Uas P17325115064 Neisyaannisa

KEMENTERIAN KESEHATAN R.
I
POLITEKNIK KESEHATAN BANDUNG
JURUSAN KEPERAWATAN GIGI
JL. PRO. EYCKMAN NO. 40 TLP. 2033630
BANDUNG
KARTU SURVEY KESEHATAN GIGI DAN MULUT

USAHA KESEHATAN GIGI MASYARAKAT
NAMA: Adang Gender: 1P= 1 No. Resp.: 1
W=2 Tanggal : 06 01 2017
Umur: 12 tahun Pekerjaan (orang tua/wali) : Wiraswasta
ALAMAT: Kp. Babakan RT,RW,Kelurahan: 01 12 Majasetra
KANAN KIRI
Keadaan gigi B E
DIAGNOSA DA G3 0 0 0 0
Letak Caries M 1 0 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 KODE:
DIAGNOSA A A PS A A A A A A A A PS EG A 0 1
Letak Caries O 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O 0 0 0 KMD-GI =
DIAGNOSA A EA PS A A A A A A A A PS A A 1 0 KMD-ART
Keadaan gigi 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 KMP VITA
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O O KMA = A
DIAGNOSA EA DA 1 0 0 0 PERSISTE
Keadaan gigi B B 1 0 0 0 GOYANG
Segment Segment Segment

Plaque Score Calculus Score D= 2 d= 3
1 0 1 DI 1 0 1 CI M= 0 e= 1
0 1 0 1 0.67 0 1 0 1 0.67 F= 0 f= 0
OHI - S = 1.33 ____ ____
Artinya : SEDANG DMF = 2 def = 4
CPITN
Gigi Index Score Segmen JumlahKode
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 1 1
0 17 46 41 31 36 37 0 0 0 1 1 0 0 0 1 0 0 0
0
1. DIAGNOSA 2. RENCANA PERAWATAN

1.1. Keadaan gigi : GT GS 2.1. Kebersihan Mulut :
- Gigi sehat =0 26 16 = A - Tak memerlukan scaling = 0
- Gigi lubang/karies =1 1 3= B - Memerlukan scaling = 1 3
- Tumpatan dgn karies =2 1 0= C - Instruksi menyikat gigi = 2
- Tumpatan tanpa karies =3 0= D - Memerlukan scaling dan = 3 1 3
- Gigi dicabut karena karies =4 0 1= E intruksi menyikat gigi 1
- Gigi dicabut karena sebab lain =5 0 -
- Sealant =6 0 0= F 2.2. CPITN
- Mahkota khusus =7 0 0= G - Tidak memerlukan perawatan = 0
- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan mulut = 1
- Gigi tidak termasuk kriteria =9 0 - - Memerlukan Scaling dan EIKM = 2
di atas - Memerlukan Scaling dan EIKM = 3
- Memerlukan Perawatan Khusus dan EIKM = 4
1.2. Keadaan penyakit Periodental :
- Sehat =0 2.2. Konservasi : GT GS
- Gingivitis pada satu segment =1 0 0 - Tumpatan ART 1 3 gigi
- Gingivitis lebih satu segment =2 0 1 - Tumpatan GI 1 0 gigi
- Pocket pada satu segment =3 0
- Pocket lebih dari satu segment =4 0
2.3. Pencabutan : CE INF
1.3. Keadaan Pathologi Mulut : - Gigi sulung 1 0 gigi
- Tak ada =0 - Gigi tetap 0 0 gigi
- Ada =1
2.4. Observasi :
1.4. Kelainan Dentofacial :
- Tak ada kelainan =0
- Ada kelainan =1
1.5. Kebersihan Mulut :

- Baik =0 2
- Tak bersih satu segment =1 2.5. Dirujuk ke : Puskesmas
- Tak bersih lebih satu segment =2 4 *Keterangan : Exo
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
VITAL = PV LABIAL = L
0
NONVITAL = PN PALATAL = P
=A RK = Rampan Karies
ISTENSI = PS
NG °3/°4 = G3/G4
1
KEMENTERIAN KESEHATAN R.I
BANDUNG

NAMA: Anisa Pratiwi Gender: 2P= 1 No. Resp.: 2
W=2 Tanggal : 06 01 2017
Umur: 6 tahun Pekerjaan (orang tua/wali) : IRT
KANAN KIRI
Keadaan gigi B A A A A A A A F B
DIAGNOSA DA EA 1 0 0 0
Letak Caries M O O 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 KODE:
DIAGNOSA A A 0 0
Letak Caries 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries 0 0 0 KMD-GI =
DIAGNOSA A PS A A 0 0 KMD-ART
Keadaan gigi 0 0 0 0 0 0 KMP VITA
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA EA G4 DA 1 0 0 0 PERSISTE
Keadaan gigi B A A A - A A A B 1 0 0 1 GOYANG

2 1 2 DI 1 0 1 CI M= 0 e= 0
0 2 1 2 1.67 0 1 0 1 0.67 F= 0 f= 0
OHI - S = 2.33 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 0 0
0 17 46 41 31 36 37 0 0 0 2 2 0 0 0 2 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
- Tak bersih satu segment =1 2.5. Dirujuk ke :
- Tak bersih lebih satu segment =2 6 *Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Asep Ramdan Gender: 1P= 1 No. Resp.: 3
W=2 Tanggal : 06 01 2017
Umur: 7 tahun Pekerjaan (orang tua/wali) : POLRI
ALAMAT: Kp. Manirancan RT,RW,Kelurahan: 01 12 Majasetra
KANAN KIRI
Keadaan gigi B A A A A A F B
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 KODE:
DIAGNOSA A A A A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A A PS A PS A 0 0 KMD-ART
Keadaan gigi 0 0 0 0 0 0 0 0 KMP VITA
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA EA G4 G4 DA 1 0 0 0 PERSISTE
Keadaan gigi B A A - - A A B 1 0 0 2 GOYANG

3 1 3 DI 2 0 1 CI M= 0 e= 0
0 3 1 3 2.33 0 2 0 1 1 F= 0 f= 0
OHI - S = 3.33 ____ ____
Artinya : BURUK DMF = 0 def = 4
CPITN
17 16 11 21 26 27 0 2 0 0 1 0 2 0 1 2 2
0 17 46 41 31 36 37 0 0 2 2 2 1 0 2 2 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Ashri Azizah N Gender: 2P= 1 No. Resp.: 4
W=2 Tanggal : 07 01 2017
Umur: 8 tahun Pekerjaan (orang tua/wali) : TNI
ALAMAT: Kp. Manirancan RT,RW,Kelurahan: 06 6 12 Majasetra
KANAN KIRI
Keadaan gigi A A A A F B
DIAGNOSA EA 1 0 0 0
Letak Caries O O 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 KODE:
DIAGNOSA A A A A A A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A A A A PS A 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O KMA = A
DIAGNOSA G4 DA 0 0 0 0 PERSISTE
Keadaan gigi A A A - A A B 1 0 0 1 GOYANG

1 0 2 DI 0 0 2 CI M= 0 e= 0
0 1 0 2 1 0 0 0 2 0.67 F= 0 f= 0
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 1 0 0 0 1 2 2
0 17 46 41 31 36 37 0 0 0 0 0 1 0 0 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Asri Anggraeni Gender: 2P= 1 No. Resp.: 5
W=2 Tanggal : 07 01 2017
Umur: 9 tahun Pekerjaan (orang tua/wali) : PNS
KANAN KIRI
DIAGNOSA EA 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 KODE:
DIAGNOSA A A A A A A 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 0 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 0 KME-GI= E
DIAGNOSA A A A A A A A A PS A 0 0 KMD-ART
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0 KMP VITA
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA G4 DA 0 0 0 0 PERSISTE
Keadaan gigi A - B 1 0 0 1 GOYANG

1 0 2 DI 0 0 2 CI M= 0 e= 0
0 1 0 2 1 0 0 0 2 0.67 F= 0 f= 0
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 1 0 0 0 1 2 2
0 17 46 41 31 36 37 0 0 0 0 0 1 0 0 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Chindy Maulidia Gender: 2P= 1 No. Resp.: 6
W=2 Tanggal : 07 01 2017
Umur: 10 tahun Pekerjaan (orang tua/wali) : Buruh
KANAN KIRI
Keadaan gigi A A
DIAGNOSA 0 0 0 0
Letak Caries 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 KODE:
DIAGNOSA A A A A A A A A A A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A A A A A A A PS A A 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries M O KMA = A
Keadaan gigi B - B 1 0 0 1 GOYANG

