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DAFTAR HADIR PESERTA PROLANIS

UPT PUSKESMAS PURI


TANGGAL : 22 APRIL 2017

NO. NAMA PESERTA ALAMAT NO. KARTU BPJS TTD


1 Assaat Brayung 0000099743376 1
2 Sutami Brayung 0001294358163 2
3 Supiani Brayung 0000725920727 3
4 Nur Alfiah Brayung 0001270876217 4
5 Riadi Brayung 0000725624774 5
6 Achmad Brayung 0001043735984 6
7 Jianah Brayung 0000724736485 7
8 Nanik umi Brayung 0000726439803 8
9 Tarwiyah Brayung 0000795926824 9
10 Umi malikah Ngrayung 0000724708029 10
11 Narsih Ngrayung 0001043736074 11
12 Ngatminah Ngrayung 0000724737486 12
13 Nursan Ngrayung 0001043736063 13
14 Sodakotin Ngrayung 0000725509528 14
15 Ainun Ngrayung 0000725456597 15
16 Kusmiati Ngrayung 0000725503645 16
17 Sulasmani Ngrayung 0000725517898 17
18 Misdi Ngrayung 0000725739952 18
19 Siti khalimah Ngrayung 0001043735984 19
20 Ponirah Brayung 0001043736647 20
21 Jasimah Brayung 0000724747138 21
22 Siti roisah Belahan 0000725453515 22
23 Temah Belahan 0000726389021 23
24 Supianah Belahan 0000726431499 24
25 Sumamik Belahan 0000725533299 25
26 Amini Belahan 0000725536697 26
27 Marliyah Belahan 0000098649459 27
28 Sumarni Belahan 0000725541388 28
29 Siswati Belahan 0000725964355 29
30 Sumarmi Belahan 0000726433558 30
31 Juwariyah Belahan 0000725744103 31
32 Inuk Nur Handayani Brayung 0000725955377 32
33 umiyami Brayung 0000098518544 33
34 Ngatiyah Brayung 0001308919059 34
35 Abdul rohman Brayung 0001316600256 35
NO. NAMA PESERTA ALAMAT NO. KARTU BPJS TTD
36 Hadi Supratman Brayung 0000099392005 36
37 Sai'in Brayung 0000724734775 37
38 Katijah Brayung 0000724936877 38
39 Sumi Brayung 0000724744304 39
40 Kasiatin Brayung 000072578412 40
41 Siti Shobiroh Brayung 0000098516834 41
42 Pa'ini Brayung 0000724734621 42
43 Daim Brayung 0000724744304 43
44 Salimah Brayung 0000725897686 44
45 Sholichatun Brayung 0000099743387 45
46 Mistiyah Kintelan 0000720417887 46
47 Rohman Kintelan 0001796374765 47
48 Suyati Kintelan 0000725309122 48
49 Kati Sumberejo 0000726390955 49
50 Keminah Sumberrejo 0000725316783 50
51 Wasiah Sumberrejo 0000725311001 51
52 Rifai Sumberejo 0001894849661 52
53 Atinah Kertoharjo 0000725374274 53
54 Sutianah Kertoharjo 0000725433996 54
55 Sumianah Kertoharjo 0000725350353 55
56 Sawi Kertoharjo 0000725342163 56
57 Karsiti Sumberejo 0001043735938 57
58 Sarni Kintelan 0002016159489 58
59 Parlik Kintelan 0000725297411 59
60 Sri kusmiati Puri 0000725782004 60
61 Wiji Puri 0000724765318 61
62 Saniah Puri 0000725810769 62
63 Paini Puri 0002073766061 63
64 Sapawi Puri 0000725817251 64
65 Parlan Puri 0001043737378 65
66 Rini Puri 0001275741472 66
67 Khusnul k Temon 0000724649883 67
68 Rodiyah Sawo 0000725804831 68
69 Andri Sawo 0001043737648 69
70 Asemak Sawo 0000724665969 70
71 Samat Sawo 0001869755275 71
72 Muslikah Puri 0001809572038 72
73 Suhartatik Puri 0000100986412 73
74 Kartosobirin Puri 0000725810264 74
75 Suwarsih Tegal Sari 0000725812198 75
NO. NAMA PESERTA ALAMAT NO. KARTU BPJS TTD
76 Anang K PPI 0000098492196 76
77 Kusen Banjar Agung 0000098577808 77
78 M.Suryadi Ploso sari 0000098498283 78
79 Siti Isniwati kintelan 0000098501826 79
80 Imam A Puri 0000098495919 80
81 M. Agus Salim Jabon 0000098733576 81
82 B. Kusmiati Banjar Agung 0000098577819 82
83 Sriani Medali 0000098503031 83
84 Murati kintelan 0000725441321 84
85 Rotin sumber rejo 0000726403296 85
86 Kastun sumber rejo 0001043735859 86
87 Sunarsih Puri 0002201172557 87
88 Agus basuki Tangunan 0001480351555 88
89 Ahmad Suhabudin Medali 0000098744444 89
90 Mustikah Puri 000072457004 90
91 Siti Roisah B kintelan 0000725397085 91
92 Saropah Brayung 0000724743437 92
93 Rini B kintelan 0000725425503 93
94 Sulikah Belahan 0000725891949 94
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100 100

Mojokerto, 22 April 2017


Pemeriksa,

dr. FATATIE NURIYANA


NIP. 19800707 201001 2 005
PEMERINTAH KABUPATEN MOJOKERTO
DINAS KESEHATAN
UPT PUSKESMAS PURI
Desa Tangunan Kecamatan Puri Telp. 0321-510765
MOJOKERTO
pkmpurimojokerto@gmail.com
drg lailatul fajri 85730213511
DAFTAR HADIR
PESERTA PROLANIS PUSKESMAS PURI
TANGGAL 08 APRIL 2017

NO.
NO NAMA PESERTA NO KARTU ALAMAT NO. TELP
REG
1 1 60 SRI KUSMIATI (P) 0000725782004 puri HT
2 2 36 AMRIK (P) 0000725823909 Balong Lombok DM
3 3 13 SITI ROMLAH (P) 0000725638228 Kebo Gerang DM
4 4 51 GINAH (P) 0000726095248 Mlaten HT
5 5 29 SETIYOWATI (P) 0000725512735 Karang Tengah DM
6 6 31 KARSINI (P) 0000725734337 Karang Tengah HT
7 7 35 MUHARTI (P) 0000101363387 Puri Kencana DM
8 8 16 SEMIN SAMADI (L) 0000101363376 Sumber tempur HT
9 9 4 NUR ALFIYAH (P) 0001270876217 Brayung DM
10 10 73 kani (P) 0000726251883 Karang Tengah HT
11 11 32 SARIYEM (P) 0000726286443 Karang Tengah HT
12 12 62 SANIAH (P) 0000725810769 Puri DM
13 13 37 JUMAINAH (P) 0000725486771 Balong Lombok DM
14 14 41 PONARI (L) 0000726679236 Poh Gurih HT
15 15 47 SALUKI (L) 0001306268818 Mlaten DM
16 16 1 kasti (P) 0001873688859 Sumber Girang DM
17 17 15 AINUN (P) 0000725456597 Ngrayung DM
18 18 10 NUR AMIMAH (P)nur ami0000724694769 kluar dulu HT

