Post on 07-Jul-2018
8/18/2019 Mr. 4a Pengkajian Awal Terapi Wicara Pada Pasien Anak
1/2
RSUP. Dr. WAHIDIN SUDIROHUSODO MAKASSAR
PENGKAJIAN AWAL TERAPI WICARA PADA PASIEN ANAK
A. Identitas
Nama :…………………………
Tgl Lahir :…………………………
Jenis Kelamin : L / P
No Rekam Medis :……………………………
Tgl Kunjungan :……………………………
Jam :…………………………..
.Ri!a"at Kelahiran :
1. Pre Natal : Resiko Jatuh ( ) Demam Tinggi ( )Kelilit Tali Pusar ( )
2. Post Natal : Lahir : Normal ( ), S ( ), ! ( )
"enangis ( ) Ti#ak menangis ( )
$$ Lahir : %........ Kg P$ :%...%..&m
'. Natal : Demam tinggi ( ) keang ( )erna atuh ( )
#.Ri!a"at Kesehatan
Keluhan *tama :%%%%%%%%%%%....
%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%
$. Ri!a"at Tum%uh Kem%ang :
1. Perkem+angan isik-"otorik
Tengkura :%%.%$ulan
"erangkak :.%%... $ulan
Du#uk :%%.%$ulan
$er#iri :%%.% $ulan
Jalan :%%% $ulan
2. Perkem+angan $ahasa /i&ara Taha 1 :
Re0leksi !o&alisation :%...%$ulan Taha 2 :
$a++ling :%......$ulan Taha ' :
Lalling :%...%$ulan Taha :
&holalia :%.%.$ulan Taha 3 :
True See&h :..%...$ulan
&.Tum%uh Kem%ang 'aat ini :
a. Perkem+angan isik -Psikomotorik%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
+. Perkem+angan $ahasa #an Kogniti0%%..%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&. Perkem+angan so&ial - "ental %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
MR.4a/TERAPI WICARA
8/18/2019 Mr. 4a Pengkajian Awal Terapi Wicara Pada Pasien Anak
2/2
Nama #an Tan#a tangan Terai /i&ara
(%%%%%...........%%%%%%%%%....)