LAPORAN BUMIL

BULAN
TAHUN
NO

NAMA IBU HAMIL

UMUR

NAMA SUAMI

ALAMAT

Pondok, Sambirejo

Ny Endang

29 th

2
3

Ny Sari Irma
Ny Fitri Puspitasari

20 th
24 th

Tn. Tri Hermawan

Sejeruk, Musuk
Jatiarum, Dawung

2
1

1
0

0
0

Ny Siti Fatonah

22 th

Tn. Supriyadi

Bayanan, Sambirejo

Ny Vera

20 th

Tn. Didik Hartadi

Sidorejo, Blimbing

Ny Untari

17 th

Tn. Yam Roni

Kadipiro, Kadipiro

Ny Sri Ekawati

23 th

Pondok, Sambirejo

Ny Hendri

22 th

Tn. Purngadirman

Kembang, Jetis

Ny Riski

19 th

Tn. Kuat Mulyadi

Kembang, Jetis

10
11

Ny Sugiyarsi
Ny Supartini

31 th
25 th

Tn. Sutarmo

Sidorejo, Blimbing
Salam, Blimbing

2
2

1
1

0
0

12

Ny Dewi

20 th

Garut, Dawung

13

Ny Sulastri

29 th

Pakis, Blimbing

14

Ny Nila Wiwin

26 th

Sidomulyo, Dawung

15

Ny Yuli Ardriani

23 th

Jatiarum, Dawung

16

Ny Fitri

18 th

Tn. Giyanto

Gadingrejo, Kadipiro

17

Ny Lilis

20 th

Tn. Rois

Bulakrejo, Blimbing

18

Ny Tri Handayani

21 th

Tn. Tri Wibowo

Nangsri, Dawung

19

Ny Yayuk

31 th

Tn. Suyanto

Selang, Jetis

20

Ny Siska

32 th

Tn. Dhana

Salam, Blimbing

21

Ny Rina

20 th

Basan, Sambi

22

Ny Erna

24 th

Tn. Eko Supriyanto

Jatiarum, Dawung

23

Ny Ruriana

19 th

Tn. Wagiman

Bangunrejo, Sambiorejo

24

Ny Dewi

20 th

Tn. Wawan

Garut, Dawung

Tn. Wantoro

Klinik/BPM

LAPORAN BUMIL
BULAN
TAHUN
NO

NAMA IBU HAMIL

UMUR

Ny. Sri Yatmi

31 th

Ny. Surani

41 th

3
4
5

Ny. Dewi
Ny. Yanti
Ny. Mulyani

20 th
23 th
31 th

Ny. Suparni

33 th

NAMA SUAMI
Tn. Anang
Tn. Wawan

ALAMAT

Tegalrejo, Kadipiro

Bangunrejo, Sambirejo

Garut, Dawung
Pakis, Blimbing
Tegalrejo, Kadipiro

1
1
2

0
0
1

0
0
0

Badran, Blimbing

Klinik/BPM

LAPORAN BUMIL

UMUR KEHAMILAN

TGL TT I

TGL TT II

32+2
32+2
29
14+4

26-4-16

21

2015

+4

22+5
34+4
38+5

2015

2016

37

2015

2015

2015

2016

2015

9/6/2016

+6

32+5
HPHT 28-06-2016
32+4
30+2
33+1
33

+1

34+4
30

+3

9-7-2016

25+4
30+6

05-5-2005

-2006

36+2

-4-2016

20-5-2016

16+4

23+7
1-2008

2009

21

+1

2016

17-8-2016

34+6

2015

21-7-2016

JENIS RESTI

Penanggung Jawab
Klinik/BPM .

(..)

LAPORAN BUMIL

UMUR KEHAMILAN

TGL TT I

TGL TT II

2015

21/7/2016

10+1
33+3
35+5
34
31
25+4

JENIS RESTI

Penanggung Jawab
Klinik/BPM .

(..)