19 19 ELISABET WARSIKI (P) 0000725574183

20 20 32 INUK
(P)
NURHANDAYANI
0000725955377 Brayung DM
21 21 53 PADI (L) 0001797789508 Mlaten DM
22 22 58 PURADI (L) 0000726740076 Bedog DM
23 23 50 JUMI'AH (P) 0000726675366 kluar dulu HT
24 24 14 SUKARTO (L) 0000725669212 Sumber tempur DM
25 25 61 WIJI (P) 0000724765318 Puri HT
26 26 60 NGATEMI (P) 0000726699249 Bedog DM
27 27 34 SITI AMANAH (P) 0001294578156 Puri Kencana DM
28 28 57 PANI (L) 0001043743105 Bedog DM
29 29 69 ANDRI (L) 0001043737648 Sawo HT
30 30 9 RUSMI (P)rusmilah 0000726265181 Kebo Gerang HT
31 31 75 SUWARSIH (P) 0000725812198 Tegal Sari DM
32 32 62 PARTI (P) 0000725791408 Bedog HT
33 33 63 AJIN (L) 0000725790431 Bedog HT
34 34 8 RAWATI jd wagi (P) 0000099401376 Sumber Girang HT
35 35 70 ASEMAK (L) 0000724665969 Sawo DM
36 36 12 NGATMINAH (P) 0000724737486 Ngrayung DM
37 37 20 SUTINI (P) 0000725601969 Sumber tempur DM
38 38 22 KASMILAH (P) 0000726233771 Sumber tempur DM
SUNAMI JD
39 39 3 CHOIRUMAN (P) 0000099419319 Sumber Girang DM
40 40 17 SULASMANI (P) 0000725517898 Ngrayung HT
41 41 19 LASMI (P) 0000725911806 Sumber tempur HT
42 42 14 SODAKOTIN (P) 0000725509528 Ngrayung HT
43 43 17 KALIMAH (P) 0000725704828 Sumber tempur HT
44 44 55 AROPAH (P) 0000726669033 Mlaten DM
45 45 49 KATI (P) 0000726390955 Sumberejo DM
46 46 5 purnomo suhartini (P) 0001962893259 Sumber Girang DM
47 47 4 SUNAHWATI (P) 0000725641659 DM
48 48 55 SUMIANAH (P) 0000725350353 Kertoharjo HT
49 49 21 UTAMI (P) 0000726207546 Sumber tempur HT
50 50 54 SUTIANAH (P) 0000725433996 Kertoharjo HT
51 51 7 NGATIAH (P) 0002064069314 Sumber Girang DM
52 52 64 SUMARMI (P) 0000726120448 Mlaten HT
53 53 29 SISWATI (P) 0000725964355 Belahan HT
54 54 46 SAMIAJI (L) 0000726120382 Mlaten HT
55 55 18 KARSONO (L) 0001321099773 Sumber tempur DM
56 56 50 KEMINAH (P) 0000725316783 Sumberrejo DM
57 57 24 TUMINAH (P) 0000725669256 Sumber tempur HT
58 58 65 samiasih (P) 0001878891142 Sumolawang HT
59 59 ARIYAH (P) 0000725744103
60 60 38 SOLIKHAH (P) 0000099383128 Sumolawang HT
61 61 11 SAMDIONO (L) 0000725935983 Kebo Gerang HT
62 62 42 SETU (L) 0000726225131 Poh Gurih DM
63 63 16 KUSMIATI (P) 0000725503645 Ngrayung HT
64 64 45 KUMILAH (P) 0000726741797 Mlaten HT
65 65 3 SUPI (P) SUPIANI 0000725920727 Brayung HT
66 66 83 DEWI MURIFAH (P) 0001405126956 Sumber Girang ht
67 67 80 HARTATIK (P) 0000726181176 Sumber Girang ht
68 68 SEMA'UN (L) 0001261644963 MENINGGAL
69 69 39 CHASANAH (P) 0000726271481 Poh Gurih HT
70 70 82 RUMADJI (L) 0002064069066 Sumber Girang HT
71 71 63 PAINI (P) 0002073766061 Puri DM
72 72 65 PARLAN (L) 0001043737378 Puri HT
73 73 40 KOSIAH (P) 0000726333928 Poh Gurih DM
74 74 57 KARSITI (P) 0001043735938 Sumberejo HT
75 75 84 JAMUDAH (P) 0001043742161 Sumber Girang HT
76 76 5 RIADI (L) 0000725624774 Brayung DM
77 77 51 WASIAH (P) 0000725311001 Sumberrejo DM
78 78 6 AKHMAD (L) 0001292653631 Brayung DM
79 79 30 SUMARMI (P) 0000726433558 Belahan HT
80 80 28 SUMARNI (P) 0000725541388 Belahan DM
81 81 19 SITI KHALIMAH (P) 0001043735984 Ngrayung DM
82 82 22 SITI ROISAH (P) 0000725453515 Belahan DM
83 83 26 AMINI (P) 0000725536697 Belahan HT
84 84 10 UMI MALIKAH (P) 0000724768029 Ngrayung DM
85 85 47 rokhman (L) 0001796374765 Kintelan DM
86 86 SUMIATI (P) 0000726193124
87 87 11 NARSIH (P) 0001043736074 Ngrayung HT
88 88 2 RAWON (L) 0001043742317 Kebo Gerang HT
89 89 2 SUTAMI (P) 0001294358163 Brayung HT
90 90 68 RODIYAH (P) 0000725804831 Sawo DM
91 91 71 SAMAT (L) 0001869755275 Sawo HT
92 92 27 DJONAH (P) 0000725707888 Sumber Girang DM
KHUSNUL KHOTIMAH
93 93 67 (P) 0000724649883 Temon HT
94 94 81 TRIMAN (L) 0000726228955 Kebo Gerang HT
95 95 25 SUMAMIK (P) 0000725533299 Belahan HT
96 96 79 SOPIAH (P) 0000726229855 Kebo Gerang HT
97 97 26 PII (L) 0000725918624 Sumber Girang DM
98 98 SUPINAH (P) 0000726431499
99 99 SAREH (L) 0000726454293
100 100 27 MARLIYAH JD PINGI (P)0000098649459 Belahan HT
101 101 KHOLIFAH (P) 0000726454552
102 102 SURIANI (P) 0001043745658
103 103 JAFARIL (L) 0000725826339 MENINGGAL
104 104 SHOLIHAN (L) 0001043745647
105 105 MUINAH (P) 0000726249655
106 106 SOYIBIN (L) 0000726249622
107 107 SUTOPO (L) 0000726639333
108 108 SARMINI (P) 0000726453044
109 109 MAS ULUN (L) 0000726452919
110 110 61 SUTOMO (L) 0000726699115 Bedog DM
111 111 13 NURSAN (L) 0001043736063 Ngrayung DM
112 112 86 maskur (L) 0001800859241 Mlaten HT
113 113 WELAS ASIH (P) 0001817673581
NANIK UMI KALSUM
114 114 8 (P) 0000726439803 Brayung DM
115 115 PAERI (L) 0000725848468
116 116 66 RINI (P) 0001275741472 Puri DM
117 117 48 SUPRAYITNO (L) 0001803599076 Mlaten DM
118 118 supini (P) 0001964981777 MENINGGAL
119 119 TRI MURYANI (P) 0001081323718
120 120 64 SAPAWI (L) 0000725817251 Puri HT
121 121 9 tarwiyah (L) 0001795926824 Brayung HT
122 122 ASMAH (P) 0000726728466
123 123 74 KARTO SUBIRAN (L)karto0000725810264 puri DM
124 124 LAMTI (P) 0000726667705
125 125 23 TEMAH (P) 0000726389021 Belahan HT
126 126 48 SUYATI (P) 0000725309122 Kintelan HT
127 127 7 JIANAH (P) 0000724736485 Brayung HT
128 128 46 MISTIYAH (P) 0000726417887 Kintelan HT
129 129 79 SITI ISNIWATI (P) 0000098501826 kintelan DM

130 130 78 MUHAMMAD


(L)
SURYADI
0000098498283 Ploso sari HT
131 131 77 KUSEN ASHARI (L) 0000098577808 Banjar Agung DM
132 132 82 B. KUSMIATI (P) 0000098577819 Banjar Agung DM
133 133 88 AGUS BASUKI (L) 0001480351555 Tangunan DM
MOKHAMAD AGUS
134 134 81 SALIM (L) 0000098733576 Jabon DM
IMAM AJIB
135 135 80 ISPURNAWAN (L) 0000098495919 Puri DM
136 136 1 ASSA`AT (L) 0000099743376 Brayung DM
137 137 18 MISDI (L) 0000725739952 Ngrayung HT
138 138 MUBAYANAH (P) 0000725803817 MENINGGAL
139 139 RIANI (P) 0000724706008
140 140 83 SRIANI (P) 0000098503031 Medali DM
141 141 49 Saumayah (P) 0001704628056 Mlaten DM
142 142 52 SUTI (P) 0000725385699 Mlaten DM
143 143 30 SENAH (P) 0001295332571 Karang Tengah HT

