No.

RM:

Nama Pasien : ...............................................................................................................................

Tgl. Lahir/ Umur : ...............................................................................................................................

Jenis Kelamin : L / P Anak ke....................................................BBL/ PBL :....................................

Nama Ayah : ...............................................................................................................................

Nama Ibu : ...............................................................................................................................

Pekerjaan Orang Tua : ...............................................................................................................................

Alamat : ...............................................................................................................................

No. Telpn : ...............................................................................................................................

Pelayanan Kelahiran oleh : ...............................................................................................................................

Macam Kelahiran : Normal/ Abnormal .................................................................................................

Hal-hal lain yang penting : ...............................................................................................................................

- Penyakit yang diderita : ...............................................................................................................................

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

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

- Pernah dirawat/ Opname :......................................................................kali @ ...................................... .Hari

PEMERIKSAAN KESEHATAN
Dipesan
Tanggal Umur BB Gejala Pemeriksaan dan Tindakan/ Nasehat
kembali

PEMERIKSAAN KESEHATAN RM. 07.03.0

 Dipesan
Tanggal Umur BB Gejala Pemeriksaan dan Tindakan/ Nasehat
kembali

RM. 07.03.0
 No. RM:

Nama Pasien : ...............................................................................................................................

Tgl. Lahir/ Umur : ...............................................................................................................................
Jenis Kelamin :L/P
Pekerjaan : ...............................................................................................................................
Pendidikan : ...............................................................................................................................
Alamat : ...............................................................................................................................
No. Telpn : ...............................................................................................................................
Hal-hal lain yang penting : ...............................................................................................................................
- Penyakit yang diderita : ...............................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................

- Alergi terhadap jenis obat tertentu : ................................................................................................................

- Pernah dirawat/ Opname :......................................................................kali @ ...................................... .Hari

PEMERIKSAAN KESEHATAN

Tanggal Gejala Pemeriksaan / Tindakan Diagnosa Dipesan kembali

RM. 07.02.0

PEMERIKSAAN KESEHATAN
Tanggal Gejala Pemeriksaan / Tindakan Diagnosa Dipesan kembali
 RM. 07.02.0

No. RM:
Nama Pasien : .........................................................................TTL : ............................................
Nama Suami : .........................................................................TTL : ............................................
Pekerjaan Pasien : .........................................................................Pendidikan : ................................
Pekerjaan Suami : .........................................................................Pendidikan : .................................
Alamat : ...............................................................................................................................
No. Telpn : ...............................................................................................................................
Riwayat Kehamilan/ persalinan yang lalu :

Tahun Kelam Keadaan Ditolo

No Hasil Persalinan BB Keteran
Kelahir in pada ng
. Lahir gan
an LH LM AB L P Kelahiran Oleh

Riwayat kehamilan sekarang G......................................P...........................................A........................................

HPT ..................................................................Taksiran Partus............................................................................

Riwayat Haid teratur/ tidak : Siklus ....................................................................................................................

Contoh Kontrasepsi terakhir ...............................Kunjungan pertama hamil ..........................TT .........................

Pemberian imunisasi : Capeng :..........................................................................X Tahun..........................

Hamil :..........................................................................X Tahun..........................

Hal Penting :...........................................................................................................................................

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

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

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

HASIL PEMERIKSAAN

Tanggal Keluhan Pemeriksaan / Tindakan Dipesan kembali

RM. 07.01.0
HASIL PEMERIKSAAN

Tanggal Keluhan Pemeriksaan / Tindakan Dipesan kembali

RM. 07.01.0