ASSESSMENT FORMAT

Date / Time Log Home sick : 10 November 2017 / 11:30 WITA

Room : Orchids

Number registration medical (RM) : 060603

Diagnosis medical : seizures fever

Date assessment : November 12, 2017

1.A.Identitas Patient

Name : Children M.A.

Age : 12-07-2012 / 3 years

Type sex :man

Religion :muslim

Tribe / nation :Bugis/Indonesia

Education :-

Work :-

Status : under age

Address : road flower katosoa Number 19 sub districts kendari west

B. Insurers answer

Name :Madam “M”

Type sex : Women

Work : Housewifes

Relationship with client : mothers

Address : road flower katosoa Number 19 sub districts kendari west

2.History health

A. Complaints main
Seizures 3X fever at home

B. History disease now

Patient come with complaint seizures fever

P: Paliative provocative / provoking incidents

What causes symptoms?

What can aggravate?

= on moment eat arise pain

What can reduce?

= On moment break

Q: quantity quality

How symptoms felt

= like stabbed

As far as where symptoms perceived: medium

R: Ragion / radiation

Where symptoms felt

= ditenggorokan

is spread

= no

S; severity: scale

How much level perceived severity?

= moderate

On scale how?

=4

T = Time

When symptoms start arise?

= on afternoon day

How much often symptoms perceived?

= arrive arrived

Arrived arrived or gradually

= arrive arrived

how long symptoms felt

= Every 5 minutes

3. History health first

Family client say that client no ever treated in home sick previous.client ever fever but no as now
experienced client

4. History Allergy

No there is

5. history health family

Family client say that his family no one ever fever but no to below hospital