kir haji.xls

7/25/2019 KIR HAJI.xls

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Jenis ONH : REGULER/ KHUSUS/ KBIH No.URUT :.....................

FORMULIR BANTU PEMERIKSAAN KESEHATAN HAJI TAHAP I

PUSKESMAS BULIK KABUPATEN LAMANDAU Pas Photo

4 X 6

Nama Jemaah :...... ... ... ... ... ... ... ... ... ... ... .. .. ... ... ... ... ... ... ... ... ... ...

Bin/Binti :.......................................................................

Temat/T!".Lahi#/Um$#/Se% :.............................................................L& / P#

'"amat/ Ko(e os :.......................................................................

........................................................................ No.Te"eon :..................................................................................

........................................................................ No.HP :..................................................................................

Pen(i(i&an :... ... ... ... ... ... ... ... ... ... ... ... .. .. ... ... ... ... ... ... ... ... ... ... . No.Po#si :... .. .. ... ... ... ... ... ... ... ... ... ... .. .. ... ... ... ... ... ... ... ... ... ... ... .. .. ... .

Stat$s e#&a)inan :....................................................................... Ke"$a#!a *! +isa (ih$+$n!i : ...............................................................

Pe&e#,aan :....................................................................... '"amat :..................................................................................

Tan!!a" Pe#i&sa :...................................................................... ...................................................................................

A.FAKTOR RESIKO JEMAAH HAJI 7.Kelenjar dan pembl! "e#a! ben$n" -Go"on!an a#ah '/B/O/'BRH:012/032

. :............................................................... a.Inse&si : Penon,o"an 032 -G$"a a#ah Se)a&t$ 0GS2 :...............

5. :............................................................... +.Pa"asi :massa em+esa#an 032tan(a e#a(an!an 032 -.Ko"este#o" :..........................................

. :............................................................... %.Dada +.U#ine

a.Umum -7aos&ois

B.RI&A'AT KESEHATAN -Inse&si :Simet#is89et#a&si Peni"aian :+enin!8&e#$h032(. RI&A'AT KESEHATAN SEKARAN) *RKS+ - Pa"asi :#emit$s -7ios&ois

a. :.......................................................... - Pe#&$si :Sono# Peni"aian :Eite"0328K#ista" 0328Le&osit0328E#it#osit 032

+. :.......................................................... - '$s&$"tasi :;esi&$"e#8#on&i0328)hee


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6.Kepala E. PEMERIKSAAN JI&A

a.Inse&si: +ent$& +$"at8+esa# no#ma"8 .Ke"$han somati& tana &e"ainan o#!ani&:

Simet#is ti(a& a(a

+.Peme#i&saan s*a#a K#ania" :No#ma" 5. Ke"$han si&omatis

=.7ata :Simet# is8+enin!8"ensa &e#$h032 ti(a& a(a &e"$han sa&it

H*ema 032 .Ke"$han menta" Emosiona"

(.Te"in!a :Simet#is8+ent$& no#ma"8!en(an! ti(a& a(aA(e#esi 032emosi no#ma"

F.PEMERIKSAAN PENUNJAN)

e.Hi($n! :Simet#is8o"i 0328=onhae me#ah (. Lab-ra#-r$m

?.Ten!!o#o&an (an 7$"$t :"i(ah &oto# 032 a.a#ah

- Hemo!"o+in0H+2 :.......................!#

8 Le!er - La,$ En(a a#ah:5@ 3 @

aInse&si:Simet#is8+en,o"an0328enon,o"an ;ena ,$!$"a#is 032 - J$m"ah Le&osit :C .@@@.

+.Pa"asi :7assa '+no#ma" 0328em+esa#an 9ena032 - Hit$n! Jenis :no#ma"

Pemer$4aan Ter4$n$

(.P-#r

a.Bent$&/ha+it$s : Te!a&

+.I7T0In(e& 7asa T$m+$h2 :....................

-Tin!!i Ba(an 0TB2 :......................=m

-Be#at Ba(an 0BB2 :.......................&!