REGISTRASI IMUNISASI
PUSKESMAS SAMBIREJO
Tgl. No
1/8
2/8
3/8
5/8
6/8
8/8
10/8
15/8
17/8
18/8
19/8
25/8
27/8

1
2
1
1
2
1
2
1
1
2
1
1
2
1
1
2
1
2
1
2
1

Nama Bayi
An. Fadila
An. Alif
An. Rindang K
An. Fadli
An. Ahlam
An. M. Haziq
An. Zahran
An. Arsaka
An. Davigo
An. Delvia
An. Diego
An. Mutiara
An. Kamila
An. Alya M
An. Arshila
An. Aisyah
An. Aslisya
An. Nindi
An. Shalasa
An. Zeya
An. Lafiandro

Umur
3 bln
3 bln
3 bln
4 bln
4 bln
2 bln
2 bln
5 bln
3 bln
5 bln
1,5 th
5 bln
10 hari
2 bln
4 bln
3 bln
1,5 bth
4 bln
5 bln
4 bln
2 bln

Nama Orang Tua

Tn. Supriyanto
Ny. Karnia
Tn. Purnomo/Ny. Istiana
Tn. Suyatno/Ny. Heni
Tn.M. Priharyanto/Ny. Ani
Ny. Ayu/ Tn. Sufiyanto
Ny. Vinarti/ Tn. Teguh
Tn. Hadi
Tn. Agung
Tn. Agus
Tn. Heri
Tn. Hedi/Ny. Nurul
Tn. Suwito/ Ny. Retno
Tn. Amsal/Ny. Ragil
Tn. Ngadi/Ny. Mijik
Tn. Kunaryo/Ny. Eni
Tn. Masran
Tn. Sapari/Ny. Suharni

Alamat
Nggandu, Kadipiro
Nangsri, Dawung
Bulakrejo, Blimbing
Jetis, Sambirejo
Nangsri, Dawung
Purworejo, Sambirejo
Nangsri, Dawung
Kliro, Dawung
Salam, Blimbing
Garut, Dawung
Jatirejo, Sambi
Sidoharjo, Musuk
Kalikeri, Dawung
Jatirejo, Sambi
Bukur, Dawung
Wadang, Kadipiro
Tegalrejo, Kadipiro
Purworejo, Blimbing
Jatiarum
Pakis, Blimbing
Surodadi, Dawung

HB 0

BCG

PENTABIO
II
III

RASI IMUNISASI
MAS SAMBIREJO

HASIL IMUNISASI
Polio
II
III
IV

Campak

BOOSTER
PENTABIO
Campak

Ket.

+ Vit K

REGISTRASI KB
DESA.
PUSKESMAS SAMBIREJO
Nama
No

Tanggal
Istri

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

8/2/2016
8/4/2016
8/7/2016
8/8/2016
8/8/2016
8/9/2016
8/22/2016
8/23/2016
8/23/2016
8/25/2016
8/25/2016
8/26/2016
8/27/2016

Ny. Mikiana
Ny. Siti
Ny. Ningrum
Ny. Sufi
Ny. Suwarni
Ny. Pujiatmi
Ny. Diyah
Ny. Sinem
Ny. Karnia
Ny. Parjiyem
Ny. Fitri
Ny. Imarini
Ny. Ninik

Suami
Tn. Ari
Tn. Lagi
Tn. Sriyanto
Tn. Sri Harjono
Tn. Muji Sunarso
Tn. Waluyo
Tn. Ratman
Tn. Tri Widodo
Tn. Gino
Tn. Sigit
Tn. Galih

Umur Istri
(Th)