144 144 12 PRAMESTI KAIMAN (P) 0000726224016 Kebo Gerang HT


145 145 54 SULIYAH (P) 0000726106735 Mlaten DM
146 146 56 SUTIK (P) 0000098517925 Mlaten DM
147 147 33 WARSONO (L) 0000726304059 Karang Tengah DM
148 148 15 TAMI (P)tani 0000725904753 Sumber Tempur HT
149 150 28 WARSIH 0000725574183 Sumber Tempur DM
150 151 25 MUSLIKAH 0002065405083 Sumber Tempur DM
151 152 23 JANATIN 0000725917691 Sumber Tempur DM
152 153 6 HARWATI 0001256424041 Sumber Girang DM
153 154 43 RUMILAH 0000726631334 Poh gurih HT
154 155 44 SUMIKATIN 0000726334312 Poh gurih HT
155 156 59 NI'MAH 0000726161163 Bedog DM
156 157 66 SUGIONO 0001285462495 Mlaten DM
157 158 67 SAMIYAH 0000725338247 Poh Gurih HT
158 159 68 MUNIAH 0000725497389 Poh Gurih DM
159 160 69 SUKIMAH 0000726303273 Poh Gurih DM
160 161 70 DEDIK 0000726699797 Mlaten DM
161 162 71 PARTI 0000726736904 Mlaten DM
162 163 72 PONIMAH 0000725460636 Poh Gurih DM
163 164 74 M KHOLIQ 0001436206814 Mlaten DM
164 165 75 WIWIK LUTFIANA 000110276494 Puri kencana ga terdaHT
165 166 76 BONING 0001321514324 Sumber Tempur HT
166 167 77 KASTINI 0000726560886 Poh Gurih DM
167 168 78 KUNASIH 0001043742328 Karang Tengah DM
168 169 85 ENDAH 0001726326177 sumolawang DM
169 170 20 Ponirah 0001043736647 Brayung DM
170 171 21 Jasimah 0000724747138 Brayung HT
171 172 24 Supianah 0000726431499 Belahan HT
172 173 27 Marliyah 0000098649459 Belahan HT
173 174 31 Juwariyah 0000725744103 Belahan HT
174 175 33 umiyami 0000098518544 Brayung out
175 176 34 Ngatiyah 0001308919059 Brayung DM
176 177 35 Abdul rohman 0001316600256 Brayung out
177 178 36 Hadi Supratman 0000099392005 Brayung DM
178 179 37 Sai'in 0000724734775 Brayung DM
179 180 38 Katijah 0000724936877 Brayung out
180 39 Sumi 0000724744304 Brayung out
181 40 Kasiatin 000072578412 Brayung out
182 41 Siti Shobiroh 0000098516834 Brayung HT
183 42 Pa'ini 0000724734621 Brayung DM
184 43 Daim 0000724744304 Brayung out
185 44 Salimah 0000725897686 Brayung out
186 45 Sholichatun 0000099743387 Brayung HT
187 52 Rifai 0001894849661 Sumberejo HT
188 53 Atinah 0000725374274 Kertoharjo no ga daftHT
189 56 Sawi 0000725342163 Kertoharjo DM
190 58 Sarni 0002016159489 Kintelan faskes beda HT
191 59 Parlik 0000725297411 Kintelan HT
192 60 Sri kusmiati 0000725782004 Puri HT
193 72 Muslikah 0001809572038 Puri HT
194 73 Suhartatik 0000100986412 Puri DM
195 75 Suwarsih 0000725812198 Tegal Sari DM
196 76 Anang K 0000098492196 PPI DM
197 84 Murati 0000725441321 kintelan HT
198 85 Rotin 0000726403296 sumber rejo DM
199 86 Kastun 0001043735859 sumber rejo HT
200 87 Sunarsih 0002201172557 Puri DM
201 89 Ahmad Suhabudin 0000098744444 Medali DM
90 Mustikah 000072457004 Puri
91 Siti Roisah B 0000725397085 kintelan
92 Saropah 0000724743437 Brayung
93 Rini B 0000725425503 kintelan
94 Sulikah 0000725891949 Belahan
pkmpurimojokerto@gmail.com
Mojokerto,08 April 2017
drg lailatul fajri 85730213511
Pemeriksa,

dr. FATATIE NURIYANA


NIP. 19800707 201001 2 005
ERTO

-510765

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PEMERINTAH KABUPATEN MOJOKERTO
DINAS KESEHATAN
UPT PUSKESMAS PURI
Desa Tangunan Kecamatan Puri Telp. 0321-510765
MOJOKERTO
pkmpurimojokerto@gmail.com
drg lailatul fajri 85730213511
DAFTAR HADIR
PESERTA PROLANIS PUSKESMAS PURI
TANGGAL 08 APRIL 2017

NO.
NO RE NAMA PESERTA NO KARTU ALAMAT NO. TELPTANDA TANGAN
G
1 1 60 SRI KUSMIATI (P) 0000725782004 puri HT 1
2 2 36 AMRIK (P) 0000725823909 Balong Lombok DM 2
3 3 13 SITI ROMLAH (P) 0000725638228 Kebo Gerang DM 3
4 4 51 GINAH (P) 0000726095248 Mlaten HT 4
5 5 29 SETIYOWATI (P) 0000725512735 Karang Tengah DM 5
6 6 31 KARSINI (P) 0000725734337 Karang Tengah HT 6
7 7 35 MUHARTI (P) 0000101363387 Puri Kencana DM 7
8 8 16 SEMIN SAMADI (L) 0000101363376 Sumber tempur HT 8
9 9 4 NUR ALFIYAH (P) 0001270876217 Brayung DM 9
10 10 73 kani (P) 0000726251883 Karang Tengah HT 10
11 11 32 SARIYEM (P) 0000726286443 Karang Tengah HT 11
12 12 62 SANIAH (P) 0000725810769 Puri DM 12
13 13 37 JUMAINAH (P) 0000725486771 Balong Lombok DM 13
14 14 41 PONARI (L) 0000726679236 Poh Gurih HT 14
15 15 47 SALUKI (L) 0001306268818 Mlaten DM 15
16 16 1 kasti (P) 0001873688859 Sumber Girang DM 16
17 17 15 AINUN (P) 0000725456597 Ngrayung DM 17
18 18 10 NUR AMIMAH (P)nur am0000724694769 kluar dulu HT 18
ELISABET WARSIKI
19 19 (P) 0000725574183 19

