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STATUS UGD

UMUM / ASKES PNS / ASKESKIN / SKM + BLT

Tgl periksa : . .. .. .. .. .. /. .. .. .. .. .. /200.. .. .. Pukul . .. .. .. .. .. .. .. .. .WIB

I. IDENTITAS

Nama : ........................................................... ............. ..

Umur : ..........................................................................

e!is Kelami! : ..........................................................................

Alama" : ..........................................................................

II. ANAMNESE

Kelu#a! u"ama

III. PEMERIKSAAN FISIK

Kesa$ara! : ........................................................... %&S : ..........................

Te!si : . .. .. .. .. .. .. .. .. .. .. .. .. .. .. Na$i : . .. .. .. .. .. .. .. .. .. .. . '' : . .. .. .. .. .. .. .. .. .

Status Lokalis

(. Kepala : ......................................................................................

2. Le#er : ......................................................................................

). T#*raks : ......................................................................................

. A,$*me! : ......................................................................................

-. %e!e"alia E" $a! A!us : ......................................................................................

. E"remi"as a"as : ......................................................................................

. E"remi"as ,a1a# : ......................................................................................

IV. PEMERIKSAAN PENUNJANG

. DIAGNOSA : ................................................................. ..

I. TERAPI : ................................................................. ..

II. KEADAAN PENDERITA SAAT KELUAR : ...................................................................

STATUS LOKALIS

PEMERINTAH KABUPATEN GRESIK

DINAS KESEHATAN

U P T P U S K E S M A S D U D U K S A M P E Y A N

Ja lan Raya Duduksampeyan No. 4 Te lp . !"# "$!"##%KE&AMATAN DUDUKSAMPE'AN KABUPATEN GRESIK

Kode Pos (##()