Jumlah
Anak

Umur Anak
Terkecil

24
35
46
41
41
34
29
32
18
34
23
23
21

2
2
2
3
3
3

4,5 th
10 th
13 th
8 th

10 th

2
2
1
2

6 bln
1 bln
2 bln
2 th

2,5 th

Me
Alamat Dukuh, RT
IUD
Sarirejo, Sambi
Sambirejo, Sambirejo
Musuk, Sambirejo
Siwalan, Sambirejo
Dukuh, Dawung
Purworejo, Blimbing
Jatiarum, Dawung
Jatiarum, Dawung
Nangsri, Dawung
Tegalrejo, Kadipiro
Jatiarum, Dawung
Seblabur, Blimbing
Mulyorejo, Sambi

IMP

Metode Kontrasepsi
Keterangan
STK

PIL

KDM

Lainnya

REGISTRASI ANC
KLINIK GITA MEDIKA
..
TGL

NO
6
7

NAMA PASIEN
Ny. Mulyani
Ny. Khofifah

UMUR
ALAMAT
31 th Wonotolo
23 th

Tejo Seloromo

G
1

P
0

A
0

HPHT
28-3-16

15-11-16

HPL

UK (MGG)
18+3

BB (KG)
46

36+1

55
46

AGUSTUS
1/8/16

2/8/16

3/8/16

4/8/16

5/8/16

6/8/16

Ny. Sari Irma

20 th

Sejeruk, Musuk

?-11-15

32+2

Ny. Jatiyatun

38 th

Betis, Tawangsari

15-1-16

Ny. Fitri Istiqomah

25 th

Candi Asri

1
2

Ny. Reni
Ny. Purwantari

30 th
38 th

Bontit, Srimulyo
Ngarum

3
2

2
1

3
4

Ny. Titis
Ny. Fitri Puspitasi

22 th
24 th

Polan, Menjing
Jatiarum, Dawung

1
1

Ny. Wiji

31 th

Kedungdowo, Ngarum

Ny. Warsini

34 th

Ny. Wahyu

17

+3

50,5

9-5-16

+3

11

45

0
0

16-5-16
11-5-16

9
12

54
64

0
0

0
0

18-10-15

40+3
25

64
45,5

10-12-15

35+5

55

Pelang, Selomoro

15-12-15

32

50,5

28 th

Ngarum

21-6-16

51

Ny. Siti Fatonah

22 th

Bayanan, Jambean

24-4-16

14

40

Ny. Eni Suryanti

30 th

Pokoh, Tunggul

12-12-15

34

64

Ny. Siswanti

22 th

Klecorejo, Wonotolo

27-1-16

26

2
3

Ny. Sulistyowati
Ny. Iif Latifah

24 th
25 th

Asri, Srimulyo
Kleco, Ngarum

1
1

0
0

0
0

22-2-16
30-6-16

23+6
5

53,5
54

Ny. Galuh

21 th

Pondok, Pl.Gadung

7-11-15

38+2

62

Ny. Untari

17 th

Kadipiro

18-4-16

22

44

Ny. Vera

20 th

Sidorejo, Blimbing

7-3-16

21

48

4
5

Ny. Karsini
Ny. Nining

39 th
32 th

Tegalrejo, Kadipiro
Kleco, Ngarum

4
2

3
1

0
0

27-3-16
18-12-15

22
33

81,5
66

Ny. Rani

37 th

Glagah, Mojorejo

28-12-15

31+3

47

Ny. Suryamti

29 th

Dendang, Srimulyo

17-6-16

68

Ny. Ratna

33 th

Genting

2-7-16

+6

65,5

Ny. Vitri

22 th

Kleco, Ngarum

28-5-16

5+5

42,5

Ny. Diah

22 th

Jatimalang, Kerjo

3-11-15

39+3

80

Ny. Mita

24 th

Delangan, Kaliwedi

4-5-16

12

89

+4

+6

+1
+4
+1
+6

+5
+4
+6

+6

+2

Ny. Hendri

22 th

Kembang, Jetis

5-11-16

38+5

56

Ny. Riski

19 th

Kembang, Jetis

15-11-15

37

49

+6

REGISTRASI ANC
KLINIK GITA MEDIKA
..
TGL
1/8/16

7/8/16

8/8/16

9/8/16

10/8/16

NO

NAMA PASIEN

UMUR

ALAMAT

HPHT

HPL

UK (MGG)

