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Nama :
Tanggal lahir :
Telepon :
Alamat :
FORMULIR DETEKSI DINI CORONAVIRUS DISEASE (COVID-19)
Berilahtanda centang () pada kolom yang sesuai !
GEJALA
No Pertanyaan Ya Tidak
1 Demam/ riwayat demam
2 Batuk / Pilek/ Nyeri Tenggorokan
3 SesakNapas
FAKTOR RISIKO
No Pertanyaan Ya Tidak
1
2
Riwayat perjalananke luar negeri ataukota-kota terjangkit di
Indonesiadalamwaktu14 hari sebelum timbul gejala
Kota-kota terjangkit
DKI Jakarta
Jawa Barat (Kab Bekasi, Kota Bekasi, Depok, Cirebon, Bandung,
Purwakarta, Cianjur), Jawa Tengah(Solo, Magelang), Kalimantan
Barat (Pontianak), Sulawesi Utara (Manado), Bali,Banten(Kab
Tangerang, Kota Tangerang, Kota Tangerang Selatan)danDI
Yogyakarta (Sleman)
Memiliki riwayat paparan salah satuatau lebih
a. Riwayat kontak erat dengan kasus COVID-19 ATAU
b. Bekerja ataumengunjungi fasilitas kesehatan yang
berhubungan dengan pasienkonfirmasiCOVID-19 ATAU
c. Memiliki riwayat konyak denganhewan penular (jika hewan
penular sudah teridentifikasi) ATAU
d. Memiliki demam( 38oC) atauada riwayat demam, memiliki
riwayat perjalananke luar negeri ataukontakdenganorang
yang memiliki riwayat perjalananke luar negeri
CARA PENILAIAN
Pasien Dalam Pengawasan
(PDP)
Pasien Dalam Pemantauan
(ODP)
Kesimpulan
Gejala no. 1 + no. 2 + no. 3
DAN factor risikono. 1 ATAU
Gejala no. 1 ATAU no. 2 DAN
salahsatu ataulebihFaktor
Risiko no. 2
Gejala no. 1 atauno. 1 DAN
Faktor Risikono. 1
PDP
ODP
BukanKeduanga
TINDAK LANJUT
PDP atau ODP Rujuk UGD
Nama :
Tanggal lahir :
Telepon :
Alamat :
FORMULIR DETEKSI DINI CORONAVIRUS DISEASE (COVID-19)
Berilahtanda centang () pada kolom yang sesuai !
GEJALA
No Pertanyaan Ya Tidak
1 Demam/ riwayat demam
2 Batuk / Pilek/ Nyeri Tenggorokan
3 SesakNapas
FAKTOR RISIKO
No Pertanyaan Ya Tidak
1
2
Riwayat perjalananke luar negeri ataukota-kota terjangkit di
Indonesiadalamwaktu14 hari sebelum timbul gejala
Kota-kota terjangkit
DKI Jakarta
Jawa Barat (Kab Bekasi, Kota Bekasi, Depok, Cirebon, Bandung,
Purwakarta, Cianjur), Jawa Tengah(Solo, Magelang), Kalimantan
Barat (Pontianak), Sulawesi Utara (Manado), Bali,Banten(Kab
Tangerang, Kota Tangerang, Kota Tangerang Selatan)danDI
Yogyakarta (Sleman)
Memiliki riwayat paparan salah satuatau lebih
a. Riwayat kontak erat dengan kasus COVID-19 ATAU
b. Bekerja ataumengunjungi fasilitas kesehatan yang
berhubungan dengan pasienkonfirmasiCOVID-19 ATAU
c. Memiliki riwayat konyak denganhewan penular (jika hewan
penular sudah teridentifikasi) ATAU
d. Memiliki demam( 38oC) atauada riwayat demam, memiliki
riwayat perjalananke luar negeri ataukontakdenganorang
yang memiliki riwayat perjalananke luar negeri
CARA PENILAIAN
Pasien Dalam Pengawasan
(PDP)
Pasien Dalam Pemantauan
(ODP)
Kesimpulan
Gejala no. 1 + no. 2 + no. 3
DAN factor risikono. 1 ATAU
Gejala no. 1 ATAU no. 2 DAN
salahsatu ataulebihFaktor
Risiko no. 2
Gejala no. 1 atauno. 1 DAN
Faktor Risikono. 1
PDP
ODP
BukanKeduanga
TINDAK LANJUT
PDP atau ODP Rujuk UGD

