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F OR MATAS UH ANK E P E R AWAT ANI NDI VI DU K E P E R AWAT ANGE R ONT I K Na maMa h a s i s wa

: ……………………………………….

NI M

: ……………………………………….

T a n g g a l P e n g k a j i a n

: ………………………………………. .

P E NGK AJ I AN A. DAT AUMUM a . Na maK e p a l aK e l u a r g a

:……………………………………………….

b . Al a ma t

:……………………………………………….

c . T e l p o n

:……………………………………………….

d . P e k e r j a a n

:……………………………………………….

e . P e n d i d i k a n

:……………………………………………….

f . K o mp o s i s i

:……………………………………………….

Na ma

J K

H u b . Dn gK K Umu r

P e n d i d i k a n

P e k e r j a a n

2 . Ge n o g r a m

3 . T i p eK e l u a r g a ………………………………………………………………………………………………………………………. ………………………… ………………………………………………. . ……………………………………………………………………………

K e t

4 . S u k uB a n g s a …………………………………………………………………………………………………………………………………………………. . ………………………. . …………………………………………………………………………………. ………………… 5 . Ag a ma …………………………………………………………………………………………………………………………………………………… ……………………. . …………………………………………………………………………………. …………………… 6 . S t a t u sS o s i a l E k o n o mi K e l u a r g a …………………………………………………………………………………………………………………………………………………… ……………………. . ………………………………. …………………………………………………. …………………… 7 . Ak t i v i t a sr e k r e a s i k e l u a r g a …………………………………………………………………………………………………………………………………………………… ……………………. . ………………………………. …………………………………………………. …………………… B . R I WAY ATDANT E H APP E R K E MB ANGANK E L UAR GA 1 . T a h a pp e r k e mb a n g a nk e l u a r g as a a ti n i …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… 2 . T u g a sp e r k e mb a n g a nk e l u a r g ay a n gb e l u mt e r p e n u h i …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… 3 . R i wa y a tk e l u a r g ai n t i …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… 4 . R i wa y a tk e l u a r g as e b e l u mn y a …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… C. P E NGK AJ I ANL I NGK UNGAN 1 . K a r a k t e r i s t i kr u ma h …………………………. ……………………………………………………………………. . ………………………………………… …………………………………………………………………………………………………………………………… 2 . K a r a k t e r i s t i kt e t a n g g ad a nk o mu n i t a sR W …………………………. ……………………………………………………………………. . ………………………………………… …………………………………………………………………………………………………………………………… 3 . Mo b i l i t a sg e o g r a f i sk e l u a r g a …………………………. ……………………………………………………………………. . ………………………………………… ………………………………………………………………………………………………………………………… 4 . P e r k u mp u l a nk e l u a r g ad a ni n t e r a k s i d e n g a nma s y a r a k a t …………………………. ……………………………………………………………………. . ……………………………………………

………………………………………………………………………………………………………………………… 5 . S i s t e mp e n d u k u n gk e l u a r g a …………………………. ……………………………………………………………………. . ………………………………………… …………………………………………………………………………………………………………………………… D. S T R UK T URK E L UAR GA 1 . K o mu n i k a s i k e l u a r g a …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… 2 . S t r u k t u rk e k u a t a nk e l u a r g a …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… 3 . S t r u k t u rp e r a n …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… 4 . No r mak e l u a r g a …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… E . F UNGS I K E L UAR GA 1 . F u n g s i a f e k t i f …………………………. ……………………………………………………………………. . ………………………………………………… ………………………………………………………………………………………………………………………………