2 0 1 DI 0 0 0 CI M= 0 e= 0
0 2 0 2 1.17 0 0 0 0 0 F= 0 f= 0
OHI - S = 1.17 ____ ____
Artinya : BAIK DMF = 0 def = 2
CPITN
17 16 11 21 26 27 0 0 1 1 0 0 0 1 0 2 2
0 17 46 41 31 36 37 0 0 0 1 1 0 0 0 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Cintya Elsa Nurjanah Gender: 2P= 1 No. Resp.: 7
W=2 Tanggal : 08 01 2017
KANAN KIRI
Keadaan gigi - -
DIAGNOSA G3 G4 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 1 0 0 0 0 0 0 0 0 1 6 0 0 0 KODE:
DIAGNOSA A DA A PS A A A A PS A PN A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A A PS A A A A A A A A A A A 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries KMA = A
DIAGNOSA G4 0 0 0 0 PERSISTE
Keadaan gigi - 0 0 0 1 GOYANG

2 0 1 DI 0 0 0 CI M= 0 e= 0
0 1 0 2 1 0 0 0 0 0 F= 0 f= 0
OHI - S = 1 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 1 0 0 0 1 0 1 1
0 17 46 41 31 36 37 0 0 0 2 2 0 0 0 2 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Danis Husni Mahesa Gender: 1P= 1 No. Resp.: 8
W=2 Tanggal : 08 01 2017
KANAN KIRI
Keadaan gigi B B A A A A A A F B
DIAGNOSA DA DG EA 1 0 0 0
Letak Caries M D O O 1 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA A A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A A PS A 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O O O KMA = A
Keadaan gigi B F A A - A A A B 1 0 0 1 GOYANG

1 0 1 DI 0 0 0 CI M= 0 e= 0
0 1 0 1 0.67 0 0 0 0 0 F= 0 f= 1
OHI - S = 0.67 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 0 0
0 17 46 41 31 36 37 0 0 0 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
0
BANDUNG

NAMA: Desi Ratnasari Gender: 2P= 1 No. Resp.: 9
W=2 Tanggal : 07 01 2017
KANAN KIRI
Keadaan gigi A A A A A A A A F B
DIAGNOSA EA 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA A A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A A A A 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA EA 1 0 0 0 PERSISTE
Keadaan gigi B A A A A A A A 0 0 0 0 GOYANG

2 1 2 DI 1 0 1 CI M= 0 e= 0
0 2 1 2 1.67 0 1 0 1 0.67 F= 0 f= 0
OHI - S = 2.33 ____ ____
CPITN
17 16 11 21 26 27 1 2 0 0 2 1 2 0 2 0 0
0 17 46 41 31 36 37 0 1 2 0 0 2 1 2 0 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Dina Nurdiana Dewi Gender: 2P= 1 No. Resp.: 10
W=2 Tanggal : 08 01 2017
ALAMAT: Kp. Sukamanah RT,RW,Kelurahan: 04 06 Majasetra
KANAN KIRI
Keadaan gigi B F A A A A F B
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 KODE:
DIAGNOSA A A A A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A A PS A A A 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DG G4 DA 0 0 0 0 PERSISTE
Keadaan gigi F B A - A A B 1 1 0 1 GOYANG

1 0 0 DI 0 0 0 CI M= 0 e= 0
0 1 0 0 0.33 0 0 0 0 0 F= 0 f= 0
OHI - S = 0.33 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 1 1
0 17 46 41 31 36 37 0 0 0 0 0 1 0 0 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Romlah Asiah Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 31 12 2016
Umur: 10 tahun Pekerjaan (orang tua/wali) : Lain-lain
ALAMAT: Jln. Sukajadi No. 40 RT,RW,Kelurahan: 04 05 Bandung
KANAN KIRI
Keadaan gigi B A A B A
DIAGNOSA EG DG EA 1 1 0 0
Letak Caries O O O 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 9 0 9 9 0 0 0 0 9 9 9 9 9 9 0 0 0 KODE:

DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA 0 0 KMD-ART
Keadaan gigi 9 9 0 0 0 9 0 0 0 0 9 0 0 0 9 9 0 0 KMP VITA
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

DIAGNOSA 0 0 0 0 PERSISTE
Keadaan gigi A A 0 0 0 0 GOYANG

0 1 0 DI 1 0 2 CI M= 0 e= 0
0 2 0 0 0.5 0 0 1 0 0.67 F= 0 f= 0
OHI - S = 1.17 ____ ____
CPITN
15 11 26 0 0 0 0 0 0 0 0
0 46 31 36 0 0 0 0 0 0 0 0 0
0

- Gigi sehat =0 15 5=A - Tak memerlukan scaling = 0
- Tumpatan tanpa karies =3 0 0= D - Memerlukan scaling dan = 3 1
- Mahkota khusus =7 0 0= G - Tidak memerlukan perawatan
- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan mulut
- Gigi tidak termasuk kriteria =9 17 - - Memerlukan Scaling dan EIKM
di atas - Memerlukan Scaling dan EIKM
- Memerlukan Perawatan Khusus dan EIKM
- Tak ada =0 0 - Gigi tetap 0 0 gigi
- Ada =1
2.4. Observasi :
- Tak ada kelainan =0 0
- Ada kelainan =1

- Baik =0 2
- Tak bersih satu segment =1 2.5. Dirujuk ke : Puskesmas Sukajadi
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
ONVITAL = PN PALATAL = P
A RK = Rampan Karies
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 0
= 3
= 4
0 3
0 0
BANDUNG
KARTU SURVEY KESEHATAN GIGI DAN M

NAMA: Deva Budi Permata Gender: 2P= 1 No. Resp.:

W=2 Tanggal :
Umur: 6 tahun Pekerjaan (orang tua/wali) :
ALAMAT: Jln. Kartini II No. 21 RT,RW,Kelurahan:
KANAN
Keadaan gigi A A A A
DIAGNOSA
Letak Caries
55 54 53 52 51 61
Keadaan gigi 9 9 9 9 9 9 9 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 9 9 9 9 9 0 0
85 84 83 82 81 71
Letak Caries O O
DIAGNOSA PV EG
Keadaan gigi B B A A
Segment Segment
Plaque Score Calculus Score

0 0 0 DI 0 0
0 1 0 1 0.3333 0 1 1
OHI - S = 0.833333
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
1.1.
Keadaan gigi : GT GS
- Gigi sehat =0 4 11 = A
- Gigi lubang/karies =1 0 0= B
- Tumpatan dgn karies =2 0 0= C
- Tumpatan tanpa karies =3 0 0= D
- Gigi dicabut karena karies =4 0 0= E
- Sealant =6 0 0= F
- Mahkota khusus =7 0 0= G
- Gigi tidak tumbuh =8 0 -
- Gigi tidak termasuk kriteria =9 28 -
di atas
1.2.
Keadaan penyakit Periodental :
- Sehat =0
- Gingivitis pada satu segment =1 0 0
- Gingivitis lebih satu segment =2 0 3
1.3.
Keadaan Pathologi Mulut :
- Tak ada =0 0
- Ada =1
1.4.
Kelainan Dentofacial :
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
- Tak bersih satu segment =1
- Tak bersih lebih satu segment =2 2
KESEHATAN GIGI DAN MULUT
EHATAN GIGI MASYARAKAT
No. Resp.: 02
02 01 2017
Pekerjaan (orang tua/wali) : Lain-lain
RT,RW,Kelurahan: 01 11 Bandung
KIRI
A A B B
EG EG 0 2 0 0
O O 0 0 0 0
62 63 64 65 0
9 9 9 9 9 9 9 0 0 0 KODE:
0 0
0 0 DIAGNOSA LETAK CARIES
22 23 24 25 26 27 28 KME-ART= EA MESIAL = M
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D
0 0 0 KMD-GI = DG OCLUSAL = O
0 0 KMD-ART = DA BUCCAL = B
9 9 9 9 9 9 9 0 0 KMP VITAL = PV LABIAL = L
72 73 74 75 0 >0 0 KMP NONVITAL = PN PALATAL = P

