FORMULIR KUNJUNGAN RUMAH PK I

A. Identitas Pasien / KeluargaNama : ..........................................................................................................Umur : ..........................................................................................................Jenis Kelamin : ..........................................................................................................Alamat : ..........................................................................................................

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............................................................................................................No. Telp : ..........................................................................................................Sarana kesehatan yang digunakan : .............................................................................

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B. PemeriksaanKeluhan yang dirasakan : ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Tanda Vital TD : Nadi : RR : Suhu :

Status MentalBingung Disorientasi Menarik diri Cemas Depresi Sering marahKeterangan : ............................................................................................................................................................................................................................................................................................................................................................................................Sistem IntegumenWarna kulit : ..........................................................................................................Akral : ..........................................................................................................CRT : ..........................................................................................................DiaphoresisJaundiceLukaMukosa mulut : ..........................................................................................................Lain – lain : ..........................................................................................................

............................................................................................................Sistem KardiovaskulerAritmia Distensi Vena JugularisNyeri dada Edema Perifer

Lain – lain : ......................................................................................................................................................................................................................

Sistem PernafasanWheezing BatukRonchi SputumLain – lain : ..........................................................................................................

............................................................................................................Sistem PencernaanIntake makanan: ..........................................................................................................Intake cairan : ..........................................................................................................Sonde Flatus DiareMual/Muntah Distensi KonstipasiHematemesis Nyeri perutFrekuensi BAB : ..........................................................................................................Bising usuh : ..........................................................................................................Lain – lain : ..........................................................................................................

............................................................................................................Sistem PerkemihanDisuria Inkontontinensia KonsistensiHematuria RetensiFrekuensi : ..........................................................................................................Jumlah : ..........................................................................................................Lain – lain : ..........................................................................................................

............................................................................................................Sistem PersyarafanNyeri Kepala Reflek pupil TremorLain – lain : ..........................................................................................................

............................................................................................................Sistem MuskuloskeletalParalisis Tonus otot HemiparesisRentang gerak/ROM : .................................................................................................

...................................................................................................Kekuatan otot : ..........................................................................................................Keseimbangan : ..........................................................................................................Keterangan : ......................................................................................................................................................................................................................................................Nyeri SpesifikLokasi : ..........................................................................................................Tipe : ..........................................................................................................Intensitas : ..........................................................................................................Durasi : ..........................................................................................................Skala : ..........................................................................................................Keterangan : ......................................................................................................................................................................................................................................................

Riwayat PengobatanAlergiJenis obat yang dikonsumsi : .....................................................................................

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.......................................................................................Efek Samping : ..........................................................................................................

C. Kegiatan sehari – hariMakan/Minum : ..........................................................................................................

............................................................................................................Istirahat : ..........................................................................................................

............................................................................................................BAB/BAK : ..........................................................................................................

............................................................................................................Kebersihan diri : ..........................................................................................................

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D. Perilaku tidak sehatMerokok , ket : ...........................................................................Minum kopi , ket : ...........................................................................Mengkonsumsi garam , ket : ...........................................................................Minum alcohol/NAPZA , ket : ..........................................................................Perilaku seks bebas , ket : ..........................................................................

E. SpiritualTaat beribadah : .......................................................................................................... Kepercayaan yang berlawanan dengan kesehatan : ...................................................

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F. PsikologiKeadaan emosi pada saat ini :Marah Ketakutan Putus asaKeterangan : ......................................................................................................................................................................................................................................................

G. Factor resiko masalah kesehatanLantai rumah licin : .....................................................................................................

............................................................................................................Pola rentang gerak : .....................................................................................................

............................................................................................................Penataan perabot rumah : ............................................................................................

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Hubungan tidak harmonis : .....................................................................................................................................................................................................

Lain – lain : ......................................................................................................................................................................................................................

H. Tingkat kemandirian dalam kehidupan sehari – hari (dengan memberikan tanda “√”pada kolom yang sesuai)No Jenis Kegiatan Sehari – hari Mandiri Dengan

bantuan1 Makan dan minum2 Berpindah dari kursi ke tempat tidur dan

sebaliknya3 Kebersihan diri : cuci muka, menyisir,

mencukur, dan aktivitas kamar mandi4 Berjalan di jalan yang datar5 Naik turun tangga6 Berpakaian, termasuk mengenakan

sepatu7 Mengontrol buang air besar8 Mengontrol buang air kecil9 Olahraga / latihan fisik10 Pemanfaatan waktu luang / rekreasi

Pasuruan, ……………..………

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