Form Asesmen Awal Medis Rajal Mata Baru

RUMAH SAKIT KURNIA SERANG Jln. Raya Cilegon Km.8 Telp. 0254-232648 Fax. 0254-8235050 Kramatwatu Serang - Banten

Nama pasien : No. RM pasien : L/P Tanggal lahir/Umur : Dokter yang merawat : (tempel barcode bila ada)

ASESMEN AWAL MEDIS RAWAT JALAN MATA Anamnesa :

AV OD

:

AV OS

:

Ukuran kaca mata lama OD = ........................................ ........................................ OS = .................................. ........................................ ...... Kedudukan Bola Mata OD

 Adisi ........................... ........................... OS

Pergerakan ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ...................................................

Palpebra Konjungtiva Kornea Bilik Mata Depan Iris dan Pupil Lensa Vitreous dan Fundus Tekanan Intra Okuler

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

Tes lshihara : Normal / Red green deficiencies / Absolut colour blindness Schimer test OD = .................... .................... OS = .................... Diagnosa OD = 

OS = Terapi

:

Serang,…………………………… TTD DPJP

(……………………………………)

RM 124