O KMA = A RK = Rampan Kar
EG 0 2 0 0 PERSISTENSI = PS
A A B A 0 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 0 d= 0
0 CI M= 0 e= 0
1 0.5 F= 0 f= 0
____ ____
DMF = 0 def = 0
Segmen JumlaKode
3 0 3 0 1 1
1 0 1 0 1 3
0
2. RENCANA PERAWATAN
- Tak memerlukan scaling = 0
- Memerlukan scaling = 1 3
- Instruksi menyikat gigi = 2
- Memerlukan scaling dan = 3 1 3
intruksi menyikat gigi 1
2.2. CPITN
- Tidak memerlukan perawatan = 0
- Edukasi Instruksi Kesehatan mulut = 1
- Memerlukan Scaling dan EIKM = 2 3
- Memerlukan Scaling dan EIKM = 3
2.2. Konservasi : GT GS
- Tumpatan ART 0 0 gigi
- Tumpatan GI 0 4 gigi

- Gigi sulung 0 0 gigi
- Gigi tetap 0 0 gigi
2.4. Observasi :
2.5. Dirujuk ke : Puskesmas Sukajadi

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG
KARTU SURVEY KESEHATAN GIG

USAHA KESEHATAN GIGI MASYA
NAMA: Eristia Pradina Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jln. Raya No. 5
KANAN
Keadaan gigi A
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 9 0 1 0 9 0 0
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries O O
DIAGNOSA EG EG
Keadaan gigi 9 9 1 1 0 9 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Keadaan gigi A
Segment Segment

0 0 0 DI 1
0 0 0 0 0 0 1
OHI - S = 1
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
1.1. Keadaan gigi : GT GS
- Gigi sehat =0 17 4
- Gigi lubang/karies =1 5 0
- Tumpatan dgn karies =2 0 0
- Tumpatan tanpa karies =3 0 0
- Gigi dicabut karena karies =4 0 0
- Gigi dicabut karena sebab lain =5 0
- Sealant =6 0 0
- Mahkota khusus =7 0 0
- Gigi tidak tumbuh =8 0
- Gigi tidak termasuk kriteria =9 10
di atas

- Sehat =0
1.3. Keadaan Pathologi Mulut :

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 0
RVEY KESEHATAN GIGI DAN MULUT
HA KESEHATAN GIGI MASYARAKAT
No. Resp.: 03
Tanggal : 04 01 2017
RT,RW,Kelurahan: 03 11 Tanjungsari
KIRI
A
0 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 0 0 0 0 0 KODE:
0 1
0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
O O 0 0 0 KMD-GI = DG
EG EG 0 4 KMD-ART = DA
0 0 9 0 1 1 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

KMA = A
0 0 0 0 PERSISTENSI = PS
A 0 0 0 0 GOYANG
Segment
Calculus Score D= 5 d= 0
1 1 CI M= 0 e= 0
1 1 1 F= 0 f= 0
____ ____
DMF = 5 def = 0
Segmen JumlaKode
0 1 2 0 2 0 0 0
2 0 2 2 2 0 0 0
0
=A - Tak memerlukan scaling = 0
=B - Memerlukan scaling = 1 1
=C - Instruksi menyikat gigi = 2
=D - Memerlukan scaling dan = 3 1
=E intruksi menyikat gigi 3
-
=F 2.2. CPITN
=G - Tidak memerlukan perawatan
- - Edukasi Instruksi Kesehatan mulut
- - Memerlukan Scaling dan EIKM
- Memerlukan Scaling dan EIKM

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:
DIAGNOSA LETAK CARIES

KME-ART= EA MESIAL = M
KME-GI= EG DISTAL = D
KMD-GI = DG OCLUSAL = O
KMD-ART = DA BUCCAL = B
KMP VITAL = PV LABIAL = L
KMP NONVITAL = PALATAL = P

KMA = A RK = Rampan Karies
PERSISTENSI = PS
GOYANG °3/°4 = G3/G4
1
= 0
= 1
= 2 2
= 3
= 4
BANDUNG
KARTU SURVEY KESEHATAN GIGI

USAHA KESEHATAN GIGI MASYAR
NAMA: Ega Mawarni Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Pondok Indah No. 3
KANAN
Keadaan gigi D A
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 9 4 9 1 9 0 0
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 9 0 0 9 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Keadaan gigi A
Segment Segment

1 2 0 DI 0
0 1 0 1 0.8333 0 0
OHI - S = 0.833333
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26
0 45 31 36 0
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
9
URVEY KESEHATAN GIGI DAN MULUT
AHA KESEHATAN GIGI MASYARAKAT
No. Resp.: 04
Tanggal : 04 01 2017
RT,RW,Kelurahan: 01 01 Sukajadi
KIRI
A
0 0 0 0
0 0 0 0
61 62 63 64 65 0
0 1 9 0 0 0 0 0 0 0 0 KODE:
EG 0 1
P 1 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
0 0 9 0 0 0 0 0 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

KMA = A
A 0 0 0 0 GOYANG
Segment
0 0 CI M= 1 e= 0
0 0 0 F= 0 f= 1
____ ____
DMF = 3 def = 1
Segmen JumlahKode
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:

KMP NONVITAL = PPALATAL = P

PERSISTENSI = PS
2
= 0
= 1
= 2 0
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Supri Gender: 1 P=1

W=2
Umur: 7 tahun
ALAMAT: Jln. Sarijadi No. 10
KANAN
Keadaan gigi B A
DIAGNOSA EG
Letak Caries O
55 54 53 52
Keadaan gigi 9 9 1 9 0 9 0
DIAGNOSA EG
Letak Caries B
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi A
Segment
Plaque Score
2 0 0 DI
0 1 1 1 0.833333 0
OHI - S = 2.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
1.1. Keadaan gigi : GT
- Gigi sehat =0 11
- Gigi lubang/karies =1 1
- Tumpatan dgn karies =2 0
- Tumpatan tanpa karies =3
- Gigi dicabut karena karies =4 0
- Sealant =6 3
- Mahkota khusus =7 0
di atas

- Sehat =0
- Gingivitis pada satu segment =1 0
- Gingivitis lebih satu segment =2 0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 05 01 2017
RT,RW,Kelurahan: 01 01 sarijadi
A
0 1 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 9 9 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 9 6 6 9 9 9 0
81 71 72 73 74 75 0
0 0 0 0
A 0 0 0 0
Segment Segment
Calculus Score D= 1
2 2 3 CI M= 0
2 1 2 2 F= 0
____
DMF = 1
Score Segmen
1 1 1 1 1 0
2 2 2 2 2 0
GS 2.1. Kebersihan Mulut :
4=A - Tak memerlukan scaling
1= B - Memerlukan scaling
0= C - Instruksi menyikat gigi
0= D - Memerlukan scaling dan
0= E intruksi menyikat gigi
-
0= F 2.2. CPITN
0= G - Tidak memerlukan perawatan
2.2. Konservasi : GT
0 - Tumpatan ART 0
2 - Tumpatan GI 1
2.3. Pencabutan : CE
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1
0 DIAGNOSA LETAK CARIES
0 0 KMD-GI = DG OCLUSAL = O
0 KMD-ART = DA BUCCAL = B
0 KMP VITAL = PV LABIAL = L
>0 0 KMP NONVITAL = PN PALATAL = P

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Janita Putri Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jln. Raya Antapani no.235
KANAN
Keadaan gigi A
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA EG EG
Letak Caries B P
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA DG
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi A
Segment
Plaque Score
2 1 1 DI
0 2 1 2 1.5 0
OHI - S = 3.666667
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 35 0
1. DIAGNOSA
- Gigi sehat =0 7
- Sealant =6 6
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 05 01 2017
RT,RW,Kelurahan: 15 01 Antapani
A
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 6 1 1 9 9 0
EG DA 0
O O 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 9 4 6 9 9 9 0
81 71 72 73 74 75 0
0 0 0 0
A 0 0 0 0
Segment Segment
Calculus Score D= 5
2 1 3 CI M= 1
2 2 3 2.166667 F= 0
____
DMF = 6
Score Segmen
2 0 2 2 2 0
2 3 1 2 3 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 3
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
3

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
0 0
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Rachmi Nurhidayanti Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Sripemandang No. 8
KANAN
Keadaan gigi A
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DA EG
Letak Caries O O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi A
Segment
Plaque Score
1 0 1 DI
0 1 1 1 0.833333 0
OHI - S = 1.333333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 14
- Sealant =6 3
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 06 01 2017
RT,RW,Kelurahan: 04 06 Baleendah
A A
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 6 9 9 9 9 0
0
1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 9 9 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 2
Score Segmen
1 1 1 1 1 0
1 1 1 1 1 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Rifky Pratama Gender: 1P= 1

