NAMA :

NO :

AGE /DOB :

DEPARTMENT/ PT :

PHYSICAL DIAGNOSTIC FORM

RIWAYAT PENYAKIT (HISTORY OF DISEASE)

Y/N Y/N
Rhinitis / Hay Fever Hearing Problems
Anemia Eye Problems
Asthma Epilepsy
T

Abnormal Blood Pressure Migraine

T

BronchitiS Head Injury

Heart Abnormalities T

Hepatitis
Chronic Skin Disorders Kidney Disorder
T

Chronic Chough Low Back Pain

Diarrhoea > 2 weeks Typhoid Fever
Diabetes T

History of surgeries

COMPLAINTS :

1. BASIC EXAMINATIONS

HEIGHT : cm BLOOD : mmHg

PRESSURE
x
WEIGHT : kg PULSE : /i

SpO2 : % EYESIGHT RIGHT (右): (Unaided)

LEFT (左): (Unaided)
TEMPRATURE : C COLOUR BLINDNESS :
BMI :

PATIENT BEHAVIOUR :

BEHAVIOUR YES NO
SMOKING
ALCOHOLIC
COFFEE DRINKER
EXCERSICE

ROKOK ( )BUNGKUS

PEMERIKSAAN FISIK/ KELUHAN TAMBAHAN :

 3. GENERAL EXAMINATION

Type Yes No Description

Pale
Oedema
Cyanosis
Jaundice
Deformity
Skin Disorder

KELUHAN PENDENGARAN :

TELINGA SERUMEN ADA/TID