20 20 32 INUK
NURHANDAYANI (P) 0000725955377
Brayung DM 20
21 21 53 PADI (L) 0001797789508 Mlaten DM 21
22 22 58 PURADI (L) 0000726740076 Bedog DM 22
23 23 50 JUMI'AH (P) 0000726675366 kluar dulu HT 23
24 24 14 SUKARTO (L) 0000725669212 Sumber tempur DM 24
25 25 61 WIJI (P) 0000724765318 Puri HT 25
26 26 60 NGATEMI (P) 0000726699249 Bedog DM 26
27 27 34 SITI AMANAH (P) 0001294578156 Puri Kencana DM 27
28 28 57 PANI (L) 0001043743105 Bedog DM 28
29 29 69 ANDRI (L) 0001043737648 Sawo HT 29
30 30 9 RUSMI (P)rusmilah 0000726265181 Kebo Gerang HT 30
31 31 75 SUWARSIH (P) 0000725812198 Tegal Sari DM 31
32 32 62 PARTI (P) 0000725791408 Bedog HT 32
33 33 63 AJIN (L) 0000725790431 Bedog HT 33
34 34 8 RAWATI jd wagi (P) 0000099401376 Sumber Girang HT 34
35 35 70 ASEMAK (L) 0000724665969 Sawo DM 35
36 36 12 NGATMINAH (P) 0000724737486 Ngrayung DM 36
37 37 20 SUTINI (P) 0000725601969 Sumber tempur DM 37
38 38 22 KASMILAH (P) 0000726233771 Sumber tempur DM 38
SUNAMI JD
39 39 3 CHOIRUMAN (P) 0000099419319 Sumber Girang DM 39
40 40 17 SULASMANI (P) 0000725517898 Ngrayung HT 40
41 41 19 LASMI (P) 0000725911806 Sumber tempur HT 41
42 42 14 SODAKOTIN (P) 0000725509528 Ngrayung HT 42
43 43 17 KALIMAH (P) 0000725704828 Sumber tempur HT 43
44 44 55 AROPAH (P) 0000726669033 Mlaten DM 44
45 45 49 KATI (P) 0000726390955 Sumberejo DM 45
purnomo suhartini Sumber Girang 46
46 46 5 (P) 0001962893259 DM
47 47 4 SUNAHWATI (P) 0000725641659 DM 47
48 48 55 SUMIANAH (P) 0000725350353 Kertoharjo HT 48
49 49 21 UTAMI (P) 0000726207546 Sumber tempur HT 49
50 50 54 SUTIANAH (P) 0000725433996 Kertoharjo HT 50
51 51 7 NGATIAH (P) 0002064069314 Sumber Girang DM 51
52 52 64 SUMARMI (P) 0000726120448 Mlaten HT 52
53 53 29 SISWATI (P) 0000725964355 Belahan HT 53
54 54 46 SAMIAJI (L) 0000726120382 Mlaten HT 54
55 55 18 KARSONO (L) 0001321099773 Sumber tempur DM 55
56 56 50 KEMINAH (P) 0000725316783 Sumberrejo DM 56
57 57 24 TUMINAH (P) 0000725669256 Sumber tempur HT 57
58 58 65 samiasih (P) 0001878891142 Sumolawang HT 58
59 59 ARIYAH (P) 0000725744103 59
60 60 38 SOLIKHAH (P) 0000099383128 Sumolawang HT 60
61 61 11 SAMDIONO (L) 0000725935983 Kebo Gerang HT 61
62 62 42 SETU (L) 0000726225131 Poh Gurih DM 62
63 63 16 KUSMIATI (P) 0000725503645 Ngrayung HT 63
64 64 45 KUMILAH (P) 0000726741797 Mlaten HT 64
65 65 3 SUPI (P) SUPIANI 0000725920727 Brayung HT 65
66 66 83 DEWI MURIFAH (P) 0001405126956 Sumber Girang ht 66
67 67 80 HARTATIK (P) 0000726181176 Sumber Girang ht 67
68 68 SEMA'UN (L) 0001261644963 MENINGGAL 68
69 69 39 CHASANAH (P) 0000726271481 Poh Gurih HT 69
70 70 82 RUMADJI (L) 0002064069066 Sumber Girang HT 70
71 71 63 PAINI (P) 0002073766061 Puri DM 71
72 72 65 PARLAN (L) 0001043737378 Puri HT 72
73 73 40 KOSIAH (P) 0000726333928 Poh Gurih DM 73
74 74 57 KARSITI (P) 0001043735938 Sumberejo HT 74
75 75 84 JAMUDAH (P) 0001043742161 Sumber Girang HT 75
76 76 5 RIADI (L) 0000725624774 Brayung DM 76
77 77 51 WASIAH (P) 0000725311001 Sumberrejo DM 77
78 78 6 AKHMAD (L) 0001292653631 Brayung DM 78
79 79 30 SUMARMI (P) 0000726433558 Belahan HT 79
80 80 28 SUMARNI (P) 0000725541388 Belahan DM 80
81 81 19 SITI KHALIMAH (P) 0001043735984 Ngrayung DM 81
82 82 22 SITI ROISAH (P) 0000725453515 Belahan DM 82
83 83 26 AMINI (P) 0000725536697 Belahan HT 83
84 84 10 UMI MALIKAH (P) 0000724768029 Ngrayung DM 84
85 85 47 rokhman (L) 0001796374765 Kintelan DM 85
86 86 SUMIATI (P) 0000726193124 86
87 87 11 NARSIH (P) 0001043736074 Ngrayung HT 87
88 88 2 RAWON (L) 0001043742317 Kebo Gerang HT 88
89 89 2 SUTAMI (P) 0001294358163 Brayung HT 89
90 90 68 RODIYAH (P) 0000725804831 Sawo DM 90
91 91 71 SAMAT (L) 0001869755275 Sawo HT 91
92 92 27 DJONAH (P) 0000725707888 Sumber Girang DM 92
KHUSNUL
93 93 67 KHOTIMAH (P) 0000724649883 Temon HT 93
94 94 81 TRIMAN (L) 0000726228955 Kebo Gerang HT 94
95 95 25 SUMAMIK (P) 0000725533299 Belahan HT 95
96 96 79 SOPIAH (P) 0000726229855 Kebo Gerang HT 96
97 97 26 PII (L) 0000725918624 Sumber Girang DM 97
98 98 SUPINAH (P) 0000726431499 98
99 99 SAREH (L) 0000726454293 99
100 100 27 MARLIYAH JD PINGI (P0000098649459 Belahan HT 100
101 101 KHOLIFAH (P) 0000726454552 101
102 102 SURIANI (P) 0001043745658 102
103 103 JAFARIL (L) 0000725826339 MENINGGAL 103
104 104 SHOLIHAN (L) 0001043745647 104
105 105 MUINAH (P) 0000726249655 105
106 106 SOYIBIN (L) 0000726249622 106
107 107 SUTOPO (L) 0000726639333 107
108 108 SARMINI (P) 0000726453044 108
109 109 MAS ULUN (L) 0000726452919 109
110 110 61 SUTOMO (L) 0000726699115 Bedog DM 110
111 111 13 NURSAN (L) 0001043736063 Ngrayung DM 111
112 112 86 maskur (L) 0001800859241 Mlaten HT 112
113 113 WELAS ASIH (P) 0001817673581 113

114 114 8 NANIK


(P)
UMI KALSUM
0000726439803 Brayung DM 114
115 115 PAERI (L) 0000725848468 115
116 116 66 RINI (P) 0001275741472 Puri DM 116
117 117 48 SUPRAYITNO (L) 0001803599076 Mlaten DM 117
118 118 supini (P) 0001964981777 MENINGGAL 118
119 119 TRI MURYANI (P) 0001081323718 119
120 120 64 SAPAWI (L) 0000725817251 Puri HT 120
121 121 9 tarwiyah (L) 0001795926824 Brayung HT 121
122 122 ASMAH (P) 0000726728466 122
123 123 74 KARTO SUBIRAN (L)karto
0000725810264 puri DM 123
124 124 LAMTI (P) 0000726667705 124
125 125 23 TEMAH (P) 0000726389021 Belahan HT 125
126 126 48 SUYATI (P) 0000725309122 Kintelan HT 126
127 127 7 JIANAH (P) 0000724736485 Brayung HT 127
128 128 46 MISTIYAH (P) 0000726417887 Kintelan HT 128
129 129 79 SITI ISNIWATI (P) 0000098501826 kintelan DM 129

130 130 78 MUHAMMAD


SURYADI (L) 0000098498283 Ploso sari HT 130
131 131 77 KUSEN ASHARI (L) 0000098577808 Banjar Agung DM 131
132 132 82 B. KUSMIATI (P) 0000098577819 Banjar Agung DM 132
133 133 88 AGUS BASUKI (L) 0001480351555 Tangunan DM 133
MOKHAMAD AGUS
134 134 81 SALIM (L) 0000098733576 Jabon DM 134