2 . F u n g s i s o s i a l i s a s i …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… 3 . F u n g s i p e r a wa t a nk e s e h a t a n …………………………. ……………………………………………………………………. . ………………………………………………… ……………………………………………………………………………………………………………………………… F . T UGASP E R AWAT ANK E L UAR GA a )Me n g e n a l ma s a l a hk e l u a r g a …………………………. ……………………………………………………………………. . …………………………………………… ………………………………………………………………………………………………………………………… b )Me n g a mb i l k e p u t u s a n …………………………. ……………………………………………………………………. . …………………………………………… ………………………………………………………………………………………………………………………… c )Me r a wa ta n g g o t ak e l u a r g ay a n gs a k i t …………………………. ……………………………………………………………………. . …………………………………………… ………………………………………………………………………………………………………………………… d )Me me l i h a r al i n g k u n g a n

…………………………. ……………………………………………………………………. . …………………………………………… ………………………………………………………………………………………………………………………… e )Me n g g u n a k a nf a s i l i t a s / p e l a y a n a nk e s e h a t a n …………………………. ……………………………………………………………………. . …………………………………………… ………………………………………………………………………………………………………………………… 4 . F u n g s i r e p r o d u k s i …………………………. ……………………………………………………………………. . …………………………………………… ………………………………………………………………………………………………………………………… 5 . F u n g s i e k o n o mi …………………………. ……………………………………………………………………. . …………………………………………… …………………………………………………………………………………………………………………………

G. S T R E S SDANK OP I NGK E L UAR GA a . S t r e s sj a n g k ap e n d e kd a np a n j a n g …………………………. ……………………………………………………………………. . ………………………………………… …………………………………………………………………………………………………………………………… b . K e ma mp u a nk e l u a r g a …………………………. ……………………………………………………………………. . ………………………………………… …………………………………………………………………………………………………………………………… c . S t r a t e g i k o p i n g …………………………. ……………………………………………………………………. . ………………………………………… …………………………………………………………………………………………………………………………… d . S t r a t e g i a d a p t a s i …………………………. ……………………………………………………………………. . ………………………………………… …………………………………………………………………………………………………………………………… 8 . P e me r i k s a a nP e n u n j a n g …………………………. ……………………………………………………………………………………………………………………… ……………………………………………………………………………………. H AR AP ANK E L UAR GA …………………………. ……………………………………………………………………. . …. . …………………………………………… ………………………………………………………. ……………………………………………………………………

K E B I AS AANS E H AR I –H AR I a .B i o l o g i s

1 .P o l ama k a n ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………… 2 .P o l ami n u m ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… …… 3 .P o l at i d u r ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………… 4 .P o l ae l i mi n a s i ( B AB / B AK ) ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………… 5 .Ak t i v i t a ss e h a r i –h a r i ( B a r t h e l I n d e x ) Ak t i v i t a s( ADL ) Ma k a n

5

De n g a n B a n t u a n

Ma n d i r i

1 0

Ak t i f i t a sk eT o i l e t 5 B e r p i n d a hd a r i k u r s i r o d aa t a us e b a l i k n y a ,t e r ma s u k5 1 0 d u d u kd i t e mp a tt i d u r

1 0 1 5

K e b e r s i h a nd i r ime n c u c imu k ame n y i s i rr a mb u td a n0 me n g g o s o kg i g i

5

Ma n d i B e r j a l a nd i p e r mu k a a nd a t a r Na i kt u r u nt a n g g a B e r p a k a i a n

0 1 0 5 5

5 2 5 1 0 1 0

Me n g o n t r o l d e f e k a s i

5

1 0

Me n g o n t r o l b e r k e mi h

5

T o t a l

1 0 1 0 0

P e n l i l a i a n : 0 2 0 2 1 6 1 6 2 9 0 9 1 9 9 1 0 0

: K e t e r g a n t u n g a n : K e t e r g a n t u n g a nb e r a t / s a n g a tt e r g a n t u n g : k e t e r g a n t u n g a nb e r a t : k e t e r g a n t u n g a nr i n g a n : Ma n d i r i

6 .R e k r e a s i ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………… 7 .I n d e k sK AT Z

:

