FORMAT LAPORAN DENVER II/SDIDTK

LAPORAN PENILAIAN
DENVER DEVELOPMENTAL SCREENING TEST II/SDIDTK

Nama Mahasiswa : ............................................................................................................

NIM : ............................................................................................................
Tanggal : ............................................................................................................

1. Identitas Anak
Nama : ............................................................................................................
Tanggal lahir : ............................................................................................................
Jenis Kelamin : ............................................................................................................
Agama : ............................................................................................................
Alamat : ............................................................................................................
2. Identitas Orang Tua
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Umur : ............................................................................................................
Agama : ............................................................................................................
Pendidikan : ............................................................................................................
Pekerjaan : ............................................................................................................
Alamat : ............................................................................................................
3. Riwayat Pertumbuhan dan Perkembangan
a. Personal Sosial:
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b. Motorik Halus :
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c. Bahasa :
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d. Motorik Kasar :
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4. Riwayat kehamilan, persalinan dan Nifas
a. Kehamilan
Trimester I :
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Trimester II :
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Trimester III :
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b. Persalinan
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c. Nifas :
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 5. Pemeriksaan Antropometri
TB : ..................................................................................................................................
BB : ..................................................................................................................................
LLA : .................................................................................................................................
LD : ..................................................................................................................................
LP : ...................................................................................................................................
LK : ...................................................................................................................................
Perhitungan hasil pertumbuhan :
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6. Perhitungan Umur Anak
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7. Pelaksanaan Denver II/SDIDTK
No Aspek Yang Dinilai Pelaksanaan Denver II/SDIDTK Hasil Denver II/SDIDTK
1 Personal Sosial
2 Motorik halus

3 Bahasa
4 Motorik Kasar

8. Interpretasi Hasil Denver II/SDIDTK untuk tiap sector

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9. Kesimpulan
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10. Saran Kepada Orang Tua (lampirkan materi, SAP, dan Media)
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11. Lampiran Form Denver II /SDIDTK
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