135 135 80 IMAM AJIB


ISPURNAWAN (L) 0000098495919 Puri DM 135
136 136 1 ASSA`AT (L) 0000099743376 Brayung DM 136
137 137 18 MISDI (L) 0000725739952 Ngrayung HT 137
138 138 MUBAYANAH (P) 0000725803817 MENINGGAL 138
139 139 RIANI (P) 0000724706008 139
140 140 83 SRIANI (P) 0000098503031 Medali DM 140
141 141 49 Saumayah (P) 0001704628056 Mlaten DM 141
142 142 52 SUTI (P) 0000725385699 Mlaten DM 142
143 143 30 SENAH (P) 0001295332571 Karang Tengah HT 143
PRAMESTI KAIMAN
144 144 12 (P) 0000726224016 Kebo Gerang HT 144
145 145 54 SULIYAH (P) 0000726106735 Mlaten DM 145
146 146 56 SUTIK (P) 0000098517925 Mlaten DM 146
147 147 33 WARSONO (L) 0000726304059 Karang Tengah DM 147
148 148 15 TAMI (P)tani 0000725904753 Sumber Tempur HT 148
149 150 28 WARSIH 0000725574183 Sumber Tempur DM 149
150 151 25 MUSLIKAH 0002065405083 Sumber Tempur DM 150
151 152 23 JANATIN 0000725917691 Sumber Tempur DM 151 out
152 153 6 HARWATI 0001256424041 Sumber Girang DM 152
153 154 43 RUMILAH 0000726631334 Poh gurih HT 153
154 155 44 SUMIKATIN 0000726334312 Poh gurih HT 154
155 156 59 NI'MAH 0000726161163 Bedog DM 155
156 157 66 SUGIONO 0001285462495 Mlaten DM 156
157 158 67 SAMIYAH 0000725338247 Poh Gurih HT 157
158 159 68 MUNIAH 0000725497389 Poh Gurih DM 158
159 160 69 SUKIMAH 0000726303273 Poh Gurih DM 159
160 161 70 DEDIK 0000726699797 Mlaten DM 160
161 162 71 PARTI 0000726736904 Mlaten DM 161
162 163 72 PONIMAH 0000725460636 Poh Gurih DM 162
163 164 74 M KHOLIQ 0001436206814 Mlaten DM 163
164 165 75 WIWIK LUTFIANA 000110276494 Puri kencana ga terHT 164
165 166 76 BONING 0001321514324 Sumber Tempur HT 165
166 167 77 KASTINI 0000726560886 Poh Gurih DM 166
167 168 78 KUNASIH 0001043742328 Karang Tengah DM 167
168 169 85 ENDAH 0001726326177 sumolawang DM 168
169 170 20 Ponirah 0001043736647 Brayung DM 169
170 171 21 Jasimah 0000724747138 Brayung HT 170
171 172 24 Supianah 0000726431499 Belahan HT 171
172 173 27 Marliyah 0000098649459 Belahan HT 172
173 174 31 Juwariyah 0000725744103 Belahan HT 173
174 175 33 umiyami 0000098518544 Brayung out 174
175 176 34 Ngatiyah 0001308919059 Brayung DM 175
176 177 35 Abdul rohman 0001316600256 Brayung out 6
177 178 36 Hadi Supratman 0000099392005 Brayung DM 9
178 179 37 Sai'in 0000724734775 Brayung DM 18
179 180 38 Katijah 0000724936877 Brayung out 20
180 39 Sumi 0000724744304 Brayung out 21
181 40 Kasiatin 000072578412 Brayung out 23
182 41 Siti Shobiroh 0000098516834 Brayung HT 24
183 42 Pa'ini 0000724734621 Brayung DM 27
184 43 Daim 0000724744304 Brayung out 31
185 44 Salimah 0000725897686 Brayung out 33
186 45 Sholichatun 0000099743387 Brayung HT 34
187 52 Rifai 0001894849661 Sumberejo HT 35
188 53 Atinah 0000725374274 Kertoharjo no ga dHT 36
189 56 Sawi 0000725342163 Kertoharjo DM 37
190 58 Sarni 0002016159489 Kintelan faskes be HT 38
191 59 Parlik 0000725297411 Kintelan HT 39
192 60 Sri kusmiati 0000725782004 Puri HT 40
193 72 Muslikah 0001809572038 Puri HT 41
194 73 Suhartatik 0000100986412 Puri DM 42
195 75 Suwarsih 0000725812198 Tegal Sari DM 43
196 76 Anang K 0000098492196 PPI DM 44
197 84 Murati 0000725441321 kintelan HT 45
198 85 Rotin 0000726403296 sumber rejo DM 52
199 86 Kastun 0001043735859 sumber rejo HT 53
200 87 Sunarsih 0002201172557 Puri DM 56
201 89 Ahmad Suhabudin 0000098744444 Medali DM 58

pkmpurimojokerto@gmail.com
Mojokerto,08 April 2017
drg lailatul fajri 8.6E+10
Pemeriksa,

dr. FATATIE NURIYANA


NIP. 19800707 201001 2 005
PEMERINTAH KABUPATEN MOJOKERTO
DINAS KESEHATAN
UPT PUSKESMAS PURI
Desa Tangunan Kecamatan Puri Telp. 0321-510765
MOJOKERTO

REKAPITULASI DAFTAR HARGA


KEGIATAN PROLANIS PUSKESMAS PURI
BULAN APRIL 2017

No Nama Alamat Nomor BPJS Jenis Pemeriksaan Jumlah Harga


1 Assaat Brayung 0000099743376 Gula Puasa, 2 JPP Rp 20,000.00
2 Nur Alfiah Brayung 0001270876217 Gula Puasa, 2 JPP Rp 20,000.00
3 Riadi Brayung 0000725624774 Gula Puasa, 2 JPP Rp 20,000.00
4 Nanik umi Brayung 0000726439803 Gula Puasa, 2 JPP Rp 20,000.00
5 Ngatminah Ngrayung 0000724737486 Gula Puasa, 2 JPP Rp 20,000.00
6 Nursan Ngrayung 0001043736063 Gula Puasa, 2 JPP Rp 20,000.00
7 Ainun Ngrayung 0000725456597 Gula Puasa, 2 JPP Rp 20,000.00
8 Siti roisah Belahan 0000725453515 Gula Puasa, 2 JPP Rp 20,000.00
9 Inuk Nur HandayaniBrayung 0000725955377 Gula Puasa, 2 JPP Rp 20,000.00
10 Ngatiyah Brayung 0001308919059 Gula Puasa, 2 JPP Rp 20,000.00
11 Hadi Supratman Brayung 0000099392005 Gula Puasa, 2 JPP Rp 20,000.00
12 Sai'in Brayung 0000724734775 Gula Puasa, 2 JPP Rp 20,000.00
13 Pa'ini Brayung 0000724734621 Gula Puasa, 2 JPP Rp 20,000.00
14 Suyati Kintelan 0000725309122 Gula Puasa, 2 JPP Rp 20,000.00
15 Kati Sumberejo 0000726390955 Gula Puasa, 2 JPP Rp 20,000.00
16 Wasiah Sumberrejo 0000725311001 Gula Puasa, 2 JPP Rp 20,000.00
17 Sawi Kertoharjo 0000725342163 Gula Puasa, 2 JPP Rp 20,000.00
18 Parlik Kintelan 0000725297411 Gula Puasa, 2 JPP Rp 20,000.00
19 Saniah Puri 0000725810769 Gula Puasa, 2 JPP Rp 20,000.00
20 Paini Puri 0002073766061 Gula Puasa, 2 JPP Rp 20,000.00
21 Rini Puri 0001275741472 Gula Puasa, 2 JPP Rp 20,000.00
22 Rodiyah Sawo 0000725804831 Gula Puasa, 2 JPP Rp 20,000.00
23 Asemak Sawo 0000724665969 Gula Puasa, 2 JPP Rp 20,000.00
24 B. Kusmiati Banjar Agung 0000098577819 Gula Puasa, 2 JPP Rp 20,000.00
25 Sriani Medali 0000098503031 Gula Puasa, 2 JPP Rp 20,000.00
26 Murati kintelan 0000725441321 Gula Puasa, 2 JPP Rp 20,000.00
27 Rotin sumber rejo 0000726403296 Gula Puasa, 2 JPP Rp 20,000.00
28 Sunarsih Puri 0002201172557 Gula Puasa, 2 JPP Rp 20,000.00
29 Siti Roisah B kintelan 0000725397085 Gula Puasa, 2 JPP Rp 20,000.00
30 Rini B kintelan 0000725425503 Gula Puasa, 2 JPP Rp 20,000.00
31 Sulikah Belahan 0000725891949 Gula Puasa, 2 JPP Rp 20,000.00
32 Keminah kintelan 0000725316783 Gula Puasa, 2 JPP Rp 20,000.00
33 Mustikah Puri 0000724657004 Gula Puasa, 2 JPP Rp 20,000.00
TOTAL Rp. 660.000,00

terbilang :
" Enam Ratus Enam Puluh Ribu Rupiah "

Mengetahui Mojokerto, 22 April 2017


Kepala Puskesmas Puri, Pemeriksa,

dr. RETNO DHANARWARIH A ANANG KUSDIANTO


NIP. 19671219 200604 2 006 NIP. 19800407 200012 1 005
p
PEMERINTAH KABUPATEN MOJOKERTO
DINAS KESEHATAN
UPT PUSKESMAS PURI
Desa Tangunan Kecamatan Puri Telp. 0321-510765
MOJOKERTO