I n d e k K e t e r a n g a n A Ma n d i r i d a l a mma k a n , k o n t i n e n s i a( B AB , B AK ) , me n g g u n a k a np a k a i a n , p e r g i k et o i l e t , b e r p i n d a h , d a nma n d i . B Ma n d i r i s e mu a n y ak e c u a l i s a l a hs a t ud a r i f u n g s i d i a t a s . C Ma n d i r i , k e c u a l i ma n d i , d a ns a t ul a g i f u n g s i y a n gl a i n . D Ma n d i r i , k e c u a l i ma n d i , b e r p a k a i a nd a ns a t ul a g i f u n g s i y a n gl a i n . E Ma n d i r i , k e c u a l i ma n d i , b e r p a k a i a n , k et o i l e t , d a ns a t u F Ma n d i r i ,k e c u a l ima n d i ,b e r p a k a i a n ,k et o i l e t ,b e r p i n d a hd a ns a t uf u n g s i y a n gl a i n . G K e t e r g a n t u n g a nu n t u ke n a mf u n g s i t e r s e b u t L a i n- K e t e r g a n t u n g a np a d as e d i k i t n y ad u af u n g s i , t e t a p i t i d a kd a p a td i k l a s i f i k a s i l a i n s e b a g a i C, D, E , Fd a nG ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… …………………………………. b .P s i k o l o g i s 1 . Me n t a l ( S P MS Q) S h o r tP o r t a b e l Me n t a l S t a t u sQu e s t i o n a i r e( S P MS Q)

S k o r e + -

N 0

P e r t a n y a a n

1 .

T a n g g a l b e r a p ah a r i i n i ?

2 .

H a r i a p as e k a r a n gi n i ?

3 .

Ap an a mat e mp a ti n i ?

4 .

B e r a p an o me rt e l e p o na n d a ?

4 a .

Di ma n aa l a ma ta n d a ?T a n y a k a nh a n y ak l i e nt i d a kme mp u n y a i t e l e p o n

5

B e r a p au mu ra n d a ?

6

K a p a na n d al a h i r ?

7

S i a p ap r e s i d e ni n d o n e s i as e k a r a n g ?

8

S i a p ap r e s i d e ns e b e l u mn y a ?

9

S i a p an a mak e c i l i b ua n d a ?

1 0

K u r a n g i 3d a r i2 0d a mt e t a pp e n g u r a n g a n3d a r i s e t i a pa n g k ab a r u , s e mu as e c a r ame n u r u n

J u ml a hk e s a l a h a nt o t a l P e n i l a i a nS P MS Q: K e s a l a h a n8-1 0f u n g s i i n t e l e k t u a l b e r a t K e s a l a h a n5–7f u n g s i i n t e l e k t u a l s e d a n g K e s a l a h a n3-4f u n g s i i n t e l e k t u a l r i n g a n K e s a l a h a n0-2f u n g s i i n t e l e k t u a l u t u h P e n i l a i a ns k o rk l i e n8=f u n g s i i n t e l e k t u a l b e r a t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

De p r e s i ( B e e k /Y e s a v a g e ) P e n i l a i a nd e n g a nme n g g u n a k a ns k a l aI n v e n t a r i sDe p r e s i B e c k( I DB ) No

Ur a i a nDe p r e s i B e c k

A. K e s e d i h a n 3

S a y as a n g a ts e d i ha t a ut i d a kb a h a g i ad i ma n as a y at a kd a p a tme n g h a d a p i n y a

2

S a y ag a l a ua t a us e d i hs e p a n j a n gwa k t ud a ns a y at i d a kd a p a tk e l u a rd a r i n y a

1

S a y ame r a s as e d i ha t a ug a l a u

0

S a y at i d a kme r a s as e d i h

B . P e s i mi s me 3

S a y ame r a s ab a h wama s ad e p a ns a y aa d a l a hs i a s i ad a ns e s u a t ut i d a kd a p a t me mb a i k

2

S a y ame r a s at i d a kme mp u n y a i a p a a p au n t u kme ma n d a n gk e d e p a n

