FILE KLINIS PODOLOGIS KARTU No____

Nama lengkap: _______________________________________________________________________________ Jenis

Kelamin:________
Alamat : ____________________________________________________________________________________________
Telepon: _________________________F.Lahir:________________________ Umur:_____________________
Pekerjaan :____________________________________________________________________________________________
Pusat Rujukan:_______________________________________________________________________________________________

Penyakit yang Anda derita:

XD HTA Arthritis Osteoarthritis Lain-lain:__________________________________
Obat :___________________________________________________________________________________________
SIMBOL Berat: _______kilo

Tinggi:_______mt

No alas kaki:________

UJIAN KAKI

PULSA PEDIUM (+) (-)

Kanan kiri

PULSA TIBIAL (+) (-)

kanan kiri

SUHU

Dingin Normal Panas

MASALAH PEREDARAN DARAH

Tetapi

BULU

Kering Normal Lembab

PENGAMATAN: PERAWATAN : INDIKASI:

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ASEPSIS ___________________________
Alas kaki yang memadai Tidak memadai Sangat tidak memadai
HASUTAN ___________________________
_____________________________________________ PEMBERSIHAN BARIS ___________________________
_____________________________________________ ONIKOTOMI ________________________
_____________________________________________ DESPIKULISASI ________________________
_____________________________________________ kering ________________________
_____________________________________________ HELOTOMI ________________________
_________________________________________________KASAR ________________________
___________________________________________ DIPOLES ________________________
___________________________________________ ASEPSIS AKHIR ________________________
___________________________________________ LAINNYA : ________________________
____________________________________________________________________________ ________________________
____________________________________________________________________________ ________________________
____________________________________________________________________________ ________________________
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___________________________________________ _________________________________ TANGGAL :____/____/________
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__________________________________________ _________________________________ PEDAGANG:
__________________________________________ _________________________________
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