REKAPITULASI HASIL PEMERIKSAAN


PESERTA PROLANIS PUSKESMAS PURI
BULAN APRIL 2017

Jenis Pemeriksaan
No Nama Alamat Nomor BPJS
Tekanan Darah GD Puasa GD 2 JPP
1 Assaat Brayung 0000099743376 150 100 mmHg 176 mg/dl 279 mg/dl
2 Sutami Brayung 0001294358163 150 100 mmHg mg/dl mg/dl
3 Supiani Brayung 0000725920727 180 100 mmHg mg/dl mg/dl
4 Nur Alfiah Brayung 0001270876217 100 70 mmHg 137 mg/dl 188 mg/dl
5 Riadi Brayung 0000725624774 120 80 mmHg 111 mg/dl 217 mg/dl
6 Jianah Brayung 0000724736485 140 90 mmHg mg/dl mg/dl
7 Nanik umi Brayung 0000726439803 120 80 mmHg 231 mg/dl 383 mg/dl
8 Tarwiyah Brayung 0000795926824 150 100 mmHg mg/dl mg/dl
9 Umi malikah Ngrayung 0000724708029 140 100 mmHg mg/dl mg/dl
10 Narsih Ngrayung 0001043736074 150 100 mmHg mg/dl mg/dl
11 Ngatminah Ngrayung 0000724737486 160 100 mmHg 115 mg/dl 269 mg/dl
12 Nursan Ngrayung 0001043736063 130 90 mmHg 110 mg/dl 148 mg/dl
13 Sodakotin Ngrayung 0000725509528 160 100 mmHg mg/dl mg/dl
14 Ainun Ngrayung 0000725456597 150 100 mmHg 127 mg/dl 238 mg/dl
15 Kusmiati Ngrayung 0000725503645 190 100 mmHg mg/dl mg/dl
16 Sulasmani Ngrayung 0000725517898 150 100 mmHg mg/dl mg/dl
17 Siti khalimah Ngrayung 0001043735984 160 100 mmHg mg/dl mg/dl
18 Jasimah Brayung 0000724747138 160 100 mmHg mg/dl mg/dl
19 Siti roisah Belahan 0000725453515 110 60 mmHg 190 mg/dl 175 mg/dl
20 Temah Belahan 0000726389021 140 110 mmHg mg/dl mg/dl
21 Supianah Belahan 0000726431499 160 100 mmHg mg/dl mg/dl
22 Sumamik Belahan 0000725533299 160 110 mmHg mg/dl mg/dl
23 Amini Belahan 0000725536697 180 100 mmHg mg/dl mg/dl
24 Marliyah Belahan 0000098649459 170 100 mmHg mg/dl mg/dl
25 Sumarni Belahan 0000725541388 150 100 mmHg mg/dl mg/dl
26 Siswati Belahan 0000725964355 140 100 mmHg mg/dl mg/dl
27 Sumarmi Belahan 0000726433558 130 90 mmHg mg/dl mg/dl
28 Juwariyah Belahan 0000725744103 180 110 mmHg mg/dl mg/dl
29 Inuk Nur HandaBrayung 0000725955377 110 70 mmHg 388 mg/dl 427 mg/dl
30 Ngatiyah Brayung 0001308919059 150 90 mmHg 151 mg/dl 218 mg/dl
31 Hadi SupratmanBrayung 0000099392005 130 90 mmHg 98 mg/dl 198 mg/dl
32 Sai'in Brayung 0000724734775 160 110 mmHg 201 mg/dl 310 mg/dl
33 Siti Shobiroh Brayung 0000098516834 150 100 mmHg mg/dl mg/dl
34 Pa'ini Brayung 0000724734621 130 80 mmHg 111 mg/dl 162 mg/dl
35 Sholichatun Brayung 0000099743387 130 90 mmHg mg/dl mg/dl
36 Mistiyah Kintelan 0000720417887 160 100 mmHg mg/dl mg/dl
37 Rohman Kintelan 0001796374765 110 90 mmHg mg/dl mg/dl
38 Suyati Kintelan 0000725309122 140 110 mmHg 102 mg/dl 152 mg/dl
39 Kati Sumberejo 0000726390955 130 90 mmHg 310 mg/dl 386 mg/dl
40 Keminah Sumberrejo 0000725316783 150 100 mmHg mg/dl mg/dl
41 Wasiah Sumberrejo 0000725311001 160 100 mmHg 108 mg/dl 152 mg/dl
42 Atinah Kertoharjo 0000725374274 170 110 mmHg mg/dl mg/dl
43 Sutianah Kertoharjo 0000725433996 110 70 mmHg mg/dl mg/dl
44 Sumianah Kertoharjo 0000725350353 120 80 mmHg mg/dl mg/dl
45 Sawi Kertoharjo 0000725342163 120 70 mmHg 218 mg/dl 188 mg/dl
Jenis Pemeriksaan
No Nama Alamat Nomor BPJS
Tekanan Darah GD Puasa GD 2 JPP
46 Karsiti Sumberejo 0001043735938 170 110 mmHg mg/dl mg/dl
47 Parlik Kintelan 0000725297411 160 100 mmHg 94 mg/dl 110 mg/dl
48 Sri kusmiati Puri 0000725782004 130 90 mmHg mg/dl mg/dl
49 Wiji Puri 0000724765318 140 100 mmHg mg/dl mg/dl
50 Saniah Puri 0000725810769 120 80 mmHg 134 mg/dl 189 mg/dl
51 Paini Puri 0002073766061 140 100 mmHg 236 mg/dl 308 mg/dl
52 Parlan Puri 0001043737378 130 90 mmHg mg/dl mg/dl
53 Rini Puri 0001275741472 120 80 mmHg 307 mg/dl 426 mg/dl
54 Khusnul k Temon 0000724649883 140 80 mmHg mg/dl mg/dl
55 Rodiyah Sawo 0000725804831 160 120 mmHg 263 mg/dl 272 mg/dl
56 Andri Sawo 0001043737648 120 70 mmHg mg/dl mg/dl
57 Asemak Sawo 0000724665969 110 70 mmHg 182 mg/dl 262 mg/dl
58 Samat Sawo 0001869755275 100 90 mmHg mg/dl mg/dl
59 Muslikah Puri 0001809572038 150 90 mmHg mg/dl mg/dl
60 B. Kusmiati Banjar Agung 0000098577819 130 80 mmHg 110 mg/dl 174 mg/dl
61 Sriani Medali 0000098503031 150 90 mmHg 101 mg/dl 168 mg/dl
62 Murati kintelan 0000725441321 110 80 mmHg 114 mg/dl 169 mg/dl
63 Rotin sumber rejo 0000726403296 140 80 mmHg 112 mg/dl 202 mg/dl
64 Kastun sumber rejo 0001043735859 140 90 mmHg mg/dl mg/dl
65 Sunarsih Puri 0002201172557 160 120 mmHg 178 mg/dl 213 mg/dl
66 Siti Roisah B kintelan 0000725397085 120 70 mmHg 146 mg/dl 137 mg/dl
67 Rini B kintelan 0000725425503 120 80 mmHg 92 mg/dl 124 mg/dl
68 Sulikah Belahan 0000725891949 120 80 mmHg 192 mg/dl 210 mg/dl
69 Mustikah Puri 0000724657004 130 80 mmHg 101 mg/dl 138 mg/dl

Mojokerto, 22 April 2017


Pemeriksa

dr. FATATIE NURIYANA


NIP. 19800707 201001 2 005
PEMERINTAH KABUPATEN MOJOKERTO
DINAS KESEHATAN
UPT PUSKESMAS PURI
Desa Tangunan Kecamatan Puri Telp. 0321-510765
MOJOKERTO

REKAPITULASI HASIL PEMERIKSAAN LABORATORIUM


PESERTA PROLANIS PUSKESMAS PURI
BULAN APRIL 2017

Jenis Pemeriksaan
No Nama Alamat Nomor BPJS
Gula Puasa 2 JPP
1 Assaat Brayung 0000099743376 176 mg/dl 279 mg/dl
2 Nur Alfiah Brayung 0001270876217 137 mg/dl 188 mg/dl
3 Riadi Brayung 0000725624774 111 mg/dl 217 mg/dl
4 Nanik umi Brayung 0000726439803 231 mg/dl 383 mg/dl
5 Ngatminah Ngrayung 0000724737486 115 mg/dl 269 mg/dl
6 Nursan Ngrayung 0001043736063 110 mg/dl 148 mg/dl
7 Ainun Ngrayung 0000725456597 127 mg/dl 238 mg/dl
8 Siti roisah Belahan 0000725453515 190 mg/dl 175 mg/dl
9 Inuk Nur HandayaBrayung 0000725955377 388 mg/dl 427 mg/dl
10 Ngatiyah Brayung 0001308919059 151 mg/dl 218 mg/dl
11 Hadi Supratman Brayung 0000099392005 98 mg/dl 198 mg/dl
12 Sai'in Brayung 0000724734775 201 mg/dl 310 mg/dl
13 Pa'ini Brayung 0000724734621 111 mg/dl 162 mg/dl
14 Suyati Kintelan 0000725309122 102 mg/dl 152 mg/dl
15 Kati Sumberejo 0000726390955 310 mg/dl 386 mg/dl
16 Wasiah Sumberrejo 0000725311001 108 mg/dl 152 mg/dl
17 Sawi Kertoharjo 0000725342163 218 mg/dl 188 mg/dl
18 Parlik Kintelan 0000725297411 94 mg/dl 110 mg/dl
19 Saniah Puri 0000725810769 134 mg/dl 189 mg/dl
20 Paini Puri 0002073766061 236 mg/dl 308 mg/dl
21 Rini Puri 0001275741472 307 mg/dl 426 mg/dl
22 Rodiyah Sawo 0000725804831 263 mg/dl 272 mg/dl
23 Asemak Sawo 0000724665969 182 mg/dl 262 mg/dl
24 B. Kusmiati Banjar Agung 0000098577819 110 mg/dl 174 mg/dl
25 Sriani Medali 0000098503031 101 mg/dl 168 mg/dl
26 Murati kintelan 0000725441321 114 mg/dl 169 mg/dl
27 Rotin sumber rejo 0000726403296 112 mg/dl 202 mg/dl
28 Sunarsih Puri 0002201172557 178 mg/dl 213 mg/dl
29 Siti Roisah B kintelan 0000725397085 146 mg/dl 137 mg/dl
30 Rini B kintelan 0000725425503 92 mg/dl 124 mg/dl
31 Sulikah Belahan 0000725891949 192 mg/dl 210 mg/dl
32 Keminah kintelan 0000725316783 147 mg/dl 118 mg/dl
33 Mustikah Puri 0000724657004 101 mg/dl 138 mg/dl

