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    DATA PESERTA CAR FREE DAY

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    12 views1 page

    Data Peserta Car Free Day

    Uploaded by

    nova cahyani

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    DATA PESERTA PROLANIS DATA PESERTA PROLANIS

    UPT PUSKESMAS KUNCIRAN UPT PUSKESMAS KUNCIRAN

    Nama : ……………………………………….. Nama : ………………………………………..

    Klub : ……………………………………….. Klub : ………………………………………..

    Tgl Lahir : ………………………… L / P Tgl Lahir : ………………………… L / P

    Alamat :………………………………….…… Alamat :………………………………….……

    Hasil Pemeriksaan : Hasil Pemeriksaan :

     BB :…………… kg  BB :…………… kg
     TB : ………….. cm  TB : ………….. cm
     L.Perut : ………….. cm  L.Perut : ………….. cm
     Tensi : ………….. mm/Hg  Tensi : ………….. mm/Hg

    Kimia Darah Kimia Darah

     GDP : ………… mg/dL  GDP : ………… mg/dL


     GDS : ………… mg/dL  GDS : ………… mg/dL
     Chol : ………... mg/dL  Chol : ………... mg/dL
     Tgr : …………. mg/dL  Tgr : …………. mg/dL
     LDL : …………. mg/dL  LDL : …………. mg/dL
     HDL : ………….. mg/dL  HDL : ………….. mg/dL

    DATA PESERTA PROLANIS


    DATA PESERTA PROLANIS
    UPT PUSKESMAS KUNCIRAN
    UPT PUSKESMAS KUNCIRAN

    Nama : ………………………………………..
    Nama : ………………………………………..
    Klub : ………………………………………..
    Klub : ………………………………………..
    Tgl Lahir : ………………………… L / P
    Tgl Lahir : ………………………… L / P
    Alamat :………………………………….……
    Alamat :………………………………….……
    Hasil Pemeriksaan :
    Hasil Pemeriksaan :
     BB :…………… kg
     BB :…………… kg
     TB : ………….. cm
     TB : ………….. cm
     L.Perut : ………….. cm
     L.Perut : ………….. cm
     Tensi : ………….. mm/Hg
     Tensi : ………….. mm/Hg

    Kimia Darah
    Kimia Darah
     GDP : ………… mg/dL
     GDP : ………… mg/dL
     GDS : ………… mg/dL
     GDS : ………… mg/dL
     Chol : ………... mg/dL
     Chol : ………... mg/dL
     Tgr : …………. mg/dL
     Tgr : …………. mg/dL
     LDL : …………. mg/dL
     LDL : …………. mg/dL
     HDL : ………….. mg/dL
     HDL : ………….. mg/dL

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