Angket Daftar Riwayat Kesehatan

Olimpiade Brawijaya 2017

A. BIODATA

Nama : ................................................................................................................

Tempat/Tgl. Lahir : ................................................................................................................

Jenis Kelamin : Laki-laki / Perempuan ( Coret yang tidak perlu )

Alamat Asal : ................................................................................................................

Alamat Malang : ................................................................................................................

No. HP : ................................................................................................................

Berat Badan : ................................................................................................................

Tinggi Badan : ................................................................................................................

Lomba yang : 1.)...........................................................................................................

diikuti 2.)............................................................................................................

3.)............................................................................................................

B. DATA KESEHATAN

Apakah Peserta pernah mengalami gejala-gejala/diperiksa/menderita/didiagnosis/

mendapat pengobatan/disarankan atau menjalani rawat inap/menjalani operasi/ dianjurkan
untuk mendapat nasihat medis/telah mendapat nasihat medis atau dirujuk ke dokter spesialis,
untuk kelainan yang disebutkan di bawah ini:

1. Jika “Ya”, mohon Peserta memberi tanda √ pada point huruf dan lingkari penyakit yang
diderita untuk setiap kelainan yang dimiliki dan mengisi Angket Daftar Riwayat
Kesehatan sesuai dengan kelainan tersebut:
a. Rabun jauh dengan menggunakan kacamata/softlens melebihi -6.0 pada satu atau
kedua mata/katarak/kelainan mata lainnya.
 b. Telinga/Hidung/Tenggorokan (THT), Sinus/Gangguan Bicara.
c. Gangguan Pernafasan/ Batuk Berkepanjangan/ Sesak Nafas/ Bronkitis/ Asma/
Tuberkulosis (TBC)
d. Nyeri Dada/Kelainan Jantung & Pembuluh Darah/Kelainan Jantung
Bawaan/Demam Rheuma/Peningkatan Kolesterol/Tekanan
e. Darah Tinggi/Stroke
f. Gangguan Saluran Pencernaan (Maag/Gastritis)/Usus/Hernia/Pankreas/Organ
Pencernaan lainnya.
g. Hepatitis A/Hepatitis B/Hepatitis C/Hati (selain Hepatitis)/Kandung Empedu.
h. Ginjal/Saluran Kemih (termasuk batu)/Cuci Darah/Prostat.
i. Alergi/Penyakit Kulit atau Kelamin/Malaria.
j. Sakit Kepala/ Pusing/ Migrain/ Vertigo/ Gangguan Kesadaran/ Otak/ Saraf/ Epilepsi/
Ayan/ Kelainan Psikologis/Kejiwaan
k. Gangguan Persendian/Rematik/Kelainan pada Otot/Sendi/Tulang/Gangguan Tulang
Belakang/Polio/Multiple Sclerosis/Asam Urat
l. Kencing Manis/Kelenjar Gondok atau Endokrin/Hormon
m. Payudara/Kandungan/Indung Telur
n. Wasir (Haemorrhoid)/Varices/Kelainan Pembuluh Darah lainnya
o. Kelainan Darah (Thalasemia/Haemofilia/Leukemia/Anemia atau Kelainan Darah
Lainnya)/Menerima Transfusi Darah
p. Tumor/Kista/Benjolan/Pembengkakan/Kanker/Nodul
q. Systemic Lupus Erithematosus (SLE)/ACA atau Penyakit Sistem Kekebalan lainnya
(Auto Immune Diseases)
r. Penyakit lain yang belum disebutkan?
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2. Apabila Peserta menderita satu atau lebih penyakit yang telah disebutkan diatas, maka dimohon
peserta menjawab pertanyaan di bawah ini:
a. Nama keadaan/penyakit:
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b. Kapan serangan terakhir?
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c. Tanggal konsultasi/perawatan:
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d. Sebutkan tindakan medis dan nama obat yang diberikan:
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e. Bagaimana hasilnya pada saat itu?
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f. Bagaimana keadaannya sekarang?
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Keterangan : Perbanyak jika diperlukan