No. REG : ........................................ No. REG : ........................................
Nama : ............................................ Umur : ..................................................... Nama : ............................................ Umur : .....................................................
Suami : ............................................ Pekerjaan : ..................................................... Suami : ............................................ Pekerjaan : .....................................................
Alamat : ............................................ Alamat : ............................................
HPHT : ................................., HPL : .............................., LILA :.............................. Cm, TB : ............................... Cm. HPHT : ................................., HPL : .............................., LILA :.............................. Cm, TB : ............................... Cm.
Jumlah Anak hidup : ........., Jumlah anak mati : ........, Jumlah anak lahir kurang bulan : ......................... anak Jumlah Anak hidup : ........., Jumlah anak mati : ........, Jumlah anak lahir kurang bulan : ......................... anak
Jarak kehamilan ini dengan persalinan terakhir : ............. Bln/Thn Jarak kehamilan ini dengan persalinan terakhir : ............. Bln/Thn
Penolong persalinan terakhir : ........................................................................................................................................... Penolong persalinan terakhir : ...........................................................................................................................................
Cara persalinan terakhir : Spontan / Tindakan .................................................................................................................. Cara persalinan terakhir : Spontan / Tindakan ..................................................................................................................
Skor awal kehamilan : ..............................., TM II : ....................................., TM III : .......................................... Skor awal kehamilan : ..............................., TM II : ....................................., TM III : ..........................................
Tgl. Usia Letak Tgl. Usia Letak
Keluhan TD BB Hamil TFU Janin DJJ LAB Tindakan Nasehat Ket. Keluhan TD BB Hamil TFU Janin DJJ LAB Tindakan Nasehat Ket.
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