BB (KG)

Ny. Endang

29 th

Pondok, Sambirejo

7-12-15

32+2

48

Ny. Epi Lestari

25 th

Ledok, Mojorejo

18-11-15

37

57

Ny. Wiji Lestari

27 th

Dondong, Srimulyo

5-12-15

35

53,5

1
2

Ny. Tri Yani

Ny. Suparmi

21 th
38 th

Bontit, Srimulyo
Lemah Ireng

1
2

0
1

0
0

9-1-16
20-1-16

29
30

47
64

Ny. Lia Novi

23 th

Karang Tempel

1-6-16

9+1

70

4
5

Ny. Dewi
Ny. Supartini

20 th
25 th

Garut, Dawung
Salam, Blimbing

1
2

0
1

0
0

15-12-15
28-6-16

32

+4

65
49

Ny. Fitri Nurhayati

28 th

Murong, Ngrampal

10-4-16

17+3

54

Ny. Sugiyarsi

31 th

Sidorejo, Blimbing

29-12-15

32

50

Ny. Ciciu

38 th

Kacangan

13-11-15

38

59

Ny. Sulastri

29 th

Pakis, Blimbing

13-1-16

30

45

Ny. Yuli Ardriani

23 th

Jatiarum, Dawung

30-1-16

33

Ny. Nia Wiwin

26 th

Sidomulyo, Dawung

20-12-15

33+1

Ny. Sri Partini

27 th

Asri, Srimulyo

8-4-16

14

76,5

Ny. Anik

31 th

Pokoh, Tunggul

9-2-16

26

60

Ny. Alvin

19 th

Pelemgadung

17-2-16

25

42

Ny. Titis

22 th

Polan, Menjing

18-10-15

41

63,5

Ny. Lilis

20 th

Bulakrejo, Blimbing

lupa

30

+3

59

Ny. Fitri Andriyani

18 th

Gadingrejo, Kadipiro

15-12-15

34+4

49

Ny. Selvi

24 th

Dondong, Srimulyo

23-2-16

24+4

45

Ny. Irma

23 th

Ngrejeng, Jambean

1-11-15

40

85

Ny. Suprapti

30 th

Mentir, Wonotolo

29-12-15

31

52

Ny. Maryati

27 th

Grasak, Bendungan

15

36

Ny. Wargini

29 th

Bayanan, Jambean

13-6-16

86

Ny. Tri Handayani

21 th

Nangsri, Dawung

8-2-16

25

+3
+4
+1

+5
+3
+2
+1

+6
+3
+4
+3

+2
+3
+3

+3
+4

46

51,5

11/8/16

1
2

Ny. Suprapti
Ny. Hanifah

19 th
23 th

Basan, Sambi
Kedungganda, Bumiaji

1
1

0
0

0
0

13-5-16
29-3-16

12+6
19

48
66

12/8/16

Ny. Sri Hartini

32 th

Tanjung, Sambirejo

2-2-16

27+5

58

Ny. Walimah

33 th

Wonotolo

26-1-16

24+2

56

UK (MGG)

BB (KG)