Mojokerto, 22 April 2017


Pemeriksa,

ANANG KUSDIANTO
NIP. 19800407 200012 1 005
PEMERINTAH KABUPATEN MOJOKERTO
DINAS KESEHATAN
UPT PUSKESMAS PURI
Desa Tangunan Kecamatan Puri Telp. 0321-510765
MOJOKERTO

REKAPITULASI HASIL PEMERIKSAAN


PESERTA PROLANIS PUSKESMAS PURI
BULAN MEI 2017

JENI BULAN MEI KET


NO. S TEK. (PENAMBAHAN/
NO RE NAMA PESERTA NO KARTU P/ I / CHO DARAH
KEL IMT CHO CHO TRIG PENGURANGAN
S BB TB (Kg/m2) GDP GDP
HBA L
G AMI GDS 1C TOT
L L LISE SISTOL PESERTA, PER
P LDL HDL RIDA DIAST
N AL E
OLE KAPA, ALASAN)
1 60 SRI KUSMIATI (P) 0000725782004 56 146 140 90
2 36 AMRIK (P) 0000725823909 P
3 13 SITI ROMLAH (P) 0000725638228 P 56 150 90
4 51 GINAH (P) 0000726095248 P 54 160 160 90
5 29 SETIYOWATI (P) 0000725512735 P
6 31 KARSINI (P) 0000725734337 P 56 153 150 80
7 35 MUHARTI (P) 0000101363387 P
8 16 SEMIN SAMADI (L) 0000101363376 L 55 163 160 100
9 4 NUR ALFIYAH (P) 0001270876217 P 42 140
10 73 kani (P) 0000726251883 P 45 158 160 90
11 32 SARIYEM (P) 0000726286443 P 43 142 150 90
12 62 SANIAH (P) 0000725810769 60 151
13 37 JUMAINAH (P) 0000725486771 P
14 41 PONARI (L) 0000726679236 L 55 159 170 100
15 47 SALUKI (L) 0001306268818 L
JENI BULAN MEI KET
NO. TEK.
S DARAH (PENAMBAHAN/
NO RE NAMA PESERTA NO KARTU P/ I / IMT CH TRI
KEL CH CH PENGURANGAN
S BB TB (Kg/ GDP HB OL GLI DIAS
G AMI GDP GDS OL OL SISTO TOL PESERTA, PER
N m2) P A1C TOT SER KAPA, ALASAN)
LDL HDL LE E
AL IDA
16 1 kasti (P) 0001873688859 P 53 147 160 90
17 15 AINUN (P) 0000725456597
18 NUR AMIMAH (P) 0000724694769 48 146 160 100
19 ELISABET WARSIKI (P) 0000725574183
20 32 INUK NURHANDAYANI (P)0000725955377 P
21 53 PADI (L) 0001797789508 L
22 58 PURADI (L) 0000726740076 L
23 JUMI'AH (P) 0000726675366 68 154 150 90
24 14 SUKARTO (L) 0000725669212 L
25 61 WIJI (P) 0000724765318 53 147 140 100
26 60 NGATEMI (P) 0000726699249 P
27 34 SITI AMANAH (P) 0001294578156 P
28 57 PANI (L) 0001043743105 L
29 69 ANDRI (L) 0001043737648 45 158 160 100
30 RUSMI (P) 0000726265181 43 142 150 90
31 75 SUWARSIH (P) 0000725812198
32 62 PARTI (P) 0000725791408 P 43 160 140 90
33 63 AJIN (L) 0000725790431 L 69 154 150 90
34 8 RAWATI jd wagi (P) 0000099401376 P
35 70 ASEMAK (L) 0000724665969
36 12 NGATMINAH (P) 0000724737486
37 20 SUTINI (P) 0000725601969 P
38 22 KASMILAH (P) 0000726233771 P
39 3 SUNAMI JD CHOIRUMAN (0000099419319 P
40 17 SULASMANI (P) 0000725517898 43 142 160 90
JENI BULAN MEI KET
NO. TEK.
S DARAH (PENAMBAHAN/
NO RE NAMA PESERTA NO KARTU P/ I / IMT CH TRI
KEL CH CH PENGURANGAN
S BB TB (Kg/ GDP HB OL GLI DIAS
G AMI GDP GDS OL OL SISTO TOL PESERTA, PER
N m2) P A1C TOT SER KAPA, ALASAN)
LDL HDL LE E
AL IDA
41 19 LASMI (P) 0000725911806 P 57 156 140 90
42 SODAKOTIN (P) 0000725509528
43 17 KALIMAH (P) 0000725704828 P 62 157 150 90
44 55 AROPAH (P) 0000726669033 P
45 49 KATI (P) 0000726390955
46 5 purnomo suhartini (P) 0001962893259 P
47 47 SUNAHWATI (P) 0000725641659
48 55 SUMIANAH (P) 0000725350353 53 154 140 80
49 21 UTAMI (P) 0000726207546 P 47 148 140 90
50 54 SUTIANAH (P) 0000725433996 58 145 150 80
51 7 NGATIAH (P) 0002064069314 P
52 64 SUMARMI (P) 0000726120448 P 60 157 150 90
53 29 SISWATI (P) 0000725964355 P 70 155 140 100
54 46 SAMIAJI (L) 0000726120382 L
55 18 KARSONO (L) 0001321099773 L
56 50 KEMINAH (P) 0000725316783
57 24 TUMINAH (P) 0000725669256 P 54 145 160 90
58 65 samiasih (P) 0001878891142 P 43 143 150 80
59 ARIYAH (P) 0000725744103
60 38 SOLIKHAH (P) 0000099383128 P
61 11 SAMDIONO (L) 0000725935983 L 45 143 150 90
62 42 SETU (L) 0000726225131 L
63 KUSMIATI (P) 0000725503645 61 147 190 100
64 45 KUMILAH (P) 0000726741797 P 39 139 160 90
65 3 SUPI (P) 0000725920727 P 40 145 180 100

JENI BULAN MEI KET


NO. TEK.
S DARAH (PENAMBAHAN/
NO RE NAMA PESERTA NO KARTU P/ I / IMT CH TRI
KEL CH CH PENGURANGAN
S BB TB (Kg/ GDP HB OL GLI DIAS
G AMI GDP GDS OL OL SISTO TOL PESERTA, PER
N m2) P A1C TOT SER KAPA, ALASAN)
LDL HDL LE E
AL IDA
66 83 DEWI MURIFAH (P) 0001405126956 P 150 90
67 80 HARTATIK (P) 0000726181176 P
68 SEMA'UN (L) 0001261644963 meninggal
69 39 CHASANAH (P) 0000726271481 P 140 100
70 82 RUMADJI (L) 0002064069066 L
71 63 PAINI (P) 0002073766061
72 65 PARLAN (L) 0001043737378 52 170 200 120
73 40 KOSIAH (P) 0000726333928 P
74 57 KARSITI (P) 0001043735938
75 84 JAMUDAH (P) 0001043742161 P 54 155 170 100
76 RIADI (L) 0000725624774 L
77 51 WASIAH (P) 0000725311001
78 AKHMAD (L) 0001292653631
79 30 SUMARMI (P) 0000726433558 P 45 154 130 90
80 28 SUMARNI (P) 0000725541388 P 43 148 150 100
81 SITI KHALIMAH (P) 0001043735984
82 SITI ROISAH (P) 0000725453515
83 26 AMINI (P) 0000725536697 P 66 152 180 100
84 UMI MALIKAH (P) 0000724768029
85 47 rokhman (L) 0001796374765
86 SUMIATI (P) 0000726193124
87 NARSIH (P) 0001043736074 64 152 150 100
88 2 RAWON (L) 0001043742317 L
89 2 SUTAMI (P) 0001294358163 P 75 151 150 100
90 68 RODIYAH (P) 0000725804831

