PEMERINTAHAN KABUPATEN PANDEGLANG

DINAS KESEHATAN
UPT PUSKESMAS BOJONG
Jl Saketi Malingping Km.10 Bojong-Pandeglang 42274 email : puskesmas.bojong@gmail.com

NAMA : ............................................
UMUR : ............................................
ALAMAT : ............................................
TGL Px. : ...........................................
Uterus : Gestational Sach (GS) Ada / Tidak ada.
Janin : Tunggal / Kembar, Hidup / Mati, Intrauterin / Ekstrauterin, CRL…………..….cm,
DJJ……….….dpm, HPL=……………………UK = ………...... minggu………..….hari.
Air Ketuban (Amnion) : Cukup / Kurang / Lebih.
Kantong gestasi : Regular / Iregular, diameter……….……………cm.
Uterus&adneksa : Tak tampak Massa / Ada Massa.
Penilaian : ...............................................................................................................................................
...............................................................................................................................................
Saran : ...............................................................................................................................................

Pemeriksa

…………………

PEMERINTAHAN KABUPATEN PANDEGLANG

DINAS KESEHATAN
UPT PUSKESMAS BOJONG
Jl Saketi Malingping Km.10 Bojong-Pandeglang 42274 email : puskesmas.bojong@gmail.com

NAMA : ............................................
UMUR : ............................................
ALAMAT : ............................................
TGL Px. : ...........................................

Uterus : Gestational Sach (GS) Ada / Tidak ada.

Janin : Tunggal / Kembar, Hidup / Mati, Intrauterin / Ekstrauterin, CRL…………..….cm,
DJJ……….….dpm, HPL=……………………UK = ………...... minggu………..….hari.
Air Ketuban (Amnion) : Cukup / Kurang / Lebih.
Kantong gestasi : Regular / Iregular, diameter……….……………cm.
Uterus&adneksa : Tak tampak Massa / Ada Massa.
Penilaian : ...............................................................................................................................................
...............................................................................................................................................
Saran : ...............................................................................................................................................

Pemeriksa,

………………….