S k o r e

1

S a y ame r a s at e r k e c i l h a t i me n g e n a i ma s ad e p a n

0

S a y at i d a kb e g i t up a s i mi sa t a uk e c i l h a t i t e n t a n gma s ad e p a n

C. R a s ak e g a g a l a n 3

S a y ame r a s as a y ab e n a r b e n a rg a g a l s e b a g is e s e o r a n g( o r a n gt u a ,s u a mi , I s t r i )

2

S e p e r t i me l i h a tk eb e l a k a n gh i d u ps a y a , s e mu ay a n gd a p a ts a y al i h a th a n y a k e g a g a l a n

1

S a y ame r a s as a y at e l a hg a g a l me l e b i h i o r a n gp a d au mu mn y a

0

S a y at i d a kme r a s ag a g a l

D. K e t i d a k p u a s a n 3

S a y at i d a kp u a sd e n g a ns e g a l a n y a

2

S a y at i d a kl a g i me n d a p a t k a nk e p u a s a nd a r i a p a p u n

1

S a y at i d a kme n y u k a i c a r ay a n gs a y ag u n a k a n

0

S a y at i d a kme r a s at i d a kp u a s

E . R a s aB e r s a l a h 3

S a y ame r a s as e o l a h o l a hs a y as a n g a tb u r u ka t a ut a kb e r h a r g a

2

S a y ame r a s as a n g a tb e r s a l a h

1

S a y ame r a s ab u r u ka t a ut a kb e r h a r g as e b a g a i b a g i a nd a r i wa k t uy a n gb a i k

0

S a y at i d a kme r a s ab e n a r b e n a r b e r s a l a h

F . T i d a kMe n y u k a i Di r i S e n d i r i 3

S a y ab e n c i d i r i s a y as e n d i r i

2

S a y amu a kd e n g a nd i r i s a y as e n d i r i

1

S a y at i d a ks u k ad e n g a nd i r i s a y as e n d i r i

0

S a y at i d a kme mp u n y a i p i k i r a n p i k i r a nme n g e n a i me mb a h a y a k a nd i r i s e n d i r i

G. Me mb a h a y a k a nDi r i S e n d i r i 3

S a y aa k a nme mb u n u hd i r i s a y as e n d i r i j i k as a y ame mp u n y a i k e s e mp a t a n

2

S a y ame mp u n y a i r e n c a n ap a s t i t e n t a n gt u j u a nb u n u hd i r i

1

S a y ame r a s al e b i hb a i kma t i

0

S a y at i d a kme mp u n y a i p i k i r a n p i k i r a nme n g e n a i me mb a h a y a k a nd i r i s e n d i r i

H . Me n a r i kDi r i d a r i S o s i a l 3

S a y at e l a hk e h i l a n g a ns e mu ami n a ts a y ap a d ao r a n gl a i nd a nt i d a kp e r d u l i p a d ame r e k as e mu a

2

S a y at e l a hk e h i l a n g a ns e mu ami n a ts a y ap a d ao r a n gl a i nd a nt i d a ks e d i k i t p e r a s a a np a d ame r e k a

1

S a y ak u r a n gb e r mi n a tp a d ao r a n gl a i nd a r i p a d as e b e l u mn y a

0

S a y at i d a kk e h i l a n g a nmi n t ap a d ao r a n gl a i n

I . K e r a g u r a g u a n 3

S a y at i d a kd a p a tme mb u a tk e p u t u s a ns a mas e k a l i

2

S a y ame mp u n y a i b a n y a kk e s u l i t a nd a l a mme mb u a tk e p u t u s a n

1

S a y ab e r u s a h ame n g a mb i l k e p u t u s a n

0

S a y ame mb u a tk e p u t u s a ny a n gb a i k

J . P e r u b a h a nGa mb a r a nDi r i 3

S a y ame r a s ab a h was a y aj e l e ka t a ut a mp a kme n j i j i k k a n

2

S a y ame r a s ab a h waa d ap e r u b a h a n p e r u b a h a ny a n gp e r ma n e td a l a m p e n a mp i l a ns a y ad a ni n i me mb u a ts a y at i d a kme n a r i k

