Formulir Deteksi Dini Tumbuh Kembang Anak
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FORMULIR DETEKSI DINI TUMBUH KEMBANG ANAK Puskesmas.......................... . Kec.......................... Kab/Kota............................. Prov....................... Pemeriksa:................................................. I. IDENTITAS ANAK a. Nama:........................................................................... L b. Nama Aa!:........................................................" Nama Ibu:..... c. Alamat:.............................................. #. Tan$$al Pemeriksaan:............/............./%& e. Tan$$al La!ir: ............/............./%& '. (mur Anak:................... bulan II. PE)E*IKSAAN *(TIN SES(AI +AD,AL a. :..............K$" P /T :............. m /T : a. aik" b. Kuran$" c. uruk" #. Lebi!" e. *u uk: 0a/Ti#ak b. Perkemban$an Anak: 1. Sesuai %. )era$ukan: a. 2. Kasar" b. 2. 3alus" c. . a!asa" #. Sos. Keman#irian" e. *u uk: 0a/Ti#ak 4. Penimpan$an: a. 2. Kasar" b. 2. 3alus" c. . a!asa" #. Sos. Keman#irian" e. *u uk: 0a/Ti#ak III. KESI)P(LAN .................................................................................. .................................................................................. I5. TINDAKAN INTE*5ENSI .................................................................................. .................................................................................. .................................................................................. .................................................................................. .................................................................................. .................................................................................. .................................................................................. .................................................................................. ..................................................................................
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Transcript of Formulir Deteksi Dini Tumbuh Kembang Anak
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...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