W=2
Umur: 6 tahun
ALAMAT: Jln. Suramadu No. 87
KANAN
Keadaan gigi A A
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi A A A
Segment
Plaque Score
2 2 2 DI
0 2 1 2 1.833333 0
OHI - S = 4
Artinya : BURUK
CPITN
Gigi Index
15 11
0 31 0
1. DIAGNOSA
- Gigi sehat =0 9
- Tumpatan tanpa karies =3 0
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 04 01 2017
A A A
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 9 9 9 9 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 9 9 9 9 9 9 0
81 71 72 73 74 75 0
0 0 0 0
A A A 0 0 0 0
Segment Segment
Calculus Score D= 0
3 2 1 CI M= 0
2 3 2 2.166667 F= 0
____
DMF = 0
Score Segmen
1 1 1 1 1 0
2 2 0 2 2 0
11 = A - Tak memerlukan scaling
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Ciumbuleuit
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEHATA

USAHA KESEHATAN GIG
NAMA: Bima Agung Putra Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Lalangbuana No. 53
KANAN
Keadaan gigi A
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi A A
Segment
Plaque Score
2 1 1 DI
0 1 1 1 1.166667 0
OHI - S = 2.333333
Artinya : SEDANG
CPITN
Gigi Index
16 11 25
0 45 31 35 0
1. DIAGNOSA
- Gigi sehat =0 7
- Sealant =6 4
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
RTU SURVEY KESEHATAN GIGI DAN MULUT
No. Resp.: 09
Tanggal : 05 01 2017
A
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 4 6 9 9 9 0 0
0 0
0 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 0
0 0
0 0 0 9 6 6 9 9 9 0 0
81 71 72 73 74 75 0 >0
0 0 0 0
A 0 0 0 0
Segment Segment
Calculus Score D= 2
2 1 1 CI M= 3
1 1 1 1.166667 F= 0
____
DMF = 5
Score Segmen
0 1 0 0 1 0
1 1 0 1 1 0
5=A - Tak memerlukan scaling =
0= B - Memerlukan scaling =
0= C - Instruksi menyikat gigi =
0= D - Memerlukan scaling dan =
-
0= F 2.2. CPITN
0 - Tumpatan ART 0 0
2 - Tumpatan GI 1 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:

0 KMD-GI = DG OCLUSAL = O
0 KMP NONVITAL = PN PALATAL = P

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
JumlaKode
3 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: Della Imaisa Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Cibarengkok No. 56
KANAN
Keadaan gigi A
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA EG
Letak Caries B
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi A
Segment
Plaque Score
1 0 0 DI
0 2 1 0 0.67 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 10
- Sealant =6 4
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 06 01 2017
ART GI
A
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 6 5 1 9 9 0
DG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
P 0
EG 0
0 0 1 9 0 0 0 9 9 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 4
1 0 0 CI M= 1
1 2 1 0.8333333 F= 0
____
DMF = 5
Score Segmen
1 1 1 1 1 0
1 1 1 1 1 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 4
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA K
NAMA: Anggisa Aldefiona Gender: 2P= 1

W=2
Umur: 7 tahun
ALAMAT: Jl. Tanjakan mama utara no 8
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O O
DIAGNOSA EA EG
Segment
Plaque Score
0 1 0 DI
0 0 0 0 0.17 0
OHI - S = 0.17
Artinya : BAIK
CPITN
Gigi Index
X X 11 X X -
1 - X X 31 X X 1
1. DIAGNOSA
- Gigi sehat =0 2
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
USAHA KESEHATAN GIGI SEKOLAH
No. Resp.: 01 Pekerjaan (orang tua/w

Tanggal : 01 12 2016
Tempat tanggal lahir: Bandung 2 Desember 2009
RT,RW,Kelurahan: 02 03 Padalarang
- A A A A A
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 9 9 9 9 9 9 9 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 9 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
PS 1 1 1 0
A A A A A A 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
0 0 0 0 F= 0
____
DMF = 0
Score Segmen
X X 0 0 X - 0 0 0
- X X 0 X X 0 0 0
1-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
1
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
Pekerjaan (orang tua/wali) : TNI
KIRI
0 0 KODE:
0
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
0 KMD-ART = DA
0 KMP VITAL = PV
>0 0 KMP NONVITAL = PN

KMA = A
PERSISTENSI = PS
d= 2
e= 0
f= 0
____
def = 2
Jumlah ScKode
0 0
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
= 0
= 1
= 2 0
= 3
= 4
GS
1 gigi
1 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVE
USAHA
NAMA: Elmira Maulida Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jl. Raya Padalarang no 87
KANAN
Keadaan gigi - - - -
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O
DIAGNOSA A PS
Keadaan gigi E E A -
Segment
Plaque Score
2 0 0 DI
0 0 0 1 0.5 0
OHI - S = 0.5
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 X -
1 - X 46 31 X X 1
1. DIAGNOSA
- Gigi sehat =0 21
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 02
Tanggal : 01 12 2016
Tempat tanggal lahir: Bandung 3 Desember 2005
RT,RW,Kelurahan: 02 05 Padalarang
- - - - - A
0 0 0
0 0 0
51 61 62 63 64 65
1 0 0 0 0 0 9 9 9
EA PS
M
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 0 0 0 0 0 0 9 9
81 71 72 73 74 75
0 0 1
- - - E - E 0 0 0
Segment Segment
Calculus Score D=
0 0 0 CI M=
0 0 0 0 F=
____
DMF =
Score Segmen
X 0 0 0 X - 0 0
- X 0 0 X X 0 0
14 -
0= F 2.2. CPITN
2.2. Konservasi :
0 - Tumpatan ART
0 - Tumpatan GI
2.3. Pencabutan :
- Gigi sulung
0 - Gigi tetap
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
Pekerjaan (orang tua/wali) : POLRI
KIRI
0
0
0
0 0 0 KODE:
1 0
0 0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
0 0 KMP VITAL = PV
0 >0 0 KMP NONVITAL = PN

KMA = A
0 PERSISTENSI = PS
0 GOYANG °3/°4 = G3/G4
1 d= 0
0 e= 4
0 f= 0
____
1 def = 4
Jumlah ScKode
0 0 0
0 0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
= 0
= 1
= 2 0
= 3
= 4
GT GS
1 0 gigi
0 0 gigi
CE INF
0 1 gigi
0 0 gigi
as Ciumbuleuit
BANDUNG
KARTU SURV
USAH
NAMA: Qiana Umaiza Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jl. Puri Fajar no 67
KANAN
Keadaan gigi E - B -
DIAGNOSA G4
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O
DIAGNOSA EA
Keadaan gigi - B - -
Segment
Plaque Score
0 1 0 DI
0 0 1 0 0.33 0
OHI - S = 0.33
Artinya : BAIK
CPITN
Gigi Index
X X 11 X X -
1 - X X 31 X X 1
1. DIAGNOSA
- Gigi sehat =0 11
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 03
Tanggal : 01 12 2016
Tempat tanggal lahir: Bandung 6 Juni 2005
RT,RW,Kelurahan: 05 10 Cimahi
- - A A A B
G3 0 0 0
O 0 0 1
51 61 62 63 64 65
0 0 9 9 9 9 9 9 9
PS
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 9 9 9 0 0 9 9 9
81 71 72 73 74 75
PS 1 0 1
A A A A - - 0 0 0
Segment Segment
Calculus Score D=
0 0 0 CI M=
0 0 0 0 F=
____
DMF =
Score Segmen
X X 0 0 X - 0 0
- X X 0 X X 0 0
4-
0= F 2.2. CPITN
2.2. Konservasi :
0 - Tumpatan ART
0 - Tumpatan GI
2.3. Pencabutan :
- Gigi sulung
0 - Gigi tetap
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
Pekerjaan (orang tua/wali) : Buruh
KIRI
0
1
0
0 0 0 KODE:
0 0
0 0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
0 0 KMP VITAL = PV

KMA = A
0 PERSISTENSI = PS
0 GOYANG °3/°4 = G3/G4
0 d= 8
0 e= 1
0 f= 0
____
0 def = 9
Jumlah ScKode
0 0 0
0 0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
= 0
= 1
= 2 0
= 3
= 4
GT GS
0 1 gigi
0 0 gigi
CE INF
2 1 gigi
0 0 gigi
as Ciumbuleuit
BANDUNG
KARTU SURVEY
USAHA KE
NAMA: Rizky Farel Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: Jl. Cihampelas no 77
KANAN
Keadaan gigi E - - -
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 1 0 DI
0 2 1 0 0.83 0
OHI - S = 0.83
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 X -
1 - 47 46 31 36 X 1
1. DIAGNOSA
- Gigi sehat =0 21
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0

