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HASIL PEMERIKSAAN STATUS GIGI DAN MULUT OLEH HASIL PEMERIKSAAN STATUS GIGI DAN MULUT OLEH

KADER UKGMD PUSKESMAS 1 SUMPIUH KADER UKGMD PUSKESMAS 1 SUMPIUH

1. Identitas Pasien 1. Identitas Pasien


 Nama : ........................................................L/P  Nama : ........................................................L/P
 Usia : ...........................................................  Usia : ...........................................................
 Alamat : ...........................................................  Alamat : ...........................................................

2. Keluhan 2. Keluhan
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3. Nama Penyakit : a. Gigi Berlubang/karies 5. Nama Penyakit : a. Gigi Berlubang/karies


b. Gigi Goyang b. Gigi Goyang
c. Gusi Bengkak/berdarah c. Gusi Bengkak/berdarah
d. Lain-lain d. Lain-lain
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4. Nasihat 3. Nasihat
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Sumpiuh,............................. Sumpiuh,.............................

Kader Pemeriksa Kader Pemeriksa

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