FORMAT PENGKAJIAN

DEVELOPMENTAL SCREENING TEST II

PROFESI NERS STIKES BULELENG

Nama Mahasiswa : …………………………………

NIM :………………………………….

1. IDENTITAS ANAK
Nama :
Tanggal lah :
Jenis kelamin :
Agama :
Pendidikan :
Alamat :

2. IDENTITAS ORANG TUA

Nama :
Tanggal lahir :
Jenis kelamin :
Agama :
Pendidikan :
Pekerjaan :
Alamat :

3. RIWAYAT PERTUMBUHAN DAN PERKEMBANGAN

a) Personal sosial/kemandirian bergaul
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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. PENGHITUNGAN UMUR
Tanggal test :
Tanggal lahir :
Umur anak :

5. PELAKSANAAN TEST DDST II

SEKTOR RESPON ANAK KESIMPULAN

Personal
sosial

Motorik
halus .

Bahasa

Motorik
kasar

6. INTERPRETASI HASIL TEST DARI DDST II

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7. KESIMPULAN DARI KEEMPAT SEKTOR
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8. SARAN KEPADA ORANG TUA/PENGASUH

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 LAPORAN
DENVER DEVELOPMENTAL SCREENING TEST (DDST) II
Pada An. Umur: Tanggal:
Di RSUD Kabupaten Karangasem
Tahun 2018

OLEH :

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SEKOLAH TINGGI ILMU KESEHATAN STIKES BULELENG

PROGRAM PROFESI NERS
2018