REGISTRASI ANC
KLINIK GITA MEDIKA
..
TGL

NO

NAMA PASIEN

UMUR

ALAMAT

HPHT

HPL

13/8/16

Ny. Wiji

31 th

Kedungdowo, Ngarum

10-12-15

37+2

54,5

14/8/16

2
1

Ny. Purwati
Ny. Riski

35 th
19 th

Garut, Dawung
Kembang, Jetis

5
1

2
0

2
0

6-12-16
15-11-15

35
39

58,5
49,5

Ny. Septi

30 th

Tegalrejo, Kadipiro

15-5-16

12+2

58

3
4

Ny. Waginingrum
Ny. Nuri

33 th
29 th

Tanggul, Gondang
Kaliwedi, Gondang

1
3

0
2

0
0

22-12-15
27-2-16

34+1
24

71
58

Ny. Wiji Lestari

27 th

Srimulyo

5-12-16

39+2

56

2
3

Ny. Nurul Anis

Ny. Winarsih

29 th
30 th

Mentir, Bener
Asri, Srimulyo

2
2

1
1

0
0

10-5-16
2-4-16

5+4
20

54
43,.5

Ny. Rina

20 th

Basan, Sambi

24-12-15

36+2

54

Ny. Siska

32 th

Salam, Blimibing

5-3-16

23+5

73

Ny. Yayuk

31 th

Pelang, Jetis

25-1-16

30+6

58

7
1

Ny. Margini
Ny. Wahyu

25 th
22 th

Kaliwedi, Gondang
Jambeyan, Bumiaji

2
1

1
0

0
0

26-12-16

25
33

53
51

Ny. Erna

24 th

Jatiarum, Dawung

22-4-16

6+4

66

Ny. Ida

22 th

Bayanan, Jambeyan

12-4-16

18+6

45

Ny. Siti Nur

21 th

Rejosari, Bendongan

17-6-16

47

Ny. Umi

30 th

Betis, Tawangsari

14-12-15

36

62,5

Ny. Mutiara

19 th

Bangunrejo, Sambiorejo

28-3-16

21

45

4
1

Ny. Sofi
Ny. Rani

27 th
37 th

Ceme, Wonotolo
Glagah, Mojorejo

2
2

1
1

0
0

5-12-15
28-12-15

35
32

56
47,5

Ny. Ariyani

43 th

Bandungan, Wonotolo

27-2-16

23+6

66

Ny. Sulis

24 th

Sidoharjo, Musuk

11-4-16

16

44,5

Ny. Dewi

20 th

Garut, Dawung

15-12-15

34

64

Ny. Suwarni

32 th

Asri, Srimulyo

12-4-16

18

50

15/8/16

16/8/16

17/8/16

18/8/16

+3

+5

+1
+3
+1
+6

+1
+6
+1

19/8/16

20/8/16

Ny. Titik

32 th

Ngarum

26-11-15

40+2

58

1
2

Ny. Asih
Ny.Iif Latifah

28 th
25 th

Ngemplak, Srimulyo
Kleco, Ngarum

1
1

0
0

0
0

13-3-16
30-6-16

22
7

56
453

3
1

Ny. Rani
Ny. Nurjanah

22 th
34 th

Kr. Tanjung, Ngarum

Jatirejo, Sambi

2
2

1
1

0
0

28-6-16
16-4-16

7+3
18

77
44

UK (MGG)

BB (KG)

