YAYASAN ABDI KARYA (YADIKA)SEKOLAH MENENGAH KEJURUANSMK YADIKA MANADOJl. Raya Mapanget. Kec. Talawaan Kab. Minahasa UtaraTelp. (0431) 813393 Fax. (0431) 813392 Email: manadosmkyadika@yahoo.co.id

REPORT OF STUDENT HEALTYStudent name: _____________program : _________________________________________________________________Nis : _______________________ Age: year(s) month(s) week(s) day(s)Gender: male femalestatus: Dormitory OutsiderAddress: _________________________________________________________________Phone number: _________________________________________________________________Mother name: _________________________________________________________________mother age: year(s) month(s) week(s) day(s)mother occupation : _________________________________________________________________Father name: _________________________________________________________________Father age: year(s) month(s) week(s) day(s)Father occupation : _________________________________________________________________

AssessmentA. Health HistoryChief Complaints (PQRST)P:Q:R:S:T:History of Present Illness

Past Historya. Childhood Illness :

b. Accident(s)Type :Date/month/year :

c. Allergy:

d. Disease with Hospitalization(s)Cause(s) :Date/month/year :

e. Illness without hospitalization:Cause(s) :Date/month/year:

f. Medications :

Legend: = Female = Male = Dead Female = Dead Male = Pt (male) = Pt (female)= Divorced= Twin = AdoptedFamily History (3 Generations Genogram)

Physical Examination1. Vital SignsT : ___C P :___x/m R :___x/m BP: ____mmHg Weight: _____kg

Social Data Social activitiesorganization(s) :_________________________________________________not involved

Spiritual DataWorship attendancealways often sometimes rare neverNeeds priests/friends to prayyesnoPsychological DataExpressionsad frowning smiling comfort appearance Emotionanxious afraid angry irritability relax Coping strategyindependentneed assistance