LABEL IDENTITAS PASIEN RM 01.26.

017
RM 01.26.017
RUMAH SAKIT
HERMINA PASTEUR
LOGO Jln. Dr. Djundjunan No. 107
RS Kelurahan Pajajaran Bandung 40173 LABEL IDENTITAS PASIEN
Telp. (022) 6072525 (Hunting)
Fax: (022) 6037815
Website : www.herminahospitals.com

ASESMEN RAWAT JALAN GIGI

Status Lokalis:
1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

5.5 5.4 5.3 5.2 5.1 6.1 6.2 6.3 6.4 6.5
8.5 8.4 8.3 8.2 8.1 7.1 7.2 7.3 7.4 7.5

a. Gigi / gingivitis : ______________________________________________________________________________

ada
b. Calculus : ______________________________________________________________________________
ada regio anterior bawah
c. Karies : ______________________________________________________________________________
tidak ada
tidak ada
d. Sisa akar/ Radix : ______________________________________________________________________________
e. Gigi missing : _______________________________________________________________________________
48,38
f. Filling : _______________________________________________________________________________
tidak ada
g. Protesa tidak ada
: _______________________________________________________________________________
h. Lidah : _______________________________________________________________________________
dbn
i. Occlusi : Normal Bite/ Cross Bite/ Open Bite / Deep Bite
j. Torus : Tidak ada / Ada , jika ada dimana ____________________________________________________
k. Palatum : Rendah / Sedang / Tinggi
l. Diastoma/ Crowding : -___________________________________________________________________________
m. Lain-lain ______________________________________________________________________________________

01/08/2023
_______________________
Bandung,

______________________________
TandaTangan dan Nama JelasDokter
drg hanny Sabarini
Maret, 2018