PELACAKAN DAN KONFIRMASI KASUS GIZI BURUK

DINAS KESEHATAN KABUPATEN...................................

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PUSKESMAS :.........................................

I. DENTITAS UMUM
a. Nama balita : ........... Jenis Kelamin : L/P
b. Anak Ke : ........... Dari ....... Tgl Lahir : .........
c. Berat badan : ........... Kg
d. Tinggi Badan : ........... Cm
e. LILA : ........... Cm
f. Nama Ibu : ....................................
g. Umur : ....................................
h. Pendidikan : ....................................
i. Pekerjaan :.....................................
j. Nama Ayah : ....................................
k. Umur :.....................................
l. Pendidikan :.....................................
m. Pekerjaan : ....................................
n. Alamat : ....................................
o. Gakin/ Non : ....................................

II.RIWAYAT ANAK
a. BB Lahir : .........
b. ASI Eksklusif ya/tdk : .........
c. Mulai umur berapa diberi MP-ASI : .........
d. Status Imunisasi : .........
e. Penolong persalinan : .........
f. Apakah anak rutin dibawa ke Posyandu : .........
g. Bagaimana pola makan dan menyusui anak :
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III. HASIL KONFIRMASI (LIHAT TABEL WHO 2005)

BB/U :
TB/U (PB/U) :
BB/TB (BB/PB) :
IMT/U :
Gizi Buruk : ya atau tidak

IV. RIWAYAT PENYAKIT ANAK

a.Penyakit penyerta sekarang :

b.Sebutkan penyakit yang pernah diderita mulai dari lahir sampai sekarang :
1...............................
2...............................
3...............................
4...............................
V. POLA KONSUMSI

a.Sebutkan pola makan keluarga kemarin :

- Bahan makanan pokok : ......................
- Lauk hewani : ......................
- Lauk nabati : ......................
- Sayur : ......................
- Buah : ......................

VI. LINGKUNGAN SOSIAL

1. Keadaan Rumah (pengamatan) :...............................

2. Kepemilikan Rumah :...............................
3. Sumber Air :...............................
4. Jenis Jamban Keluarga :...............................
5. Ventilasi Rumah (pengamatan) :...............................
6. Tempat membuang Sampah :...............................

VI.PENANGANAN

a. Penanganan Sebelum Konfirmasi.....................................................................

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b. Penanganan Sesudah Konfirmasi.....................................................................
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Mengetahui, ................,...............2015
Kepala Puskesmas Yang Melaksanakan Perjalanan ,

NIP........................ NIP...........................