Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 1. Saringan Status Kesihatan (Lelaki Dewasa) BSSK/ LD/ 2008 Pind 1/ 2013
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2 Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 1 A. BIODATA 1. Nama Penuh 2. Tarikh Lahir H H B B T T T T 3.. K.Pengenalan/ Passport 4. Warganegara Malaysia Warga Asing (nyatakan)... Melayu Bumiputera Sabah Lain-lain (Nyatakan) 5. Bangsa Cina India Bumiputera Sarawak Orang Asli 6. Tahap Pendidikan Tiada pendidikan formal Rendah Menengah Pengajian Tinggi Pekerjaan Utama Status Perkahwinan Belum Berkahwin Sudah Berkahwin Duda 9. Alamat Rumah 10.. Telefon Rumah: Bimbit: B. SEJARAH PERUBATAN/ PEMBEDAHAN (Tandakan di mana berkaitan) 1. Adakah anda/ ahli keluarga mengalami penyakit berikut: Sendiri Keluarga* a. Tekanan darah tinggi/ Hypertension b. Penyakit kencing manis/ Diabetes c. Penyakit jantung d. Penyakit angin ahmar/ Stroke e. Penyakit lelah/ Asthma f. Penyakit barah/ Kanser g. Penyakit sawan/ Epilepsy h. Penyakit mental i. Penyakit bawaan keturunan/ genetik seperti Thalassemia j. Penyakit kelenjar/ Thyroid k. Penyakit berjangkit seperti TB, Hepatitis, Jangkitan kelamin l. Penyakit buah pinggang (*Keluarga bermaksud adik beradik/ ibu bapa kandung) 1
3 Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 2 B. SEJARAH PERUBATAN/ PEMBEDAHAN (Bulatkan atau nyatakan di mana berkaitan) 2. Adakah ahli keluarga yang mati mengejut (Lelaki sebelum 45 tahun, wanita sebelum 50 tahun) 3. Adakah anda menghidap lain-lain penyakit? Jika nyatakan: Adakah anda mengambil sebarang ubat-ubatan? 5. Adakah anda pernah melalui a. Alahan ubat yang teruk b. Sebarang pembedahan, Jika nyatakan:... C. GEJALA SEMASA 1. Adakah anda mengalami a. Ketulan/ bengkak kelenjar limfa di leher b. Lelehan/ pengeluaran luar biasa dari telinga/ hidung c. Telinga berdengung d. Hilang pendengaran e. Kebas pada sebelah bahagian muka f. Perubahan atau ketulan pada payudara g. Batuk berpanjangan h. Batuk berdarah i. Masalah pembuangan air kecil atau air besar j. Lelehan/ pengeluaran luar biasa dari kemaluan k. Luka (ulser) yang lambat sembuh dibahagian kemaluan l. Penebalan kulit atau pembengkakan dikerandut zakar m. Masalah ketegangan zakar untuk membolehkan persetubuhan / kurang nafsu syahwat/ kurang daya tahan D. CORAK PEMAKANAN 1 Adakah anda mengambil makanan berikut setiap hari? a. Sarapan Pagi b. Makan Tengahari c. Makan Malam 2
4 Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 3 D. CORAK PEMAKANAN (sambungan) 2. Adakah anda mengambil pelbagai jenis makanan termasuk : a. Susu b. Sayur-sayuran c. Buah-buahan E. PENILAIAN AKTIVITI FIZIKAL 1. Adakah anda bersenam sekurang-kurangnya 150 minit seminggu (senaman intensiti sederhana contoh berjalan pantas selama 30 minit sekurang-kurangnya 5 kali seminggu) F. PENGAMBILAN BAHAN/ UBATAN 1. Adakah anda mengambil bahan berikut a. Rokok/ Tembakau b. Dadah c. Alkohol G. SEJARAH PENDERAAN 1. Pernahkah anda dibuli atau didera, sama ada secara emosi, fizikal atau seksual? H. PENILAIAN KESIHATAN MENTAL 1. Skor DASS (untuk diisi oleh petugas kesihatan) I. UKURAN BIOMETRI 1. Berat kg TAFSIRAN UKURAN 2. Tinggi m Kurang berat badan (BMI < 18.5) (BMI ) Lebih berat badan (BMI ) 3. BMI kg/m2 Obesiti Tahap 1 (BMI ) Obesiti Tahap 2 (BMI ) Obesiti Tahap 3 (BMI > 40) 4. Tekanan Darah mmhg < 120/80 Pre HPT < 140/90 HPT > 140/90 5. Lilitan Pinggang cm < 90 cm > 90 cm 3