=. Rasio LPP :...........................-Lin!&a# Pin!!an! :...................=m

-Lin!&a# Pin!!$" :...................=m

,.Kl$#

a. Inse&si :Sa)o matan!/&$nin! "an!sat8+e#sih

+.Pa"asi:Oe(em0328&en*a"/&e#i$t

/.Kepala

a.Inse&si: +ent$& +$"at8+esa# no#ma"8

Simet#is

+.Peme#i&saan s*a#a K#ania" :No#ma"

=.7ata :Simet#is8+enin!8"ensa &e#$h032

H*ema 032

(.Te"in!a :Simet#is8+ent$& no#ma"8!en(an!

te"in!a $t$h8en(en!a#an no#ma".

e.Hi($n! :Simet#is8o"i 0328=onhae me#ah

?.Ten!!o#o&an (an 7$"$t :"i(ah &oto# 032

5 Le!er

aInse&si:Simet#is8+en,o"an0328enon,o"an ;ena ,$!$"a#is 032

+.Pa"asi :7assa '+no#ma" 0328em+esa#an 9ena032

6.Kelenjar dan pembl! "e#a! ben$n"

a.Inse&si : Penon,o"an 032

+.Pa"asi :massa em+esa#an 032tan(a e#a(an!an 032

8.Dada

a.Umum (dada)

-Inse&si :Simet#is89et#a&si

- Pa"asi :#emit$s

- Pe#&$si :Sono#

- '$s&$"tasi :;esi&$"e#8#on&i0328)hee


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- Inse&si : Simet#is

- Pa"asi :#emit$s

- Pe#&$si : sono#

- '$s&$"tasi :;esi&$"e#8#on&i0328)heeo"o& ($+$#2massa 0328he#nia0328(a#ah 032+. Sistem/ Kh$s$s

-Sistem Re#o($&si :+en,o"an 0328n*e#i te&an 0328"o$# a"+$s 032

-Sitem Kemih :+en,o"an 0328n*e#i te&an 032B'K "an=a#


4/7

Jenis ONH : REGULER / KHUSUS / KBIH No. URUT : .....................

FORMULIR BANTU PEMERIKSAAN KESEHATAN HAJI TAHAP I

PUSKESMAS BULIK KABUPATEN LAMANDAU Pas Photo

4 X 6

Nama Jemaah : .... .. ... .. .. ... .. ... .. .. ... .. .. ... .. ... .. .. ... .. .. ... .. ... .. .. ... .. ..

Bin/Binti : .......................................................................

Temat/T!".Lahi#/Um$#/Se% : ............................................................. L& / P#

'"amat / Ko(e os : .......................................................................

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

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

Pen(i(i&an : .......................................................................

Stat$s e#&a)inan : ....................................................................... No.Te"eon : ..................................................................................

Pe&e#,aan : ....................................................................... No.HP : ..................................................................................

Tan!!a" Pe#i&sa : ............................................................ No.Po#si : ..................................................................................

Ke"$a#!a *! +isa (ih$+$n!i : ............................................................

'"amat : ..................................................................................

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

A. FAKTOR RESIKO JEMAAH HAJI 8. Le!er

. : ............................................................... a. Inse&si : Simet#is 01/328 Pem+esa#an Ke"en,a# 01/328

5. : ............................................................... +. Pa"asi : em+esa#an Ke"en,a# &anan 01/328 &i#i 01/32

. : ...............................................................

B. RI&A'AT KESEHATAN 7. Kelenjar dan Pembl! )e#a! Ben$n"

(. RI&A'AT KESEHATAN SEKARAN) *RKS+ a. Inse&si : J$m"ah A ..........8 a#na A F.....

a. : .......................................................... +. Pa"asi : J$m"ah A FFF..8 &e&en*a"an A ..........8 NT A ............

+. : ..........................................................

=. : .......................................................... %. Dada

,. RI&A'AT PEN'AKIT DAHULU *RPD+ a.Umum

a. : ......................................................... - Inse&si : simet#is 01/328 #et#a&si 01/328 ;ene&tasi 01/328 +ent$& (a(a8

+. : ......................................................... en!!$naan otot +ant$ naas 01/32

=. : ......................................................... - Pa"asi : ste#m #emit$s &anan/&i#i 0sama/ti(a& sama2

/. RI&A'AT PEN'AKIT KELUAR)A *RPK+ - Pe#&$si : sono#/hie#sono#8 e&a&/#e($

- '$s&$"tasi : ;esi&$"e#8 #on&i8 )heeomos 7etis - Pa"asi : te&anan ;ena ,$!$"e# 01/328 &$at an!&at im$"s 01/328

,. Tanda 1$#al e#!ese#an im$"s 01/32

a. Te&anan a#ah - Pe#&$si : +atas Jant$n! 0&oni!$#asi ,ant$n!2

- Sisto" : .............. mmH! - '$s&$"tasi : +$n*i ,ant$n! I 01/32 II 01/328 +isin! ,ant$n! 01/32

- iasto" : .............. mmH! c.Paru

+. Na(i - Inse&si : en!em+an!an (a(a &a/&i sama 01/328 #et#a&si 01/328

- ?#e&$ensi : ........... Ka"i/7enit ;ene&tasi 01/328 +ent$& (a(a8 en!!$naan otot +ant$ naas 01/32

