2-3 B. PEMERIKSAAN FIZIKAL (untuk diisi oleh pengamal perubatan berdaftar) 1. Tinggi: cm Berat Badan: . kg (Height) (Weight) 2. Indeks Jisim Tubuh (BMI): kg/m2 BMI <18.5 (kurang berat badan) BMI 18.5-24.9 (normal) BMI 25-29.9 (lebih berat badan) BMI > 30 (kegemukan / obes) 3. Penglihatan (Vision): Mata Kanan (Right Eye) Mata Kiri (Left Eye) Dengan Kaca Mata (With glasses) 6/_ Dengan Kaca Mata (With glasses) 6/_ Tanpa Kaca Mata (Without glasses) 6/_ Tanpa Kaca Mata (Without glasses) 6/_ Kadar Nadi (Pulse rate) : _________/min Rentak (Rhythm): ___________ Tekanan Darah (Blood Pressure ) :_________ sistolik mm/Hg _________ diastolik mm/Hg Pemeriksaan Klinikal Payudara: Biasa (Normal) / Luar Biasa (Abnormal) _________________ (Clinical Breast Examination) Pap smear:____________________________________________ C. UJIAN MAKMAL 1. Glukosa Darah: Rawak (Random) ___________ mmol/l Puasa (Fasting) ___________ mmol/l 2. Serum Lipid: Total Cholesterol ___________ mmol/l Nota: Jalankan ujian lanjut jika diperlukan. D. Catatan __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Tandatangan Pemeriksa :__________________________ Tarikh : ____________________ Nama :__________________________ Cop Rasmi: atau;
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