5 Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 4 J. PEMERIKSAAN FIZIKAL (Tandakan di mana berkaitan) 1. General Hydration Poor Good Pallor Nail Clubbing Cyanosis Jaundice Ankle oedema Nicotine stained teeth Nicotine stained fingers Odour of cigarette smoke Skin (petechia, spider naevi etc, specify...) * Lymph nodes *(specify location) * 2. Eye Visual acuity Left Right Sclera Icteric Clear Cataract Fundus examination 3. Head & Neck Leukoplakia at oropharynx Thyroid enlargement Parotid Swelling Lump *(specify).. Others *(specify) Respiratory Chest Expansion Hyper-resonance Air entry Breath Sounds Additional Sounds Wheeze Rhonchi Crepitation 4
6 Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 5 J. PEMERIKSAAN FIZIKAL (sambungan) (Tandakan di mana berkaitan) 5. Cardiovascular Peripheral pulses Absent Irregular Present Regular Cardiomegaly Heart Sound Basal crepitation 6. Breasts Left Right Axillae 7. Abdomen Tenderness Liver Palpable t Palpable Spleen Palpable t Palpable Ascites Bowel sounds Absent Present Others (specify): Musculoskeletal Gait Spinal deformity Pelvic deformity Upper limb Tone Power Others (specify) Lower limb Tone Power Others (specify) 9. Nervous System Sensation Reflexes 10. Reproductive/ Genitourinary Penile abnormality Inguinal swelling / lump Testicular volume Scrotal contents 5
7 Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 6 K. RISIKO / MASALAH KESIHATAN DIKESAN (Tandakan dan nyatakan) Jenis risiko Perincian 1. Sejarah Keluarga 2. Gejala semasa 3. Pemakanan tidak sihat 4. aktif secara fizikal 5. Pengambilan bahan / ubatan 6. Penderaan 7. Kesihatan mental 8. Ukuran Biometri 9. Pemeriksaan Fizikal 10. Lain-lain (nyatakan) 6
8 Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 7 L. PENGENDALIAN RISIKO / MASALAH KESIHATAN * 1. Promosi & Pendidikan 2. Pemberian Risalah / Bahan Pendidikan Kesihatan 3. Khidmat Nasihat / Kaunseling 4. Rujukan Dietician/ Nutritionist 5. Rawatan Farmakologikal 6. Rujukan Pakar / Agensi-agensi berkaitan 7. Penyiasatan/ Investigation 8. Temujanji / Susulan Tarikh: Tandatangan, Nama & Cop Jawatan : 7
9 Project Saringan Status Kesihatan (L.D):Layout 1 1/9/14 4:06 PM Page 8 M. PANDUAN PENGENDALIAN RISIKO / MASALAH KESIHATAN Risiko Kanser NPC Nasihat & Risalah Kanser NPC Rujukan ke Pegawai Perubatan Kolorektal Stool occult blood Rujukan ke Pegawai Perubatan Paru-paru Testis CXR Rujukan ke Pakar Perubatan Keluarga Rujukan ke Pegawai Perubatan Payudara Pemeriksaan klinikal payudara Rujukan ke Pegawai Perubatan Risiko Tuberkulosis Sputum AFB CXR Risalah Etika Batuk Masalah Seksual Reproduktif Risiko Diabetes FBS/ RBS Nasihat & Risalah Penyakit Diabetes Risiko Kardiovaskular ECG Lipid profile Risalah Pemakanan tidak sihat Nasihat & Risalah pemakanan sihat Pengambilan bahan Rokok-Fagerstrom Dadah-ASSIST Alkohol-AUDIT aktif secara fizikal Nasihat & Risalah aktiviti fizikal Risiko didera Kesihatan Mental Rujukan ke Pegawai Perubatan Nasihat & Risalah Kesihatan Mental Tekanan darah abnormal Diari BP Nasihat & Risalah Penyakit Hipertensi Masalah berat badan Risalah pemakanan sihat 8
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