Download - Status BM
DATA REKAM MEDIK PENDERITA
I. DATA PRIBADI
Nama
:Alamat
:Telepon
:Tanggal Lahir
:Jenis Kelamin
:Tinggi Badan
:
Berat Badan
:
Pekerjaan
:Status Pernikahan
:
Kerabat Terdekat
:II. RIWAYAT DENTAL1. Keluhan Utama
: ................................................................................
.................................................................................................................................. 2.Riwayat Penyakit Sekarang: ................................................................................
..................................................................................................................................3.Riwayat Dental yang Lalu: ................................................................................
..................................................................................................................................III. PEMERIKSAAN UMUM1. PEMERIKSAAN EKSTRA ORAL *
a. Kepala dan Leher
Kepala
: ............................................................................................Gld. Thyroid
: ............................................................................................
V. Jugularis
: ............................................................................................
Wajah-leher
: ............................................................................................
b. Kelenjar Limfe
- Submandibularis Sin: ........................................................................................................
Dext: ........................................................................................................- Submentalis: ............................................................................................- Cervicalis
: ............................................................................................2. PEMERIKSAAN INTRA ORAL *
a. Rongga Mulut
Bibir
: ............................................................................................Buccal mucosa: ............................................................................................
Lidah
: ............................................................................................
Dasar mulut
: ............................................................................................
Palat. Durum
: ............................................................................................
Palat. Molle
: ............................................................................................
Tonsil
: ............................................................................................
Oropharynx
: ............................................................................................
Calculus
Maxilla: Ant regio
.....................................................................Post regio
..................................................................... Mandibula: Ant regio.....................................................................Post regio.....................................................................
b. Gingiva
Maxilla: Ant regio
.....................................................................Post regio
..................................................................... Mandibula: Ant regio.....................................................................Post regio.....................................................................IV. STATUS INTRA ORAL PEMERIKSAAN GIGI-GIGI DAN JARINGAN LUNAKElemen
: ................................................................................
Caries (lokasi dan kedalaman): ................................................................................
Tes dingin
: ................................................................................
Tes panas
: ................................................................................
EPT
: ................................................................................
Perkusi
: ................................................................................
Druk
: ................................................................................
Sordes dan calculus
: ................................................................................
Kemerahan
: ................................................................................
Oedematous
: ................................................................................
Mudah berdarah
: ................................................................................
Resesi gingiva
: ................................................................................
Goyang
: ................................................................................
Pocket (lokasi dan kedalaman): ................................................................................V. PEMERIKSAAN PENUNJANG
Interpretasi:
........
............................NB: untuk pengisian STATUS INTRA ORAL PEMERIKSAAN GIGI-GIGI DAN JARINGAN LUNAK gunakan tanda dibawah ini:
( 0 ) = tidak dilakukan pemeriksaan
( + ) = dilakukan pemeriksaan, ada keluhan
( - ) = dilakukan pemeriksaan, tidak ada keluhanPAGE 4