+2

REGISTRASI ANC
KLINIK GITA MEDIKA
..
TGL

21/8/16

22/8/16

24/8/16

25/8/16
26/8/16

NO

NAMA PASIEN

UMUR

ALAMAT

HPHT

HPL

Ny. Wulandari

22 th

Purworejo II, Blimbing

18-2-16

26+4

48

Ny. Mita

24 th

Belangan, Kaliwedi

4-5-16

15+3

44

Ny. Fitri

19 th

Sonorejo, Sb. Macan

28-12-15

32+6

50

5
6

Ny. Harmini
Ny. Yahniati

32 th
26 th

Kr. Tempel, Srimulyo

Garut, Dawung

3
2

2
1

0
0

25-11-15
1-6-16

37+3
2bln

51,5
74

Ny. Sarmi

29 th

Kr. Asem, Wonotolo

10-2-16

27+5

70

2
3

Ny. Tri Handayani

Ny. Indraswati

33 th
25 th

Tawangsari, Tunggul
Jatiarum, Dawung

3
2

2
0

0
1

6-2-16
24-12-15

29+6
36

66
88

Ny. Ery

27 th

Kr. Rejo, Srimulyo

20-12-15

35+2

66

Ny. Eni

30 th

Pokoh, Tunggul

12-12-15

36+6

64,5

Ny. Sri Yatmi

31 th

Tegalrejo, Kadipiro

10-6-16

10+1

42

Ny. Surani

41 th

Bangunrejo, Sb. Rejo

1-1-16

33

67

Ny. Kunti

36 th

Ngoncol, Nglorog

14-2-16

27

65

2
3

Ny. Dewi
Ny. Tanti

20 th
23 th

Garut, Dawung
Pakis, Blimbing

1
1

0
0

0
0

15-12-15
31-12-15

35
34

67
56

Ny. Mulyani

31 th

Tegalrejo, Kadipiro

3-1-16

33+4

76,5

5
6

Ny. Dian
Ny. Asih Miyati

25 th
32 th

Gendingan
Mangir, Blimbing

2
2

1
1

0
0

9-7-16
15-6-16

7
10

45
73

Ny. Suparni

33 th

Badran, Blimbing

5-2-16

25+4

51

Ny. Suprapti

30 th

Mentir, Wonotolo

29-12-15

33

52,5

1
2
3

Ny. Ping-ping
Ny. Tri Wahyuni
Ny. Darni

24 th
28 th
31 th

Sidorejo, Blimbing
Bekasar, Sambirejo
Kleco, Ngarum

1
1
3

0
0
1

0
0
0

20-1-16
20-5-16
3-2-16

31
14
29

70
38
58

Ny. Gini

30 th

Sumber, Gedungan

22-6-16

9+2

55

+3
+5
+5

+5

+4
+2

27/8/16

28/8/16

5
1

Ny. Wiji Lestari

Ny. Suyatni

27 th
36 th

Dundus, Srimulyo
Betis, Tawangsari

2
2

1
1

0
0

5-12-16
15-5-16

38
14

56
69

2
3

Ny. Sri Lestari

Ny. Endang

25 th
29 th

Ledok, Mojorejo
Punduk, Sambirejo

1
2

0
1

0
0

18-11-15
7-12-15

41+1
36

59
52

Ny. Sutarni

28 th

Tawangsari, Tunggul

8-3-16

26+1

59

Ny. Aska Wulandari

25 th

Keten, Wonotolo

29-3-16

21

42

+5

STRASI ANC
GITA MEDIKA
..
TD (mmHg)
106/61
125/74

AGUSTUS
102/53
132/72
112/69
110/77
124/80
119/82
91/62
114/60
129/75
117/83
121/72
116/61
101/58
137/85
109/81
99/58
107/82
110/65
112/71
126/65
128/81
123/81
98/64
111/90
105/79

LAB

TFU

DJJ

KET

137/99
104/68

STRASI ANC
GITA MEDIKA
..
TD (mmHg)
105/56
119/73
110/67
102/68
146/96
126/91
131/69
128/72
112/77
142/88
123/77
104/50
90/60
111/63
135/75
106/74
108/77
130/51
114/80
116/63
96/50
132/82
113/70
106/73
105/65
112/60

LAB

TFU

DJJ

KET

10/70
135/80
104/57
120/70

STRASI ANC
GITA MEDIKA
..
TD (mmHg)
104/65
124/80
109/69
105/90
109/72
102/67
102/66
119/70
121/67
112/59
141/102
143/84
125/79
94/68
110/65
108/65
108/73
115/59
91/68
111/64
113/67
96/55
115/75
105/71
112/67

LAB

TFU

DJJ

KET

127/73
128/77
131/80
120/80
99/66

STRASI ANC
GITA MEDIKA
..
TD (mmHg)
1234/85
126/80
108/69
109/66
111/88
99/61
124/74
128/96
133/87
113/67
123/74
108/66
111/78
109/83
100/60
107/66
110/70
132/60
124/69
101/62
100/60
100/70
110/60
127/73

LAB

TFU

DJJ

KET

98/70
110/70
135/85
106/75
122/83
113/74