- Isi : =$&$/&$#an! - Pa"asi : ste#m #emit$s &anan/&i#i 0sama/ti(a& sama2

- Te!an!an : =$&$/&$at/"emah - Pe#&$si : sono#/hie#sono#8 e&a&/#e($

- Ritme : ......................... - '$s&$"tasi : ;esi&$"e#8 #on&i8 )hee


5/7

D. PEMERIKSAAN JI&A

. Ke"$han somati& tana &e"ainan o#!ani& :

5. Ke"$han Psi&omatis :

. Ke"$han 7enta" Emosiona" :

E. PEMERIKSAAN PENUNJAN)

(. Lab-ra#-r$m a. Dara!

- Hemo!"o+in 0H+2 : !#

- La,$ En(a a#ah :

- J$m"ah Le&osit :

- Hit$n! Jenis :

- Go"on!an a#ah '/B/O/'BRH:012/032

- G$"a a#ah Se)a&t$ 0GS2 :

- Ko"este#o" :

b. Ur$ne

- 7aos&ois

Peni"aian :- 7ios&ois

Peni"aian :

- G"$&osa U#ine

Peni"aian :

- P#otein U#ine

Peni"aian :

- Test Kehami"an :

F. DIA)NOSA *K-de Re#$+

. .......................................... Ko(e : ...............

5. .......................................... Ko(e : ..............

. .......................................... Ko(e : ...............4. .......................................... Ko(e : ................

). KESIMPULAN

. Kate!o#i : 7an(i#i / O+se#;asi / Pen!a)asan / T$n(a.

5. Sa#an / an,$#an :

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

+. ...................................................................

=. ...................................................................

(. ...................................................................

o&te# Peme#i&sa8

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

NIP / NRPTT.


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PEMERINTAH KABUPATEN LAMANDAU

PUSKESMAS BULIK

J". T,i"i& Ri)$t No. RT. @ Nan!a B$"i& 465

LEMBAR PERTAMA UNTUK KANTOR &ILA'AH DEPARTEMEN A

Go". a#ah : B

Ko(e ia!nosis :

SURAT KETERAN)AN PEMERIKSAAN KESEHATAN PERTAMA

an! +e#tan(a tan!an (i +a)ah ini :

Nama : dr . AMELIA A BADRI

Ja+atan : o&te# P$s&esmas B$"i&

'"amat : Nan!a B$"i&

Nama =a"on Jemaah ha,i : Tn. M. TE)UH 0IPTADI9 S. K-m9 M. E:. De;

Bin H. 'RI?IN BH'KTI

Jenis &e"amin : La&i 3 La&i

Pe&e#,aan : P N S

'"amat : J". T#ans Ka"imantan8 s. K$,an RT. @

7emen$hi s*a#at &esehatan (en!an +ai&

7emen$hi s*a#at &esehatan (en!an e#hatian

7emen$hi s*a#at &esehatan (en!an =atatan

Ti(a& memen$hi s*a#at &esehatan

S$#at &ete#an!an eme#i&saan &esehatan e#tama ini (ie#!$na&an se+a!ai e#s*a#atan $nt$

Pas hoto 4 X 6

o&te# Peme#i&sa8

dr . AMELIA A BADRI

NRPTT : ..@@4

Keterangan :

-2 Ko(e ia!nosis (it$"is men$#$t &o(e I>3X

Ke#eran"an (i+$at #an!&a $nt$& &ee#"$an :

. Be#at Ba(an : &! . Kanto# i"a*ah ea#temen '!ama

5. Tin!!i Ba(an : 6 =m 5. >a"on Jemaah Ha,i *an! +e#san!&$tan

. Te&anan a#ah : @/@ mmH! . '#si

. 7ata : 7en!!$na&an Ka=a 7ata

6. GS : 5@ m!/("

7en!in!at s$mah / ,an,i ,a+atan (an t$!as o&te# ses$ai (en!an S$#at Ke$t$san tentan!en$n,$&an Tim Peme#i&sa Kesehatan Jemaah Ha,i Ka+$aten (en!an ini mene#an!&an +ah

Te"ah (ie#i&sa (en!an te"iti a(a tan!!a" @ B$"an Jan$a#i Tah$n 5@68 (en!an &esim$"a+ah)a *an! (ie#i&sa :


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LEMBAR KEDUA UNTUK 0ALON JEMAAH HAJI BERSAN)KUTAN

LEMBAR KE TI)A UNTUK ARSIP PUSKESMAS

AMA LEMBAR PERTAMA UNTUK KANTOR &ILA'AH DEPARTEMEN A)AMA

men

a :

n

kir haji.xls

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