Tanggal : 01 12 2016
Tempat tanggal lahir: Bandung 8 Oktober 2003
- A A - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 9 9 9 0
PS PS 0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EA 1
0 0 0 0 0 1 0 9 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 1
0 0 0 CI M= 0
0 0 0 0 F= 0
____
DMF = 1
Score Segmen
X 0 0 0 X - 0 0 0
- 0 0 0 0 X 0 0 0
17 -
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
Pekerjaan (orang tua/wali) : Swasta
KIRI
0 0 KODE:
0
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
0 KMD-ART = DA
0 KMP VITAL = PV

KMA = A
PERSISTENSI = PS
d= 0
e= 1
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
= 0
= 1
= 2 0
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KE
NAMA: Alvin Fadillah Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: Jl. Cibarengkok no 89
KANAN
Keadaan gigi E B - -
DIAGNOSA DA
Letak Caries O
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 1 1 DI
0 1 1 0 0.83 0
OHI - S = 0.83
Artinya : BAIK
CPITN
Gigi Index
X X 11 26 X -
1 - X X 31 X X 1
1. DIAGNOSA
- Gigi sehat =0 20
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0

Tanggal : 01 12 2016
Tempat tanggal lahir: Bandung 11 Juli 2006
RT,RW,Kelurahan: 03 12 Sukabungah
- - - - E -
0 0 0 0
1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 8 9 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 9 9 9 0
81 71 72 73 74 75 0
PS PS 0 0 2 0
A A - - - - 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
0 0 0 0 F= 0
____
DMF = 0
Score Segmen
X X 0 0 X - 0 0 0
- X X 0 X X 0 0 0
15 -
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
Pekerjaan (orang tua/wali) : Wiraswasta
KIRI
0 0 KODE:
0
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
0 KMD-ART = DA
0 KMP VITAL = PV

KMA = A
PERSISTENSI = PS
d= 1
e= 2
f= 0
____
def = 3
Jumlah ScKode
0 0
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
=
=
=
=
=
GS
1 gigi
0 gigi
INF
2 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KE
NAMA: Nevi Nuraeni Gender: 2P= 1

W=2
Umur: 9 tahun
ALAMAT: Jl. Ciburial no 7
KANAN
Keadaan gigi C B - -
DIAGNOSA DA
Letak Caries O
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA PS
85 84 83 82
Letak Caries
DIAGNOSA A A
Keadaan gigi B B - -
Segment
Plaque Score
1 1 1 DI
0 1 1 0 0.83 0
OHI - S = 0.83
Artinya : BAIK
CPITN
Gigi Index
X X 11 26 X -
1 - X X 31 X X 1
1. DIAGNOSA
- Gigi sehat =0 18
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0

Tanggal : 02 12 2016
Tempat tanggal lahir: Cimahi 18 Mei 2007
RT,RW,Kelurahan: 03 14 Ngamprah
- - - - - -
0 0 0 0
1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 9 9 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 9 9 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
0 0 0 0 F= 0
____
DMF = 0
Score Segmen
X X 0 0 X - 0 0 0
- X X 0 X X 0 0 0
16 -
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
0 KMD-ART = DA
0 KMP VITAL = PV

KMA = A
PERSISTENSI = PS
d= 4
e= 0
f= 1
____
def = 5
Jumlah ScKode
0 0
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
=
=
=
=
=
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
C
BANDUNG
KARTU SURVEY
USAHA KE
NAMA: Vera Virganita Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jl. Talang Atas no 98
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 2 1 DI
0 2 1 2 1.67 0
OHI - S = 1.67
Artinya : SEDANG
CPITN
Gigi Index
X X 11 26 X -
1 - X 46 31 36 X 1
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0

Tanggal : 02 12 2016
Tempat tanggal lahir: Bandung 10 November 2005
RT,RW,Kelurahan: 04 02 Ngamprah
- - - B - -
G3 0 0 0 0
0 0 1 0
51 61 62 63 64 65
0 0 0 0 0 0 0 9 9 0
PS 0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
PS 1
0 0 0 0 0 0 0 9 9 0
81 71 72 73 74 75 0
G3 0 0 0 0
- B - - E E 0 0 1 0
Segment Segment
Calculus Score D= 1
0 0 0 CI M= 0
0 0 0 0 F= 0
____
DMF = 1
Score Segmen
X X 0 0 X - 0 0 0
- X 0 0 0 X 0 0 0
16 -
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 0
- Gigi sulung 2
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
0 KMD-ART = DA
0 KMP VITAL = PV

KMA = A
PERSISTENSI = PS
d= 2
e= 2
f= 0
____
def = 4
Jumlah ScKode
0 0
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
=
=
=
=
=
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
C
BANDUNG
KARTU SURVEY
USAHA KE
NAMA: Khanza Azahra Gender: 2P= 1

W=2
Umur: 8 tahun
ALAMAT: Jl. Raya Cipatat no 88
KANAN
Keadaan gigi A A - -
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries D O
DIAGNOSA DA DA
Segment
Plaque Score
2 2 2 DI
0 2 2 2 2.00 0
OHI - S = 2.00
Artinya : SEDANG
CPITN
Gigi Index
X X 11 X X -
1 - X X 31 X X 1
1. DIAGNOSA
- Gigi sehat =0 14
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0

Tanggal : 02 12 2016
Tempat tanggal lahir: Bandung 10 November 2005
RT,RW,Kelurahan: 04 04 Cipatat
B - - B A A
G4 G3 0 0 0 0
0 0 1 1
51 61 62 63 64 65
9 0 0 0 9 9 9 9 9 0
PS PS 0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
PS 0
0 0 0 0 0 0 0 9 9 0
81 71 72 73 74 75 0
G3 0 0 0 0
- B - - E E 2 0 1 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
0 0 0 0 F= 0
____
DMF = 0
Score Segmen
X X 0 X X - 0 0 0
- X X 0 X X 0 0 0
9-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 3
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
0 KMD-ART = DA
0 KMP VITAL = PV

KMA = A
PERSISTENSI = PS
d= 5
e= 2
f= 0
____
def = 7
Jumlah ScKode
0 0
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
=
=
=
=
=
GS
2 gigi
0 gigi
INF
0 gigi
0 gigi
C
BANDUNG
KARTU SURVEY
USAHA KE
NAMA: Reyhana Puspitasari Gender: 2P= 1

W=2
Umur: 7 tahun
ALAMAT: Jl. Raya Ciburuy no 98
KANAN
Keadaan gigi A A - -
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 0 0 DI
0 0 0 0 0.17 0
OHI - S = 0.17
Artinya : BAIK
CPITN
Gigi Index
X X 11 X X -
1 - X X 31 X X 1
1. DIAGNOSA
- Gigi sehat =0 14
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0

Tanggal : 02 12 2016
Tempat tanggal lahir: Bandung 30 Oktober 2009
RT,RW,Kelurahan: 05 02 Ciburuy
B - - B B A
G4 G3 G4 0 0 0 0
0 0 1 2
51 61 62 63 64 65
9 0 0 0 9 9 9 9 9 0
PS PS 0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 9 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
0 0 0 0 F= 0
____
DMF = 0
Score Segmen
X X 0 X X - 0 0 0
- X X 0 X X 0 0 0
14 -
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 3
0 - Gigi tetap 0
2.4. Observasi :
1
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
0 KMD-ART = DA
0 KMP VITAL = PV

KMA = A
PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
Jumlah ScKode
0 0
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
=
=
=
=
=
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KE
NAMA: Akbar Ferdiasyah Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: Gg. Asri 1 no 67
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA EA
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA PS
85 84 83 82
Letak Caries
DIAGNOSA G3
Keadaan gigi - - B -
Segment
Plaque Score
1 1 1 DI
0 2 2 2 1.50 0
OHI - S = 1.50
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 -
1 - 47 46 31 36 37 1
1. DIAGNOSA
- Gigi sehat =0 14
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0