1

S a y ak h a wa t i rb a h was a y at a mp a kt u aa t a ut i d a kme n a r i k

0

S a y at i d a kme r a s ab a h was a y at a mp a kl e b i hb u r u kd a r i p a d as e b e l u mn y a

K . K e s u l i t a nK e r j a 3

S a y at i d a kme l a k u k a np e k e r j a a ns a mas e k a l i

2

S a y at e l a hme n d o r o n gd i r is a y as e n d i r id e n g a nk e r a su n t u kme l a k u k a n s e s u a t u

1

I n i me me r l u k a nu p a y at a mb a h a nu n t u kme mu l a i me l a k u k a ns e s u a t u

0

S a y ad a p a tb e k e r j ak i r a k i r as e b a i ks e b e l u mn y a

L . K e l e t i h a n 3

S a y as a n g a tl e l a hu n t u kme l a k u k a ns e s u a t u

2

S a y al e l a hu n t u kme l a k u k a ns e s u a t u

1

S a y al e l a hl e b i hd a r i y a n gb i a s a n y a

0

S a y at i d a kl e b i hl e l a hd a r i b i a s a n y a

M. An o r e k s i a 3

S a y at i d a kl a g i me mp u n y a i n a f s uma k a ns a mas e k a l i

2

Na f s uma k a ns a y as a n g a tb u r u ks e k a r a n g

1

Na f s uma k a ns a y at i d a ks e b a i ks e b e l u mn y a

0

Na f s uma k a ns a y at i d a kb u r u kd a r i y a n gb i a s a n y a

P e n i l a i a n :  0 4=De r p r e s i t i d a ka d aa t a umi n i ma l  5 7 =De p r e s i r i n g a n  8 1 5 =De p r e s i s e d a n g  > 1 5= d e p r e s i b e r a t

………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ……. Ge r i a t r i cDe p r e s s i o nS c a l e( GDS ) No 1

P e r t a n y a a n Ap aa n d as e b e n a r n y ap u a sd e n g a nk e h i d u p a n

J a wa b a n Y a / t i d a k

a n d a 2

Ap a k a ha n d at e l a hme n i n g g a l k a nb a n y a k

Y a / T i d a k

k e g i a t a nd a nmi n a ta t a uk e s e n a n g a na n d a ? 3

Ap a k a ha n d ame r a s ak e h i d u p a na n d ak o s o n g ?

Y a / T i d a k

S c o r e

4

Ap a k a ha n d as e r i n gme r a s ab o s a n ?

Y a / T i d a k

5

Ap a k a ha n d ame mp u n y a i s e ma n g a ty a n gb a i k

Y a / T i d a k

s e t i a ps a a t ? 6

Ap a k a ha n d at a k u tb a h was e s u a t uy a n gb u r u k

Y a / T i d a k

a k a nt e r j a d i p a d aa n d a ? 7

Ap a k a ha n d ame r a s ab a h a g i au n t u ks e b a g i a n

Y a / T i d a k

b e s a rh i d u pa n d a ? 8

Ap a k a ha n d as e r i n gme r a s at i d a kb e r d a y a ?

Y a / T i d a k

9

Ap a k a ha n d al e b i hs e n a n gt i n g g a l d i r u ma h

Y a / T i d a k

d a r i p a d ak e l u a rd a nme n g e r j a k a ns e s u a t uy a n g b a r u ? 1 0 Ap a k a ha n d ame r a s ame mp u n y a i b a n y a k

Y a / T i d a k

ma s a l a hd e n g a nd a y ai n g a ta n d ad i b a n d i n g k a n k e b a n y a k a no r a n g ? 1 1 Ap a k a ha n d ap i k i rb a h wah i d u pa n d as e k a r a n g

Y a / T i d a k

me n y e n a n g k a n ? 1 2 Ap a k a ha n d ame r a s at i d a kb e r h a r g as e p e r t i

Y a / T i d a k

s e p e r t i p e r a s a a na n d as a a ti n i ? 1 3 Ap a k a ha n d ame r a s aa n d ap e n u hs e ma n g a t ?

