KLINIK DOKTER KELUARGA

FAKULTAS KEDOKTERAN
UNIVERSITAS SRIWIJAYA PALEMBANG

KARTU BEROBAT
CATATAN MEDIS USIA LANJUT

No. ..... / ..... / ..... / 20...

Nama Pasien : ....................................................................................................................... (L/P)

TTL : ....................................................................................................................................
Umur : ................................ Tahun

Nama Kepala Keluarga : ......................................................................................................................

Alamat : ......................................................................................................................
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Kunjungan I :  Umum  Gigi  KIA/KB  Tindakan  Lab

INFORMASI PERSONAL

Status perkawinan :
 Lajang
 Menikah
 Cerai Mati
 Cerai Hidup
 Pisah

Pendidikan :
 Buta huruf
 Tidak Tamat SD  Tamat SD
 Tidak Tamat SMP  Tamat SMP
 Tidak Tamat SMA  Tamat SMA
 Perguruan Tinggi

Pekerjaan:
 Tidak Bekerja  Pegawai Swasta  Pegawai Negeri
 Pelajar/Mahasiswa  Pegawai BUMN  Pensiunan
 Buruh  Polri/ABRI  Lainnya ..................................................
Agama :
 Islam
 Katolik
 Prostestan
 Hindu
 Budha
 Lainnya ..................................................................

Suku bangsa :
 Melayu  Sunda
 Batak  Jawa
 Minang  Lainnya ................................................................

CATATAN KHUSUS

Riwayat penyakit dahulu :

 Di rawat di RS, Alasan : .................................................................................................................
Tanggal rawat : .....................................................................................................

 Di operasi, Alasan : .................................................................................................................

Tanggal operasi : ..................................................................................................

Riwayat penyakit keluarga :

1. Penyakit keturunan :
 DM
 Jantung
 Hipertensi
 Astma
 Lainnya
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2. Penyakit tersering :
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Faktor risiko (alergi ) :

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Masalah sosial yang berat dalam keluarga :

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PEMERIKSAAN FISIK PERTAMA

BB : ................................. kg
TB : ................................. cm
TD : ................................. mmHg

Diagnosis Pemeriksa
No. Tanggal SOAP Terapi
(ICD) (TTD)
 Diagnosis Pemeriksa
No. Tanggal SOAP Terapi
(ICD) (TTD)