlah orang yang tinggal dirumah ............................................................................
b. Kebersihan dan kerapian ruangan ..............................................................................
c. Penerangan / sirkulasi udara........................................................................................
d. Keadaan kamar mandi dan WC ...................................................................................
e. Pembuangan air kotor..................................................................................................
f. Sumber air minum........................................................................................................
g. Pembuangan sampah ..................................................................................................
h. Sumber pencemaran....................................................................................................

VIII. Rekreasi
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
IX. Pola Fungsi Kesehatan
a. Pola tidur / istirahat .....................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Pola eliminasi ..............................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
c. Pola nutrisi ...................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
d. Kebiasaan yang mempengaruhi kesehatan ................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
e. Pola kognitif perseptual
1. Pengelihatan ..........................................................................................................
...............................................................................................................................
...............................................................................................................................
2. Pendengaran .........................................................................................................
...............................................................................................................................
...............................................................................................................................