Tanggal : 02 12 2016
Tempat tanggal lahir: Bandung 27 Maret 2003
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
1
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - E 0 0 1 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
0 0 0 0 F= 0
____
DMF = 0
Score Segmen
X 0 0 0 0 - 0 0 0
- 0 0 0 0 0 0 0 0
18 -
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 0
- Gigi sulung 1
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
0 KMD-ART = DA
0 KMP VITAL = PV

KMA = A
PERSISTENSI = PS
d= 1
e= 1
f= 0
____
def = 2
Jumlah ScKode
0 0
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
=
=
=
=
=
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: PUTRI AFIFAH Gender: 2P= 1 No. Resp.:
W=2 Tanggal : 01 07 2017
ALAMAT: Jl. Siliwangi No. 10 RT,RW,Kelurahan: 01 01 Baleendah
KANAN KIRI
Keadaan gigi B A A E E E E A A B
DIAGNOSA DA DG DG DG DG DA 0 0 0 0
Letak Caries M M M 2 4 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DA DG 0 0
Letak Caries O O 1 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O O 0 0 0 KMD-GI =
DIAGNOSA DA DA 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O M O KMA = A
DIAGNOSA EA DG PS G4 DA 1 0 1 0 PERSISTE
Keadaan gigi B A A E E E - A A B 1 1 0 1 GOYANG

1 0 1 DI 1 0 1 CI M= 0 e= 7
0 1 0 1 0.67 0 1 0 1 0.67 F= 0 f= 0
OHI - S = 1.33 ____ ____
CPITN
- 16 11 21 26 - - 1 0 0 1 - 1 0 1 4 2
2 - 46 41 31 36 - 2 - 1 0 0 1 - 1 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: RICKY TITO Gender: 1P= 1 No. Resp.: 02
W=2 Tanggal : 02 07 2017
ALAMAT: Kp. Jawa No. 03 RT,RW,Kelurahan: 01 02 dayeuhkolot
KANAN KIRI
Keadaan gigi - - A - - - - A - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B O 0 0 0 KMD-GI =
DIAGNOSA DA DA 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi 0 0 0 0 GOYANG

1 0 1 DI 1 0 0 CI M= 0 e= 0
0 2 0 2 1 0 2 0 2 0.83 F= 0 f= 0
OHI - S = 1.83 ____ ____
CPITN
- 16 11 21 26 - - 0 1 0 2 - 0 1 2 2 2
2 - 46 41 31 36 - 2 - 0 1 0 0 - 0 1 0 0 0
0

- Gigi dicabut karena karies =4 0 0= E intruksi menyikat gigi
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: SHANTY NOVIANTY Gender: 2P= 1 No. Resp.: 03
W=2 Tanggal : 02 07 2017
KANAN KIRI
Keadaan gigi - - - - - - - A - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B D O 0 0 0 KMD-GI =
DIAGNOSA DA DG PS DA 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi - - - - - - - - - - 0 0 0 0 GOYANG

1 0 1 DI 1 0 0 CI M= 0 e= 0
0 1 0 1 0.67 0 0 0 0 0.17 F= 0 f= 1
OHI - S = 0.83 ____ ____
CPITN
- 16 11 21 26 - - 0 1 0 1 - 0 1 1 2 2
2 - 46 41 31 36 - 2 - 0 0 0 0 - 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: ANYA GERALDINE Gender: 2P= 1 No. Resp.: 04
W=2 Tanggal : 03 07 2017
KANAN KIRI
Keadaan gigi - - - - - - - - - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O B 0 0 0 KMD-GI =
DIAGNOSA DG PS DA 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

0 0 0 DI 0 0 0 CI M= 0 e= 0
0 1 0 1 0.33 0 0 0 1 0.17 F= 0 f= 0
OHI - S = 0.5 ____ ____
CPITN
- 16 11 21 26 - - 0 1 0 1 - 0 1 1 2 2
2 - 46 41 31 36 - 2 - 0 0 0 0 - 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: AINA SHERINA Gender: 2P= 1 No. Resp.: 05
W=2 Tanggal : 05 07 2017
ALAMAT: Kp. CIGADO No. 11 RT,RW,Kelurahan: 11 07 BALEENDAH
KANAN KIRI
Keadaan gigi B B A A - - - A A A
DIAGNOSA EG DA 0 1 0 0
Letak Caries D O 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi - - - A - - - - - - 0 0 0 0 GOYANG

1 1 1 DI 0 0 1 CI M= 0 e= 0
0 1 1 1 1 0 1 0 1 0.5 F= 0 f= 1
OHI - S = 1.5 ____ ____
CPITN
- 16 11 21 26 - - 0 1 0 1 - 0 1 1 2 2
2 - 46 41 31 36 - 2 - 0 0 0 0 - 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: ALEXANDER Gender: 1P= 1 No. Resp.: 06
W=2 Tanggal : 07 07 2017
ALAMAT: Kp. CIGADO No. 11 RT,RW,Kelurahan: 11 07 BALEENDAH
KANAN KIRI
Keadaan gigi - - A - - - - A - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DA DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B D 0 0 0 KMD-GI =
DIAGNOSA DG PS DA 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 1 1 DI 1 0 1 CI M= 0 e= 0
0 2 1 2 1.33 0 1 0 1 0.67 F= 0 f= 0
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 1 0 0 1 1 2 2
0 47 46 41 31 36 37 0 0 0 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: MERRY RIANA Gender: 2P= 1 No. Resp.: 07
W=2 Tanggal : 10 07 2017
Umur: 12 tahun Pekerjaan (orang tua/wali) : Swasta
ALAMAT: GIRI HARJA 03 RT,RW,Kelurahan: 11 08 BALEENDAH
KANAN KIRI
Keadaan gigi - - - - - - - A - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DA DG EG 0 2
Letak Caries M O O M 1 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA DG PS DA DG 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

2 1 1 DI 1 0 0 CI M= 0 e= 0
0 2 1 2 1.5 0 1 0 1 0.5 F= 0 f= 0
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 1 0 0 1 1 2 2
0 47 46 41 31 36 37 0 0 0 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: JESSICA Gender: 2P= 1 No. Resp.: 08
W=2 Tanggal : 11 07 2017
KANAN KIRI
Keadaan gigi B A - - - - - A B E
DIAGNOSA DG DG 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG EG 0 2
Letak Caries M D 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA DG DA DG 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

2 1 1 DI 1 0 0 CI M= 0 e= 1
0 2 1 2 1.5 0 1 0 1 0.5 F= 0 f= 0
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 0 1 0 1 0 1 1 2 2
0 47 46 41 31 36 37 0 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: YENITA AGUSTINA Gender: 2P= 1 No. Resp.: 09
W=2 Tanggal : 13 07 2017
KANAN KIRI
Keadaan gigi B E A - - - - A B E
DIAGNOSA DG A DG A 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG EG 0 2
Letak Caries M 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA DG DA 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 1 1 DI 1 0 0 CI M= 0 e= 2
0 1 1 1 1 0 1 0 1 0.5 F= 0 f= 0
OHI - S = 1.5 ____ ____
CPITN
17 16 11 21 26 27 0 1 0 1 0 1 1 2 2
0 47 46 41 31 36 37 0 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: YUSMAN MUHAMMADGender: 1P= 1 No. Resp.: 10
W=2 Tanggal : 14 07 2017
KANAN KIRI
Keadaan gigi B E A - - - - A B E
DIAGNOSA DG A DG A 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG EG 0 2
Letak Caries M O 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 1 1 DI 0 0 0 CI M= 0 e= 2
0 1 1 1 1 0 0 0 0 0 F= 0 f= 0
OHI - S = 1 ____ ____
CPITN
17 16 11 21 26 27 1 1 0 1 1 1 1 5 2
0 47 46 41 31 36 37 0 1 0 0 1 1 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Asri Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 01 01 2017
ALAMAT: Jl. Sukajadi 01 RT,RW,Kelurahan: 01 01 Sukajadi
KANAN KIRI
Keadaan gigi - - - - - - - - - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA DG EG 0 1 KMD-ART
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

Letak Caries - - B - - - - - - - KMA = A
Keadaan gigi O 0 0 0 0 GOYANG

0 1 0 DI 0 0 0 CI M= 0 e= 0
0 2 0 1 0.67 0 2 1 2 0.83 F= 0 f= 0
OHI - S = 1.5 ____ ____
CPITN
16 11 26 0 0 0 0 0 0 0 0
0 46 31 36 0 2 2 2 0 2 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
1 1
0 0
BANDUNG