Y a / T i d a k

1 4 Ap a k a ha n d ame r a s ab a h wak e a d a a na n d at i d a k Y a / T i d a k a d ah a r a p a n ? 1 5 Ap a k a ha n d ap i k i rb a h wao r a n gl a i nl wb i hb a i k

Y a / T i d a k

k e a d a a n n y ad a r i p a d aa n d a ? I n t e r p r e t a s i : S k o r 0 4

: n o td e p r e s s e d( t i d a kd e p r e s i / n o r ma l )

S k o r 5 9

: mi l dd e p r e s s i o n( d e p r e s i r i n g a n )

S k o r 1 0 1 5

: s e v e r ed e p r e s s i o n( d e p r e s i s e d a n g / b e r a t )

2 .K e a d a a ne mo s i

………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ……………………………………………………………………. 3 .K o n s e pd i r i I d e n t i t a sd i r i : ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………  Ga mb a r a nd i r i : ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………… I d e a l d i r i : ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………… P e r a nd i r i: ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ………… H a r g ad i r i : ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………….

4 .AP GARK e l u a r g a AP GARK e l u a r g a No 1 2

F u n g s i

Ur a i a n

Ad a p t a s i

S a y ap u a sb a h wad a p a tk e mb a l ip a d ak e l u a r g as a y au n t u k me mb a n t up a d awa k t us e s u a t ume n y u s a h k a ns a y a

H u b u n g a n

S a y ap u a sd e n g a nc a r ak e l u a r g as a y ame mb i c a r a k a ns e s u a t u d e n g a ns a y ad a nme n g u n g k a p k a nma s a l a hd e n g a ns a y a

S k o r e

3

P e r t u mb u h a n

S a y ap u a sb a h wak e l u a r g as a y ame n e r i mad a nme n d u k u n g k e i n g i n a ns a y au n t u kme l a k u k a na k t i v i t a sa t a ua r a hb a r u .

Af e k s i

S a y ap u a sd e n g a nc a r ak e l u a r g as a y ame n g e s p r e s i k a na f e k d a nb e r e s p o nt e r h a d a pe mo s i e mo s is a y a ,s e p e r t ima r a h , s e d i ha t a ume n c i n t a i .

P e me c a h a n

S a y ap u a sd e n g a nc a r at e ma n t e ma ns a y ad a ns a y a me n y e d i a k a nwa k t ub e r s a ma s a ma

4

5

K e t e r a n g a n: S k o r2j i k as e l a l u S k o r1 j i k ak a d a n g k a d a n g S k o r0j i k ah a mp i r t i d a kp e r n a h

S k o r: 8 1 0: f u n g s i s o s i a l n o r ma l S k o r: 5 7       : f u n g s i s o s i a l c u k u p S k o r: 0 4       : f u n g s i s o s i a l k u r a n g / s u k ame n y e n d i r i ………………………………………………………………………………………………………………………… ………………………………………………………………. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c .S o s i a l 1 . Du k u n g a nk e l u a r g a ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… …………………………………. 2 .H u b u n g a nd e n g a nk e l u a r g a ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… …………………………………. 3 .H u b u n g a nd e n g a no r a n gl a i n ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………….

d .S p i r i t u a l 1 .P e l a k s a n a a ni b a d a h ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………… 2 .K e y a k i n a nt e n t a n gk e s e h a t a n ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………… e .P e me r i k s a a nF i s i k T i n j a u a nS i s t e m 1 .K e a d a a nu mu n

: …………………. . . . . . . . .

