6) Reflex examination :

a) Physiological reflex : ( ) Normal ( ) No ........................ .............

b) Pathological reflex : ( ) No ( ) Yes......................................

I. Digestive System

Nutrition :

1) Tooth : ( ) Caries ( ) No

2) Use of dentures : ( ) Yes ( ) No

3) Sprue : ( ) Yes ( ) No

4) Dirty tongue : ( ) Yes ( ) No

5) Appetite : ( ) Good ( ) Less

Because..........................

6) Diet / Restriction food :............................................................................

7) Nausea : ( ) Yes ( ) No

8) Vomit : ( ) Haven't ( ) Have, ................

a) Content : ( ) Food ( ) Fluid ( ) Blood

b) Color : ( ) According to the color of the food ( ) Greenery

( ) Brown ( ) Yellow ( ) Black

c ) Frequency : ...............................X/ day

d) Amount : ...............................ml

9) Abodominal pain : ( ) Yes, ................................... ( ) No

10) Scale pain : ..............................

11) Location and character of pain :

( ) Like stabbed ( ) Twisted around ( ) cramps

( ) Hot / like burning

( ) Local ( ) Spread ( ) Moved ( ) Top right

( ) Bottom right ( ) Top lef ( ) Bottom lef

12) Heart : ( ) Palpable ( ) Not palpable

13) Abdomen : ( ) Mushy ( ) Bloated

( ) Ascites ( ) Distention

14) Abodominal circumference : ................................................ Cm

15) Installation NGT : ......................................................

16) pattern of eating habits at home :........................................................