FAKULTAS KEDOKTERAN UNIVERSITAS TANJUNG PURA/RSUD.DR.SOEDARSO

PONTIANAK

ASESMEN GERIATRI No.RM

(RAWAT JALAN, MINI-CEX)

Nama

: Laki-laki/PerempuanUmur

: .. Th

Agama

: Islam/Katolik/Kristen/Hindu/BudhaPendidikan: Tidak sekolah/SD/SMP/SMA/D3/S1/S2/S3Alamat/Hp: ..Pekerjaan: ..A. ANAMNESIS:1. Keluhan Utama : ,.. Riwayat Penyakit sekarang : ........ .....Riwayat penyakit dahulu:

........2. Kebiasaan:Ya

Tidak

Jumlah

Merokok .. perhari

Minum alkohol .. perhari

Minum kopi .. perhari

Olahraga (jenis/intensitas)........................... Dengan resep dokter Dosis dan lama pemakaian

. .............. .............. ............. Tanpa resep dokter Dosis dan lama pemakaian

. .............. .............B. PEMERIKSAAN FISIK:1. Kesan Umum.......2. Tanda vital

Kesadaran: Kompos mentis/apatis/somnolen/sopour/coma/.

Baring Duduk Berdiri Tekanan darah (TD)* ....

..

Nadi/menit

....

..

Laju respirasi/menit....

..

(*ukur TD setelah 2 menit pada posisi tersebut) Suhu derajat Celcius3. Tanda-tanda pentinga. Geriatri .........................................................................................................................................

b. Gejala gejala penting

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

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

c. Kelainan fisik penting..........................................................................................................................................

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

..........................................................................................................................................d. Kelainan psikologik..........................................................................................................................................

..........................................................................................................................................C. DIAGNOSIS C1.Sindrom Geriatri : ....................................................................... C2.Patologis:...... .................................................

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

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

C3.Psikologis:....................................................... ................................................................... D.GANGGUAN 1............ 3. 2..................................................................... 4..................................................................... E. KETIDAK MAMPUAN 1......................................................................3.....................................................................

. 2......................................................................4..................................................................... F.HAMBATAN1 3. 2.. 4.

G.TATALAKSANA1. Non Medikamentosa .. ..

..

2. Medikamentosa .. ..

.F. REKOMENDASI

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

..PONTIANAK,

Pembuat Asesmen (.)

IDENTITAS PASIEN