Ny. :......................./.......th G...P...A... UK :............

Minggu
Tn. :......................./.......th HPHT :........................
Alamat :................................................................................ TP
:........................
MKB tgl:...................................................... Jam :.................
Anamnesis : His mulai tanggal :.............................Jam :.................
Darah :......................................................
Lendir :......................................................
Ketuban Pecah/belum/kapan
:......................................................
Physis Keadaan Umum :
Cort/Pulmo : Tensi : PALPASI
Oedema : Nadi : TFU :
Reflek : Temp : Cort :
Letak :
Pemeriksaan Dalam
VT tanggal :................................ Jam :......................WIB oleh bidan/dokter
:..........................
Hasil :...............................................................................................................
......................

OBSERVASI KETERANGAN
TGL JAM HIS LAMA CORT TEMP TENSI