2 .GCS

: V…M…E…

3 .T i n g k a tk e s e d a r a n: Co mp o sme n t i s/Ap a t i s/S o mn o l e n/S u p o r /Co ma : ………oC

Na d i

: ……x / me n i t

T e k a n a nDa r a h

: ………mmH g

P e r n a f a s a n

: ……x / me n i t

T i n g g i B a d a n

: ……………c m

B e r a tB a d a n

: ……………K g

4 .S u h u

Y a

T i d a k

()

()

Umu m K e l e l a h a n P e r u b a h a nB Bs e t a h u ny gl a l u

()

()

P e r u b a h a nn a f s uma k a n

()

()

De ma m

()

()

K e r i n g a tma l a m

()

()

K e s u l i t a nt i d u r

()

()

S e r i n gp i l e k , i n f e k s i P e n i l a i a nd i r i t e r h a d a ps t a t u sk e s e h a t a n………………………………………………. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K e ma mp u a nu n t u kme l a k u k a nAK S(Ak t i v i t a sK e h i d u p a nS e h a r i h a r i ) ……………………………………………………………………………………. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I n t e g u me n

y a

t i d a k

L e s i /l u k a

()

()

P r u r i t u s

()

()

P e r u b a h a np i g me n t a s i

()

()

P e r u b a h a nt e k s t u r

()

()

P e r u b a h a nn e v i

()

S e r i n gme ma r

() ()

P e r u b a h a nr a mb u t

()

()

P e r u b a h a nk u k u

()

()

P e ma j a n a nl a mat e r h a d a pma t a h a r i

()

()

()

P o l ap e n y e mb u h a nl e s i , me ma r …………………………………………………………

H e mo o p o e t i k

y a

P e r d a r a h a n / me ma ra b n o r ma l

()

()

P e mb e n g k a k a nk e l e n j a rl i mf a

()

()

An e mi a

()

()

R i wa y a tt r a n f u s i d a r a h

K e p a l a

()

y a

t i d a k

()

t i d a k

S a k i tk e p a l a T r a u mab e r a r t i p a d ama s al a l u P u s i n g

() ()

()

()

Ga t a l p a d ak u l i tk e p a l a

()

()

Ma t a

y a

t i d a k

Ai rma t ab e r l e b i h a n

()

()

P r u r i t u s

()

()

Di p l o p i a

()

()

K a b u r

()

()

F o t o f o b i a R i wa y a ti n f e k s i

() ()

()

T e l i n g a

y a

t i d a k

P e r u b a h a np e n d e n g a r a n

()

()

()

T a n g g a l p e me r i k s a a np a l i n ga k h i r ……………………………………………………. . . Da mp a kp a d ap e n a mp i l a nAK S ………………………………………………………. . .

R a b a s

()

T i n i t u s

()

()

Ve r t i g o

()

()

S e n s i v i t a sp e n d e n g a r a n

()

()

R i wa y a ti n f e k s i

()

()

y a

t i d a k

()

T a n g g a l p e me r i k s a a np a l i n ga k h i r ……………………………………………………. . . K e b i a s a a np e r a wa t a nt e l i n g a …………………………………………………………… Da mp a kp a d ap e n a mp i l a nAK S ………………………………………………………. . .

H i d u n gd a ns i n u s R a b a s

()

()

E p i s t a k s i s

()

()

Ob s t r u k s i

()

()

Me n d e n g k u r

()

()

Ny e r i p a d as i n u s

()

Al e r g i R i wa y a ti n f e k s i P e n i l a i a nd i r i p a d ak e ma mp u a no l f a k t o r i ……………………………………………….

Mu l u td a nt e n g g o r o k

() ()

()

()

()

S a k i tt e n g g o r o k

()

()

L e s i / u l k u s

()

()

S e r a k

()

()

P e r u b a h a ns u a r a

()

()

K e s u l i t a nme n e l a n

()

()

P e r d a r a h a ng u s i

()

()

K a r i e s

()

()

K e s u l i t a nme n e l a n

()

()

Al a t a l a tp r o s t e s a

()

()

R i wa y a ti n f e k s i

()

()

y a

t i d a k

T a n g g a l p e me r i k s a a ng i g i p a l i n ga k h i r ………………………………………………… P o l ame n g g o s o kg i g i …………………………………………………………………… P o l af l o s s i n g …………………………………………………………………………….