NAMA: Balla Gender: 2P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: Jl. Sukajadi 02 RT,RW,Kelurahan:
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries - - A - - -
55 54 53 52 51 61
Keadaan gigi 9 0 0 0 0 9 0 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries O M
DIAGNOSA EG EG
Keadaan gigi 9 1 1 0 0 0 0 0 0
85 84 83 82 81 71
Letak Caries - - - - - -
DIAGNOSA
Keadaan gigi
Segment Segment

1 0 0 DI 0 0
0 1 1 1 0.6667 0 1 1
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26 0
0 46 31 36 0
1. DIAGNOSA
1.1.
- Gigi sehat =0 24 1=A
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
01 01 2017
KIRI
0 0 0 0
- - - - 0 0 0 0
62 63 64 65 0
0 0 0 0 0 0 9 0 0 0 KODE:
0 0
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D

- B - - KMA = A RK = Rampan Kar
DA 0 0 0 0 PERSISTENSI = PS
O 1 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 2 d= 1
0 CI M= 0 e= 0
1 0.5 F= 0 f= 0
____ ____
DMF = 2 def = 1
Segmen JumlaKode
0 0 0 0 0 0 0
3 2 2 0 3 2 1 3
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Celsea Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jl. Sukajadi 03
KANAN
Keadaan gigi - - O - -
DIAGNOSA EA
Letak Caries B
55 54 53 52 51
Keadaan gigi 9 0 1 0 0 9 0 0
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries O
DIAGNOSA EA
Keadaan gigi 9 0 6 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Keadaan gigi - - - - -
Segment Segment

1 1 1 DI 1
0 1 0 1 0.83 0 2
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 1 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 01 01 2017
KIRI
- - - - -
1 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 0 0 0 0 0 9 0 0 0 KODE:
0 1
0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
1 0 KMD-ART = DA
0 0 9 0 0 0 0 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

MOD KMA =KMA
KMA 0 0 0 1 PERSISTENSI = PS
- - B - - 0 0 0 0 GOYANG
Segment
0 1 CI M= 0 e= 0
1 1 1 F= 0 f= 0
____ ____
DMF = 1 def = 2
Segmen JumlaKode
2 0 2 2 2 0 0 0
2 2 3 0 2 3 1 3
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


KMA =KMA RK = Rampan Karies
PERSISTENSI = PS
3
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: Devy Gender: 2P= 1

W=2
Umur: 12 tahun
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries - - A - -
55 54 53 52 51
Keadaan gigi 9 1 1 0 0 9 0 0
DIAGNOSA EG EG
Letak Caries O O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 0 0 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

0 1 0 DI 1
0 1 0 1 0.5 0 1
OHI - S = 1.333333
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 1 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
9
No. Resp.: 04
Tanggal : 01 01 2017
KIRI
O
DA 0 0 0 0
- - B - - 1 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 0 9 0 0 0 KODE:
0 2
- 0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
O 0 0 0 KMD-GI = DG
EA 1 0 KMD-ART = DA
0 0 0 0 0 6 0 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

KMA = A
- - - - - 0 0 0 0 GOYANG
Segment
0 0 CI M= 0 e= 0
2 1 0.833333 F= 0 f= 0
____ ____
DMF = 2 def = 1
Segmen JumlahKode
2 0 0 2 0 0 0 0
2 2 2 0 2 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Endah Gender: 2P=1

W=2
Umur: 11 tahun
KANAN
DIAGNOSA EA
Letak Caries O
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
0 0 0 DI
0 2 1 3 1 0
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 22
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 01 01 2017
- - - A - -
1 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EG 0
0 0 0 9 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
2 1 2 0.833333 F= 0
____
DMF = 2
Score Segmen
0 0 0 0 0 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Fitri Gender: 2P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi - - A -
Segment
Plaque Score
3 1 2 DI
0 2 1 3 2 0
OHI - S = 4.166667
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 24
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 01 01 2017
- - - B - -
DA 0 0 0 0
O 1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EA 1
0 0 0 0 0 0 6 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 0 3 CI M= 0
3 2 3 2.166667 F= 0
____
DMF = 2
Score Segmen
2 0 2 2 2 0
3 2 2 0 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Giselle Gender: 2P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O
DIAGNOSA EA
Segment
Plaque Score
2 1 1 DI
0 1 1 1 1.166667 0
OHI - S = 2.5
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 01 01 2017
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0
EA 1
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
1 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 0 2 CI M= 0
2 1 1 1.333333 F= 0
____
DMF = 2
Score Segmen
2 0 2 2 2 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Hani Gender: 2P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 2 2 2 1.666667 0
OHI - S = 2.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 16
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 01 01 2017
- - - A - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 9 9 0
DG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
M 0
EG 0
1 0 0 9 0 0 0 9 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 4
1 0 1 CI M= 0
2 1 2 1.166667 F= 0
____
DMF = 4
Score Segmen
1 0 1 1 1 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 2
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: Indah Gender: 2P= 1

W=2
Umur: 11 tahun
KANAN
Keadaan gigi B - A -
DIAGNOSA DA
Letak Caries O
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 0 1 DI
0 1 0 1 0.833333 0
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 01 01 2017
- - - - - -
0 0 0 0
1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0 0
0 1
0 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 0
0 0
0 0 0 9 0 0 0 0 9 0 0
81 71 72 73 74 75 0 >0
B
EA 1 0 0 0
- - - B - - 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
2 2 2 1 F= 1
____
DMF = 1
Score Segmen
1 0 1 1 1 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
2 - Tumpatan GI 1 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
JumlaKode
2 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: Jasmine Gender: 2P= 1

W=2
Umur: 11 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries M - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries MOD
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 2 1 1 1.33 0
OHI - S = 3.166667
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 01 01 2017
ART GI
- - - B - -
KMA 0 0 0 1
MOD 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 0 0 0
EG 0
- - - - - - O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 9 0 1 0 0 0
81 71 72 73 74 75 0
O
DA 0 0 0 0
- - - - B - 1 0 0 0
Segment Segment
Calculus Score D= 4
2 1 1 CI M= 0
3 1 3 1.8333333 F= 0
____
DMF = 4
Score Segmen
2 1 1 2 1 0
3 2 2 0 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
3 - Tumpatan GI 3
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

KMA = KMA RK = Rampan Karies
PERSISTENSI = PS
d= 2
e= 0
f= 0
____
def = 2
Jumlah ScKode
1 1
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
1 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Amelia Putri Gender: 2P= 1 No. Resp.: A 02
W=2 Tanggal : 04 01 2017
ALAMAT: Jl. Tamansari no. 43 Bandung RT,RW,Kelurahan: 01 04 Taman Sari
KANAN KIRI
Keadaan gigi A A A B B A A
DIAGNOSA A DG G3 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG EA 1 1
Letak Caries O B 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DA PS PS 0 0 2 0 PERSISTE
Keadaan gigi A B A B A A B A A A 1 0 0 0 GOYANG

2 0 1 DI 1 0 0 CI M= 0 e= 0
0 2 0 0 0.83 0 1 0 0 0.33 F= 0 f= 0
OHI - S = 1.17 ____ ____
CPITN
17 16 11 21 26 27 2 0 0 0 2 0 0 1 1
0 17 46 41 31 36 37 0 2 1 1 0 2 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Agung Nugraha Gender:1P= 1 No. Resp.: A 10

W=2 Tanggal : 04 01 2017
ALAMAT: Gg. Utama NO. 392 Sukajadi- Bandung RT,RW,Kelurahan: 02 03 Pasteur
KANAN
Keadaan gigi A A A B B A A A A
DIAGNOSA EA PS 1 0 1 0
Letak Caries L 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O B 0
DIAGNOSA DA EG 0
Keadaan gigi 9 9 1 9 9 9 0 0 0 9 9 9 9 2 9 9 1
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O
DIAGNOSA DG PS PS DA 0 0 2 0
Keadaan gigi C A A B C A A A B 1 1 0 0
Plaque Score Calculus Score D= 2

1 0 0 DI 1 0 1 CI M= 0
0 2 0 1 0.67 0 1 0 0 0.5 F= 0
OHI - S = 1.17 ____
Artinya : BAIK DMF = 2
CPITN
Gigi Index Score Segmen
17 16 11 21 26 27 2 0 0 2 2 0 2
0 17 46 41 31 36 37 0 1 0 0 0 1 1 0 1

