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FORMAT PENDATAAN

Kecamatan : KK :
Kelurahan/Desa : Jenis Kelamin :
RT : Umur :
RW/Dusun : Pendidikan :
Alamat : Agama :
Pekerjaan : Penghasilan :
Keadaan Kesehatan :
A. ANGGOTA KELUARGA :
HUB.
SUKU/BA KEADAAN KET
NO NAMA DG.K L/P UMUR PENDIDIKAN PEKERJAAN AGAMA IMUNISASI KB
NGSA KESH. .
K
1.
2.
E. Faktor Lingkungan
1. Rumah :
- Luas : ..............m2
- Tipe : ................
- Jenis rumah : susun/petak/kavling
- Letak : dekat/jauh dengan sarana vector
- Dinding : tembok/papan/gedek
- Atap : genteng/seng/lain-lain
- Lantai : tegel/plester/tanah/basah/kering
- Cahaya : cukup/kurang
- Ventilasi : cukup/kurang
- Jumlah ruangan : ......................................................................................................

2. Air Minum :
- Asal : PAM/SPT/Sumber/Sungai
- Nilai Air : Bersih/kotor/berbau/berwarna
- Air untuk minum: dimasak/mentah
- Konsumsi : ......................................................................................................

3. Pembuangan sampah :
Dibakar/ditanam/dikompos/diambil petugas

4. Jamban dan Kamar mandi :


- Jenis jamban : cemplung/leher naga/lain-lain
- Jarak dengan sumber air : ................m
- Kebersihan : bersih/kotor/berbau
- Kamar mandi : ada/tidak ada/bersih/kotor

5. Pekarangan dan selokan :


- Pengaturan : Teratur/berserakan
- Kebersihan : Bersih/teratur
- Air Limbah : Teratur/berserakan/dimanfaatkan
- Tanaman perdu : ada/tidak
- Pemanfaatan pekarangan : ada/tidak

6. Kandang ternak :
- Bangunan : permanen/darurat
- Letak : tersendiri/seatap
- Kebersihan : bersih/kotor

7. Sarana komunikasi dan transportasi :


......................................................................................................................................
8. Fasilitas pelayanan kesehatan :
......................................................................................................................................
F. Riwayat Kesehatan Keluarga
1. Riwayat Kesehatan Keluarga
......................................................................................................................................
2. Keluarga Berencana
- Jenis : ....................................................................................
- Lama : ....................................................................................
- Komplikasi : ....................................................................................
- Pernah ganti cara/tidak : ....................................................................................
Bila pernah;jenisnya : ....................................................................................

G. Pengetahuan orang tua tentang tumbuh kembang anak


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............................................................................................................................................
H. Harapan Keluarga terhadap petugas kesehatan
............................................................................................................................................
............................................................................................................................................
I. Data Khusus
1. Jenis penyakit yang sering diderita keluarga
......................................................................................................................................

2. Riwayat Kebidanan
a. Kehamilan
................................................................................................................................
b. Persalinan
................................................................................................................................
c. Nifas
................................................................................................................................
d. Imunisasi
................................................................................................................................
e. Keluarga Berencana (KB)
................................................................................................................................
f. Nutrisi (ASI dan MPASI)
................................................................................................................................
3. Lain-lain
......................................................................................................................................

J. Skala Prioritas
1. ........................................................................................................................................
2. ........................................................................................................................................

MASALAH KESEHATAN SESUAI DENGAN PRIORITAS :


1. ......................................................................................................................................
2. ......................................................................................................................................