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