Praktek EpiData

FACULTY OF MEDICINE, GADJAH MADA UNIVERSITY

(MORBIDITY RESEARCH)
---------------------------------------------------------------------------
page 1/1
A. PATIENT IDENTITY
1. Study number (identification number) [ | | ]
2. Name of child ____________________________
3. Date of birth ___/___/______
4. Age in month [ | ] months
5. Sex of patient 1[ ] Male
2[ ] Female
B. ANAMNESIS
1. Body weight [ | ].[ ] kg
2. Body height/length [ | | ].[ ] cm
3. diarrhoea? 1[ ] Yes
2[ ] No
4. How many days he/she does the diarrhoea? [ | ] days
---------------------------------------------------------------------------
Examination Date ___/___/______ Doctor __________________
===========================================================================
 FACULTY OF MEDICINE, GADJAH MADA UNIVERSITY
(MORBIDITY RESEARCH)
---------------------------------------------------------------------------
page 1/1
A. PATIENT IDENTITY
idnum Id number (identification number) ###
name Name of child <A >
dob Date of birth <dd/mm/yyyy>
age Age ## (months)
sex Sex of patient #

B. ANAMNESIS
wt Body weight ##.# kg
ht Body height/length ###.# cm
diare diarrhoea? #
diardays How many days he/she does the diarrhoea? ## days
---------------------------------------------------------------------------
examdate Examination Date <dd/mm/yyyy>
doctor Doctor who did anamneses <A >
===========================================================================

DATA:

Idnum name dob Age sex wt ht diar diard examdate doctor

101 Ali 31-01-2010 51 1 22.5 94.3 1 2 21-05-2015 Eni
102 Hasan 06-05-2010 48 1 21.3 91.2 1 3 21-05-2015 Eni
103 Bebe 09-08-2010 45 1 20.1 88.1 2 21-05-2015 Eni
104 Yuli 12-11-2010 42 1 18.9 85.0 2 21-05-2015 Eni
105 Yono 15-02-2011 39 1 17.7 81.9 1 2 22-05-2015 Ade
106 Dino 21-05-2011 36 1 16.5 78.8 1 3 22-05-2015 Ade
107 Ruly 07-09-2012 20 2 10.5 63.3 2 22-05-2015 Ade