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Formulir deteksi dini coronavirus disease

  • 1. Nama : Tanggal lahir : Telepon : Alamat : FORMULIR DETEKSI DINI CORONAVIRUS DISEASE (COVID-19) Berilahtanda centang () pada kolom yang sesuai ! GEJALA No Pertanyaan Ya Tidak 1 Demam/ riwayat demam 2 Batuk / Pilek/ Nyeri Tenggorokan 3 SesakNapas FAKTOR RISIKO No Pertanyaan Ya Tidak 1 2 Riwayat perjalananke luar negeri ataukota-kota terjangkit di Indonesiadalamwaktu14 hari sebelum timbul gejala Kota-kota terjangkit DKI Jakarta Jawa Barat (Kab Bekasi, Kota Bekasi, Depok, Cirebon, Bandung, Purwakarta, Cianjur), Jawa Tengah(Solo, Magelang), Kalimantan Barat (Pontianak), Sulawesi Utara (Manado), Bali,Banten(Kab Tangerang, Kota Tangerang, Kota Tangerang Selatan)danDI Yogyakarta (Sleman) Memiliki riwayat paparan salah satuatau lebih a. Riwayat kontak erat dengan kasus COVID-19 ATAU b. Bekerja ataumengunjungi fasilitas kesehatan yang berhubungan dengan pasienkonfirmasiCOVID-19 ATAU c. Memiliki riwayat konyak denganhewan penular (jika hewan penular sudah teridentifikasi) ATAU d. Memiliki demam( 38oC) atauada riwayat demam, memiliki riwayat perjalananke luar negeri ataukontakdenganorang yang memiliki riwayat perjalananke luar negeri CARA PENILAIAN Pasien Dalam Pengawasan (PDP) Pasien Dalam Pemantauan (ODP) Kesimpulan Gejala no. 1 + no. 2 + no. 3 DAN factor risikono. 1 ATAU Gejala no. 1 ATAU no. 2 DAN salahsatu ataulebihFaktor Risiko no. 2 Gejala no. 1 atauno. 1 DAN Faktor Risikono. 1 PDP ODP BukanKeduanga TINDAK LANJUT PDP atau ODP Rujuk UGD
  • 2. Nama : Tanggal lahir : Telepon : Alamat : FORMULIR DETEKSI DINI CORONAVIRUS DISEASE (COVID-19) Berilahtanda centang () pada kolom yang sesuai ! GEJALA No Pertanyaan Ya Tidak 1 Demam/ riwayat demam 2 Batuk / Pilek/ Nyeri Tenggorokan 3 SesakNapas FAKTOR RISIKO No Pertanyaan Ya Tidak 1 2 Riwayat perjalananke luar negeri ataukota-kota terjangkit di Indonesiadalamwaktu14 hari sebelum timbul gejala Kota-kota terjangkit DKI Jakarta Jawa Barat (Kab Bekasi, Kota Bekasi, Depok, Cirebon, Bandung, Purwakarta, Cianjur), Jawa Tengah(Solo, Magelang), Kalimantan Barat (Pontianak), Sulawesi Utara (Manado), Bali,Banten(Kab Tangerang, Kota Tangerang, Kota Tangerang Selatan)danDI Yogyakarta (Sleman) Memiliki riwayat paparan salah satuatau lebih a. Riwayat kontak erat dengan kasus COVID-19 ATAU b. Bekerja ataumengunjungi fasilitas kesehatan yang berhubungan dengan pasienkonfirmasiCOVID-19 ATAU c. Memiliki riwayat konyak denganhewan penular (jika hewan penular sudah teridentifikasi) ATAU d. Memiliki demam( 38oC) atauada riwayat demam, memiliki riwayat perjalananke luar negeri ataukontakdenganorang yang memiliki riwayat perjalananke luar negeri CARA PENILAIAN Pasien Dalam Pengawasan (PDP) Pasien Dalam Pemantauan (ODP) Kesimpulan Gejala no. 1 + no. 2 + no. 3 DAN factor risikono. 1 ATAU Gejala no. 1 ATAU no. 2 DAN salahsatu ataulebihFaktor Risiko no. 2 Gejala no. 1 atauno. 1 DAN Faktor Risikono. 1 PDP ODP BukanKeduanga TINDAK LANJUT PDP atau ODP Rujuk UGD