L e h e r K e k a k u a n

()

()

Ny e r i /t e k a n

()

()

B e n j o l a n / ma s s a

()

()

K e t e r b a t a s a ng e r a k

()

()

P a y u d a r a

y a

t i d a k

B e n j o l a n /ma s s a

()

()

Ny e r i /n y e r i t e k a n

()

()

B e n g k a k

()

()

K e l u a r c a i r a nd a r i p u t t i n gs u s u

()

()

P e r u b a h a np a d ap u t t i n gs u s u P e r u b a h a np a d ap a y u d a r as e n d i r i ……………………………………………………….

()

()

P e r n a f a s a n

y a

t i d a k

B a t u k

()

()

S e s a kn a f a s

()

()

H e mo p t i s i s

()

()

S p u t u m

()

Me n g i As ma /a l e r g i p e r n a f a s a n

() ()

()

()

K a r d o i v a s k u l a r

y a

t i d a k

Ny e r i / k e t i d a k n y a ma n a nd a d a

()

()

()

T a n g g a l d a nh a s i l p e me r i k s a a ns i n a rXd a d at e r a k h i r …………………………………. .

P a l p i t a s i

()

()

S e s a kn a f a s

()

()

Di s p n e ap a d aa k t i v i t a s

()

()

Or t o p n e a

()

()

Mu r mu r

()

()

E d e ma

()

()

Va r i s e s

()

()

K a k i t i mp a n g

()

()

P a r e s t e s i a

()

()

P e r u b a h a nwa r n ak a k i

()

()

Ga s t r o i n t e s t i n a l

y a

t i d a k

Di s f a g i a

()

()

T a kd a p a tme n c e r n a

()

()

Ny e r i u l uh a t i

()

()

Mu a l /mu n t a h

()

()

H e ma t e me s i s

()

()

P e r u b a h a nn a f s uma k a n

()

()

I n t o l e r a nma k a n a n

()

()

Ul k u s

()

()

Ny e r i

()

()

I k t e r i k

()

()

B e n j o l a n /ma s s a

()

()

P e r u b a h a nk e b i a s a a nd e f e k a s i

()

()

S i s t e ms a r a f p u s a t

y a

t i d a k

S a k i tk e p a l a

()

()

K e j a n g

()

()

S i n k o p e / s e r a n g a nj a t u h

()

()

P a r a l i s i s P a r e s i s

() ()

()

()

Ma s a l a hk o o r d i n a s i

()

()

T i c / t r e mo r / s p a s me

()

()

P a r e t e s i a

()

()

Ce d e r ak e p a l a

()

()

Ma s a l a hme mo r i

()

()

S i s t e me n d o k r i n

y a

t i d a k

I n t o l e r a np a n a s

()

()

I n t o l e r a nd i n g i n

()

()

Go i t e r

()

P i g me n t a s i k u l i t

()

()

P e r u b a h a nr a mb u t

()

()

P o l i f a g i a

()

()

()

P o l i d i p s i

()

()

P o l i u r i a

()

()

I . I NF OR MAS I P E NUNJ ANG ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……… ANAL S ADAT A DAT A

MAS AL AH

E T I OL OGI

DAT A

MAS AL AH

E T I OL OGI

P R I OR I T ASMAS AL AH( DI AGNOS AK E P E R AWT AN/MAS AL AHK OL AB OR AS I ) ………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………

R E NCANAK E P E R AWAT AN

No

Na maK l i e n : Na maMa h a s i s wa /NI M : Umu r : P a r a f : Dx . K e p e r a wa t a n T u j u a n&K r i t e r i aH a s i l ( NOC)

I n t e r v e n s i ( NI C)

R a s i o n a l

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