7/25/2019 SAMPUL UKS

1/4

NO NAMA TGL LHR

KEA

rambut

Ksm MC

1 2 3 4 5 6 7 8 9 10 11

JNSKLM(L/P)

TB(CM)

BB(KG)

TD(mmHg)

DN(/MNT) Higi!

"r#rg

7/25/2019 SAMPUL UKS

2/4

DAAN UMUM

T$! %r& DNbibir S%t Mu'ut

Krg P& Dr& L$ P&

12 13 14 15 16 17 18 19 20

DugaK'! Jtg

TmLi&at

7/25/2019 SAMPUL UKS

3/4

R%g Mata srum! OM

G*G* + MULUT

R#!gga M'tLK GR

Gigi

LB BB Ktr L T H

21 22 23 24 25 26 27 28 29 30 31 32 33 34

Dau!T'i!ga&

TmD!gar

STATUSG*,*

7/25/2019 SAMPUL UKS

4/4

HSL PMRKS PENUNJANG

Hb A!mia

35 36 37 38 39 40 41

PERLUPRKSKMME

KRG-*T A

KESEGARANJASMAN*T'ur

CgGrm.#%