Kajian Awal Klinis.docx

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KAJIAN AWAL KLINIS No. RM : No. BPJS :

Tgl. Wawancara:

IDENTITAS PASIEN Nama Pasien : Nama KK : TTL/Umur : Jenis Kelamin : Pekerjaan : Pendidikan :

Status Pernikahan Agama Suku/Bangsa Alamat No. Telepon

: : : : :

RIWAYAT PENYAKIT DAHULU 1. Hipertensi 5. HIV/AIDS 2. Diabetes 6. TB 3. Peny. Jantung 7. Malaria 4. Anemia 8. DBD

9. Tifoid 10. Varicella 11. Herpes 12. IMS

13. Asma 14. Pneumonia 16. Peny. Tiroid 17. Malnutrisi

18. Epilepsi 19. ............ 20. ............ 21. ............

RIWAYAT PENYAKIT DALAM KELUARGA 22. Hipertensi 26. HIVAIDS 23. Diabetes 27. TB 24. Peny. Jantung 28. Malaria 25. Anemia 29. DBD

30. Tifoid 31. Varicella 32. Herpes 33. IMS

34. Asma 35. Pneumonia 36. Peny. Tiroid 37. Malnutrisi

38. Epilepsi 39. ............ 40. ............ 41. ............

56. Asap 57. Cuaca dingin 58. Cuaca panas 59. ................

60. ................ 61. ................

RIWAYAT KEBIASAAN 42. Merokok 46. ............... 43. Alkohol 47. ............... 44. NAPZA 45. ............. RIWAYAT ALERGI 48. Ikan Laut 49. Udang 50. Kepiting 51. Cumi-Cumi

52. Telur 53. Kacang 54. Susu 55. Debu

RIWAYAT ALERGI OBAT 62. Parasetamol 66. Amoksisilin 63. Antalgin 67. Cefadroksil 64. Ibuprofen 68. Kotrimoksazol 65. As. Mef 69. Ciprofloksasin

67. ............... 68. ............... 69. ...............

RIWAYAT KELAHIRAN (KHUSUS PASIEN ANAK) 70. Cukup Bulan 71. Prematur 72. BBLR 73. BBLSR

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