FORMULIR DETEKSI DINI TUMBUH KEMBANG ANAK

Puskesmas...........................Kec..........................Kab/Kota.............................Prov.......................

Pemeriksa:.................................................I. IDENTITAS ANAKa. Nama:........................................................................... Laki-laki/Perempuanb. Nama Ayah:........................................................; Nama Ibu:...........................................c. Alamat:..............................................d. Tanggal Pemeriksaan:............/............./20e. Tanggal Lahir: ............/............./20f. Umur Anak:................... bulan

II. PEMERIKSAAN RUTIN SESUAI JADWALa. BB:..............Kg; PB/TB:.............CmBB/TB: a. Baik; b. Kurang; c. Buruk; d. Lebih; e. Rujuk: Ya/Tidakb. Perkembangan Anak:1. Sesuai2. Meragukan: a. G. Kasar; b. G. Halus; c. B.Bahasa; d. Sos. Kemandirian; e. Rujuk: Ya/Tidak3. Penyimpangan:a. G. Kasar; b. G. Halus; c. B.Bahasa; d. Sos. Kemandirian; e. Rujuk: Ya/Tidak

III. KESIMPULAN..............................................................................................................................................................................................................................................................................................................

IV. TINDAKAN INTERVENSI...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................