JENI BULAN MEI KET


TEK.
NO. S (PENAMBAHAN/
P/ I / IMT CH TRI DARAH
NO RE NAMA PESERTA NO KARTU KEL CH CH PENGURANGAN
S BB TB (Kg/ GDP HB OL GLI DIAS
G AMI GDP GDS OL OL SISTO TOL PESERTA, PER
N m2) P A1C TOT SER KAPA, ALASAN)
LDL HDL LE E
AL IDA
91 71 SAMAT (L) 0001869755275 53 150 160 90
92 DJONAH
KHUSNUL (P)KHOTIMAH 0000725707888
93 67 (P) 0000724649883 63 152 140 80
94 81 TRIMAN (L) 0000726228955 L
95 25 SUMAMIK (P) 0000725533299 p 76 150 160 110
96 79 SOPIAH (P) 0000726229855 P
97 PII (L) 0000725918624
98 24 SUPINAH (P) 0000726431499
99 SAREH (L) 0000726454293
100 27 MARLIYAH JD PINGI (P) 0000098649459 P 52 148 170 100
101 KHOLIFAH (P) 0000726454552
102 SURIANI (P) 0001043745658
103 JAFARIL (L) 0000725826339 meninggal
104 SHOLIHAN (L) 0001043745647
105 MUINAH (P) 0000726249655
106 SOYIBIN (L) 0000726249622
107 SUTOPO (L) 0000726639333
108 SARMINI (P) 0000726453044
109 MAS ULUN (L) 0000726452919
110 61 SUTOMO (L) 0000726699115 L
111 NURSAN (L) 0001043736063
112 86 maskur (L) 0001800859241 L
113 WELAS ASIH (P) 0001817673581
114 NANIK UMI KALSUM (P) 0000726439803 P
115 PAERI (L) 0000725848468

JENI BULAN MEI KET


NO. TEK.
S DARAH (PENAMBAHAN/
NO RE NAMA PESERTA NO KARTU P/ I / IMT CH TRI
KEL CH CH PENGURANGAN
S BB TB (Kg/ GDP HB OL GLI DIAS
G AMI GDP GDS OL OL SISTO TOL PESERTA, PER
N m2) P A1C TOT SER KAPA, ALASAN)
LDL HDL LE E
AL IDA
116 66 RINI (P) 0001275741472
117 48 SUPRAYITNO (L) 0001803599076 L
118 supini (P) 0001964981777 meninggal
119 TRI MURYANI (P) 0001081323718
120 SAPAWI (L) 0000725817251 50 150 170 100
121 tarwiyah (L) 0001795926824 P 41 145 150 100
122 ASMAH (P) 0000726728466
123 KARTO SUBIRAN (L) 0000725810264
124 LAMTI (P) 0000726667705
125 23 TEMAH (P) 0000726389021 p 50 151 140 110
126 48 SUYATI (P) 0000725309122 41 145 140 110
127 JIANAH (P) 0000724736485 P 65 146 140 90
128 46 MISTIYAH (P) 0000726417887 82 138 160 100
129 SITI ISNIWATI SURYADI
MUHAMMAD (P) 0000098501826
130 (L) 0000098498283 52 153 160 90
131 KUSEN ASHARI (L) 0000098577808
132 82 B. KUSMIATI (P) 0000098577819
133 AGUS BASUKI (L) 0001480351555
134 MOKHAMAD AGUS SALIM0000098733576
135 IMAM AJIB ISPURNAWAN 0( 000098495919
136 ASSA`AT (L) 0000099743376 L
137 MISDI (L) 0000725739952 47 155 150 100
138 MUBAYANAH (P) 0000725803817 meninggal
139 RIANI (P) 0000724706008
140 83 SRIANI (P) 0000098503031

JENI BULAN MEI KET


NO. TEK.
S DARAH (PENAMBAHAN/
NO RE NAMA PESERTA NO KARTU P/ I / IMT CH TRI
KEL CH CH PENGURANGAN
S BB TB (Kg/ GDP HB OL GLI DIAS
G AMI GDP GDS OL OL SISTO TOL PESERTA, PER
N m2) P A1C TOT SER KAPA, ALASAN)
LDL HDL LE E
AL IDA
141 49 Saumayah (P) 0001704628056 P
142 52 SUTI (P) 0000725385699 P
143 30 SENAH (P) 0001295332571 P 52 156 150 100
144 12 PRAMESTI KAIMAN (P) 0000726224016 P 45 143 160 100
145 54 SULIYAH (P) 0000726106735 P
146 56 SUTIK (P) 0000098517925 P
147 33 WARSONO (L) 0000726304059 L meninggal
148 15 TAMI (P) 0000725904753 45 147 160 90
149 29 SETYAWATI 0000725512735 P
150 28 WARSIH 0000725574183 P
151 27 BD JONAH 0000725707838 P
152 26 PI'I 0000725918624 L
153 25 MUSLIKAH 0002065405083 P
154 23 JANATIN 0000725917691 P
155 15 TAMI 0000725904753 P
156 10 NUR AMINAH 0000724694769 P
157 9 RUSMINAH 0000726265181 P
158 6 HARWATI 0001256424041 P
159 43 RUMILAH 0000726631334 P
160 44 SUMIKATIN 0000726334312 P 54 145 160 90
161 50 JUMIAH 0000726675366 P
162 59 NI'MAH 0000726161163 P
163 66 SUGIONO 0001285462495 L
164 67 SAMIYAH 0000725338247 P 60 150 150 100
165 68 MUNIAH 0000725497389 P 61 148 140 90

JENI BULAN MEI KET


TEK.
NO. S (PENAMBAHAN/
P/ I / IMT CH TRI DARAH
NO RE NAMA PESERTA NO KARTU KEL CH CH PENGURANGAN
S BB TB (Kg/ GDP HB OL GLI DIAS
G AMI GDP GDS OL OL SISTO TOL PESERTA, PER
N m2) P A1C TOT SER KAPA, ALASAN)
LDL HDL LE E
AL IDA
166 69 SUKIMAH 0000726303273 P 54 160 150 90
167 70 DEDIK 0000726699797 L 56 165 140 90
168 71 PARTI 0000726736904 P
169 72 PONIMAH 0000725460636 P
170 74 M KHOLIQ 0001436206814 L
171 75 WIWIK LUTFIANA 000110276494 P
172 76 BONING 0001321514324 P
173 77 KASTINI 0000726560886 P
174 78 KUNASIH 0001043742328 P
175 85 ENDAH 0001726326177 P
176 JASIMAH 0000724747138 P 65 156 120 90
177 31 JUWARIYAH 0000725744103 P 61 156 180 110
178 34 NGATIYAH 0001308919059 P
179 36 HADI SUPRATMAN 0000099392005 P
180 37 SAI'IN 0000724734775 P
181 38 SITI SOBIROH 0000098516834 P
182 42 PA'INI 0000724734621 P
183 45 solichatun 0000099743387 p
184 53 ATINAH 0000725374647 P 70 145 160 100
185 56 SAWI 0000725342163
186 59 PARLIK 0007255297411
187 72 MUSLIKAH 0001809572038
188 84 MURATI 0000725441321
189 85 ROTIN 0000726403296
190 86 KASTUN 0001043735859

JENI BULAN MEI KET


NO. TEK.
S DARAH (PENAMBAHAN/
NO RE NAMA PESERTA NO KARTU P/ I / IMT CH TRI
KEL CH CH PENGURANGAN
S BB TB (Kg/ GDP HB OL GLI DIAS
G AMI GDP GDS OL OL SISTO TOL PESERTA, PER
N m2) P A1C TOT SER KAPA, ALASAN)
LDL HDL LE E
AL IDA
191 87 SUNARSIH 0002201172557
192 90 MUSTIKAH 0000724657004
193 91 SITI ROISAH B 0000725397085
194 93 RINI B 0000725425503
195 94 SULIKAH 0000725891949

Mojokerto, 20 MEI 2017


Pemeriksa

dr. FATATIE NURIYANA


NIP. 19800707 201001 2 005