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BIODATA JAMAAH

 Nama :…………………………

Bin / Binti :…………………………

Jenis Kelamin : Pria / Wanita

Tempat Lahir :…………………………

Tanggal Lahir / Umur :………………………….

Alamat :………………………….

…………………………………………………..

Kecamatan : …………………………

Kabupaten : …………………………

 No p Jamaah :

 No. p Keluarga :

 No. Porsi :

Pen!i!i"an Tera"hir :

Pe"er#aan :

$tatus Per"a%inan :

&. '(WA)AT P*N)AK(T K*LUA'+A

a. .................................................................... b. ....................................................................

c. .....................................................................

,. '(WA)AT K*$*ATAN $*KA'AN+a. .....................................................................

 b. .....................................................................

c. .....................................................................!. .....................................................................

BIODATA DOKTER PEMERIKSA

 Nama -o"ter :

 N(P :

Jabatan :

Alamat $arana :

Tanggal Pemeri"saan :

RIWAYAT KESEHATAN (ANAMNESIS)

. '(WA)AT P*N)AK(T -AULU

a. ....................................................................

 b. ....................................................................c. ....................................................................

!. .....................................................................

PEMERIKSAAN VITAL

. TAN-A (TAL

a. T*KANAN -A'A$istole/-iastole : .............../............. mmg

 b. NA-(

0re"uensi : .........................."ali/menitolume : "ecil/cu"up/besar 

'itme : reguler/ireguler 

c. NA0A$0re"uensi : .......................... "ali/menit

olume : !ang"al/cu"up/!alam!. $UU : ....................... 12

&. P3$TU' 

a.   Bentu"/habitus : proposional/ti!a" proposional b. (4T 5(n!e"s 4asa Tubuh6 : ....................

Tinggi Ba!an : ............... cmBerat Ba!an : ............... "g

c. 'asio LPP : ..............................

Ling"ar Pinggang : ....................... cmLing"ar Pinggul : ....................... cm

,. KUL(T

a. (nspe"si : ...............................................

 b. Palpasi : ..............................................

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7. L**' a. (nspe"si : ...............................................

 b. Palpasi : ...............................................

8. K*L*NJ*' -AN P*4BULU +*TA

B*N(N+a. (nspe"si : ...............................................

 b. Palpasi : ...............................................

9. -A-A

a. Umum paru(nspe"si : ................................................

Palpasi : ................................................Per"usi : ................................................

Aus"ultasi : ................................................

;. K*PALAa. (nspe"si 5termasu" bentu"< simetris6

.................................................................

 b. Pemeri"saan s=ara> "ranial.................................................................

c. 4ata : ................................................

!. Telinga : ................................................e. i!ung : ................................................

>. Tenggoro"an !an mulut

.................................................................

?. *K$T'*4(TA$

(nspe"si : ................................................

Palpasi : ................................................

Ke"uatan 3tot : ................................................

'e>e"s : ................................................

@. '*KTU4 -AN U'3+*N(TALa. Tra"tus Urinarius

(nspe"si : ................................................

Palpasi : ................................................

 b. +enitalia

(nspe"si : ............................................

Palpasi : ............................................

 b. Jantung

(nspe"si : ................................................

Palpasi : ................................................

Per"usi : ................................................

Aus"ultasi: ................................................

. P*'UT

(nspe"si : ................................................

Palpasi : ................................................

Per"usi : ................................................

Aus"ultasi : ................................................

. *K$T'*4(TA$

(nspe"si : ................................................

Palpasi : ................................................

Ke"uatan 3tot : ................................................

'e>e"s : ................................................

&. '*KTU4 -AN U'3+*N(TAL

c. Tra"tus Urinarius

(nspe"si : ................................................

Palpasi : ................................................

!. +enitalia

(nspe"si : ............................................Palpasi : ............................................

c. 'e"tum

(nspe"si : ............................................Palpasi : ............................................

PEMERIKSAAN JIWA

. Keluhan somati" tanpa "elainan organi" ...........................................................................

...........................................................................

&. Keluhan psi"osomati" ...........................................................................

...........................................................................,. Keluhan mental emosional

...........................................................................

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Pemeriksaan

1. BTA POSITIF / NEGATIF2. Status Gizi (IMT) BAIK / BURUK3. Kesehata !i"a #A / TI$AK

(K%su&tasi Psi'iate)

• Pernah mendapatkan kunjungan atau

diberi Pelayanan Kesehatan dari petugas

kesehatan YA / TIDAK

• Pernah mendapatkan penjelasan

tentang Akupressure Mandiri (Pijat) YA / TIDAK

• Dapat melakukan Akupressure Mandiri   YA / TIDAK

Gangguan Kesehatan

1. atiha Fisi'  YA / TIDAK2. $iet * Kua+ Sa,u   YA / TIDAK

(- 2 P%si/ai)3. $iet * Kua+ Buah  YA / TIDAK

(- 3 %si/ai)

Perilaku

1. Me0u0i ta+a e+a ai e+a&i 

see&u a'a a setia se&esaie&a'u'a a'ti4itas

 YA / TIDAK2. Mea'ai a&at e&iu+ ii (as'e)

 YA / TIDAK3. Tia' e&uah i seaa+ teat

 YA / TIDAK4. Meutu hiu+ a u&ut 'eti'a

atu'/esi YA / TIDAK

&. *le"tro Kar!io +ra>i 5*K+6 : 5tulisan

 penilaian !an lampiran hasil ceta"ann=a6

...........................................................................,. Pencintraan 'a!iologi / U$+ 5tulis"an

 penilaiann=a6

...........................................................................

PEMERIKSAAN KEMANDIRIAN DAN

KEBUGARAN

. Barthel (n!e"s 59@ Th6

$"ore : ………………………….

Keterangan : ……………………

&. Tes Kebugaran

4eto!e :

 Nilai : (stime%a/Bai"/2u"up/Kurang

DIAGNOSA

. .................................. Ko!e : ....................

&. .................................. Ko!e : ....................

,. .................................. Ko!e : ....................

FAKTOR RESIKO JEMAAH HAJI

. 4ero"o" )a / Ti!a"  

&. Kurang a"ti>itas >isi" )a / Ti!a" ,. 4engguna"an alat bantu )a / Ti!a" 

$ebut"an ..........................................................

7. ........................................ )a / Ti!a" 

KESIMPULAN

. Kategori :

4an!iri/3bserCasi/Penga%asan/Tun!a&. $aran/an#uran

..........................................................................

PEMERIKSAAN PENUNJANG

.   Laboratoriuma. -arah

•   emoglobin 5b6 : ……………………

•   La#u *n!ap -arah : …………………...

•   Jumlah Le"osit : ……………………

•   itung Jenis Leu"osit : ……………………

•

  +olongan -arah : …………. / 'hesus : ……•   +ula -arah $e%a"tu 5+-$6

•   Kolesterol

L-L : ……………………

-L : ……………………Trigliseri!a : ……………………

 b. Urin

•   4a"ros"opis

...................................................................

•   4i"ros"opis

...................................................................

•   +lu"osa urin

....................................................................

•   Protein urin

....................................................................

•   Test "ehamilan : posti> / negati> 

5Tgl/Bln/Th : ......./........./........./

•   Pemeri"saan urin lain atas in!i"asi

....................................................................