Formulir Skrining Tb.docx

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Formulir Skrining TB RS ELIM RANTEPAO

Nama Pasien Nomor Tanggal

No 1 2 3 4 5 6 7 8 9 10

: : :

Gejala dan tanda TB Batuk berdahak selama >2-3 minggu Batuk berdarah Demam hilang timbul > 1 bulan Keringat malam tanpa aktivitas Penurunan berat badan tanpa penyebab yang jelas Pembesaran kelenjar getah bening (benjolan didaerah leher) dengan ukuran > 2 cm Sesak nafas dan nyeri dada Pernah minum obat paru dalam waktu lama sebelumnya Ada keluarga/tetangga yang pernah sakit paruparu/TB/pengobatan paru lama Penyakit lain : - Asma - DM

Ya

Tidak

Rantepao, PETUGAS

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