I.

PMT
Janis Yang di Berikan……………………………………………….…………..…..
……………………………………………………………………….……….……….
………………………………………………………………………………………...
…………………………………………………………………………………….…..
III. LAYANAN KESEHATAN
1. Imunisasi :…………………………………………………..
2. KB
II. PENYULUHAN :…………………………………………….…….. KARTU
3. Diare :…………………………………………………... BANTU
………………………...……………………………………………………….….…..
4. Obat Cacing :…………………………………………………... PEMERIK
5. ……………………………………………………………………………………..….
Vitamin :…………………………………………………... SAAN

………………………………………………………………………………………...
IV. PMT……………………………………………………………………………………..….
Janis Yang di Berikan…………………………………………………………..
……………………………………………………………………………………..….
…………………………………………………………………………………….
……………………………………………………………………………………..….
……………………………………………………………………………………..….
V. PENYULUHAN
……………………………………………………………………………………..….
………………………...…………………………………………………………..
……………………………………………………………………………………..….
…………………………………………………………………………………….
……………………………………………………………………………………..….
…………………………………………………………………………………….
…………………………………………………………………………………….
Parmonangan,…….Januari 2024

………………………………………………
I. PEMERIKSAAN BALITA/BAYI ………………………………………………………………………………
1. Berat Badan :……………………… Kg IV. LANSIA
2. T.Badan/P.Badan :……………………… Cm 1. Tekanan Darah :…….……………………………………………..
3. Lingkar Lengan :……………………… Cm 2. Berat Badan :…………………………………………….……..
4. Lingkar Kepala :……………………… Cm 3. Tinggi Badan :…………………………………………………...
II. PEMERIKSAAN IBU HAMIL 4. Lingkar Perut :…………………………………………………...
1. HPHT :…………………….. Hari 5. HR :…………………………………………………...
2. TTP :…………………….. 6. RR :…………………………………………………...
3. Usia kehamilan :…………………….. Minggu/Bulan 7. KGD :…………………………………………………...
4. Tekanan Darah :…………………….. mm/Hg 8. Colestrol :……………………………………………………
5. HR :…………………….. Kali/Menit
9. Gula Darah :……………………………………………………
6. RR :…………………….. Kali/Menit
10. Lainnya :……………………………………………………
7. Suhu Tubuh :…………………….. C
………………………………………………………………………………
8. Berat Badan :…………………..… Kg
………………………………………………………………………………
9. T.Badan/P.Badan :…………………..… Cm
………………………………………………………………………………
10. Lingkar Lengan :…………………..… Cm
………………………………………………………………………………
11. TBBJ :…………………..… Gram
III. USIA PRODUKTIF
V. LAYANAN KESEHATAN
1. Tekanan Darah :…….……………………………………………..
1. Imunisasi :…………………………………………………...……….
2. Berat Badan :…………………………………………….……..
2. KB :…………………………………………….……………...
3. Tinggi Badan :…………………………………………………...
3. Diare :………………………………………………….………...
4. Lingkar Perut :…………………………………………………...
4. Obat Cacing :……………………………………………………….......
5. HR :…………………………………………………...
5. Vitamin :……………………………………………………….......
6. RR :…………………………………………………...
7. KGD :…………………………………………………...
8. Colestrol :……………………………………………………
9. Gula Darah :……………………………………………………
10. Lainnya :……………………………………………………
………………………………………………………………………………
………………………………………………………………………………