- Gigi sehat =0 7 12 = A - Tak memerlukan scaling
- Gigi lubang/karies =1 1 4= B - Memerlukan scaling
- Tumpatan dgn karies =2 1 2= C - Instruksi menyikat gigi
- Tumpatan tanpa karies =3 0= D - Memerlukan scaling dan
- Sehat =0 2.2. Konservasi : GT
- Gingivitis pada satu segment =1 0 0 - Tumpatan ART 1
- Gingivitis lebih satu segment =2 0 2 - Tumpatan GI 1
1.3. Keadaan Pathologi Mulut : - Gigi sulung 0
- Tak ada =0 - Gigi tetap 0
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 6
e= 0
f= 0
____
def = 6
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
atan Khusus dan EIKM = 4
GS
2 gigi
1 gigi
INF
3 gigi
0 gigi
BANDUNG

NAMA: Nagita Slavia Gender: 2P= 1 No. Resp.: N 12

W=2 Tanggal : 04 01 2017
ALAMAT: Jl. Taman Cinta no. 100 Taman Layung- Bandung RT,RW,Kelurahan: 03 04 Cibodas
KANAN
Keadaan gigi A A B E
DIAGNOSA DG G3 0 0 0 0
Letak Caries O 0 1 1 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 4 0 0 9 0 0 0 0 9 0 9 1 9 9 0
DIAGNOSA EA DG 1
Letak Caries O O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0
DIAGNOSA EA 1
Keadaan gigi 9 9 1 9 0 0 0 0 0 0 0 0 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA DA PS G4 0 0 1 0
Keadaan gigi D B E 1 0 0 1

1 0 2 DI 0 0 1 CI M= 1
0 0 1 2 1 0 0 0 1 0.33 F= 0
OHI - S = 1.33 ____
Artinya : SEDANG DMF = 3
CPITN
17 16 11 21 26 27 0 0 1 2 0 1 2
0 17 46 41 31 36 37 0 0 0 1 2 0 1 2

- Gigi sehat =0 16 2=A - Tak memerlukan scaling
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
as
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 2
e= 2
f= 1
____
def = 5
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
1 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Nana Gender:1P= 1 No. Resp.: N 11

W=2 Tanggal : 04 01 2017
ALAMAT: Jl. Kesehatan blok A3 Ecykman Bandung RT,RW,Kelurahan: 06 05 Sukajadi
KANAN
Keadaan gigi B A C
DIAGNOSA PS PS 0 0 2 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 1 0 0 0 0 0 0 0 0 0 0 3 9 9 0
DIAGNOSA DG DG 0
Letak Caries O O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O L 0
DIAGNOSA PV EA 1
Keadaan gigi 9 0 1 9 0 0 0 1 0 0 0 0 0 0 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries
DIAGNOSA PS A 0 0 1 0
Keadaan gigi B C 0 0 0 0

1 1 1 DI 1 0 1 CI M= 0
0 1 1 1 1 0 1 2 1 1 F= 0
OHI - S = 2 ____
CPITN
17 16 11 21 26 27 2 0 0 2 2 0 2
0 17 46 41 31 36 37 0 0 1 2 2 2 0 1 2 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
adi
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 0
f= 0
____
def = 4
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
0 gigi
INF
3 gigi
0 gigi
BANDUNG

NAMA: Risa Cantika Gender: 2P= 1 No. Resp.: R 88

W=2 Tanggal : 04 01 2017
ALAMAT: Jl. Pasir Layung no 108 Bandung RT,RW,Kelurahan: 01 05 Padasuka
KANAN
Keadaan gigi A A A A A A B
DIAGNOSA PS EA 1 0 1 0
Letak Caries P 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 1 9 9 9 0 0 0 0 9 9 9 4 9 9 0
DIAGNOSA DA DG 0
Letak Caries O O 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries B 0
DIAGNOSA DG 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 9 9 9 1 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries L
DIAGNOSA DA G3 PS 0 0 1 0
Keadaan gigi B A E B A A A 1 0 1 0

1 0 1 DI 1 0 0 CI M= 1
0 0 1 1 0.67 0 1 2 0 0.67 F= 0
OHI - S = 1.33 ____
CPITN
17 16 11 21 26 27 2 0 0 0 2 0 0
0 17 46 41 31 36 37 0 1 2 2 0 1 2 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
suka
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 1
f= 0
____
def = 4
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
2 gigi
0 gigi
INF
2 gigi
0 gigi
BANDUNG

NAMA: Sri Anina 2P= 1

Gender: No. Resp.: S 12
W=2 Tanggal : 04 01 2017
ALAMAT: Grand. City View blok A 13 Bandung RT,RW,Kelurahan: 03 05 Padasuka
KANAN
Keadaan gigi A
DIAGNOSA PS 0 0 1 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 0 1 0 0 0 0 1 1 0 0 0 0 2 0 9 0
DIAGNOSA EG EG EG PV 0
Letak Caries O M M O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries B 0
DIAGNOSA EG 0
Keadaan gigi 9 0 0 0 0 0 0 0 0 0 0 0 0 3 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries
DIAGNOSA 0 0 0 0
Keadaan gigi 0 0 0 0

1 0 2 DI 0 0 1 CI M= 0
0 1 1 2 1.17 0 0 2 1 0.67 F= 0
OHI - S = 1.83 ____
CPITN
17 16 11 21 26 27 0 0 1 0 0 1 0 1 1
0 17 46 41 31 36 37 0 0 1 1 2 2 1 1 2 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
suka
KIRI
0
0 0 0 0
0 0 KODE:
3
0 0 0 0
PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
JumlahKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Putra Wijaya Gender: 1P= 1 No. Resp.: P 01

W=2 Tanggal : 04 01 2017
ALAMAT: Komp. Asri blok G6 Sukagalih RT,RW,Kelurahan: 04 01 Sederhana
KANAN
Keadaan gigi A A A A B A
DIAGNOSA EG 0 1 0 0
Letak Caries D 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 0 9 9 9 3 9 9 0
DIAGNOSA EA 1
Letak Caries B 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0
DIAGNOSA DA 0
Keadaan gigi 9 9 4 9 9 9 0 0 0 0 9 9 9 0 9 9 1
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS PS DA 0 0 2 0
Keadaan gigi E A A A A A A B 1 0 0 0

0 0 1 DI 0 0 0 CI M= 1
0 1 1 2 0.83 0 0 2 0 0.33 F= 0
OHI - S = 1.17 ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0
0 17 46 41 31 36 37 0 0 2 1 1 0 2 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
hana
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 2
e= 1
f= 1
____
def = 4
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
1 gigi
INF
2 gigi
0 gigi
BANDUNG

NAMA: M. Rizky Permana Gender: 1P= 1 No. Resp.: M 10

W=2 Tanggal : 04 01 2017
ALAMAT: JL. Suka galih no 13 Sukamanah RT,RW,Kelurahan: 03 04 Sederhana
KANAN
Keadaan gigi B A A
DIAGNOSA PS PS PS 0 0 3 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 0 0 0 0 0 0 0 0 0 4 0 9 0
DIAGNOSA DG 0
Letak Caries O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0
DIAGNOSA PV 0
Keadaan gigi 9 9 1 0 0 0 0 0 0 0 0 0 0 0 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries
DIAGNOSA 0 0 0 0

2 1 1 DI 1 1 2 CI M= 1
0 1 1 1 1.17 0 1 0 0 0.83 F= 0
OHI - S = 2 ____
CPITN
17 16 11 21 26 27 1 1 1 0 0 1 1 1 1
0 17 46 41 31 36 37 0 1 1 1 0 2 1 1 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
hana
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
JumlahKode
5 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
0 gigi
INF
3 gigi
0 gigi
BANDUNG

NAMA: Zaky Maulana Gender: 1P= 1 No. Resp.: Z 01

W=2 Tanggal : 04 01 2017
ALAMAT: JL. Caringin no 88 Panghegar RT,RW,Kelurahan: 02 07 Panghegar
KANAN
Keadaan gigi A A A
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 1 0 0 9 0 0 0 0 9 0 0 2 9 9 0
DIAGNOSA DG PV 0
Letak Caries P O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 0 0 0 0 0 0 0 0 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O
DIAGNOSA EA PS PS DA 1 0 2 0
Keadaan gigi B A A B 1 0 0 0

2 0 2 DI 1 0 1 CI M= 0
0 1 1 1 1.17 0 1 1 1 0.83 F= 0
OHI - S = 2 ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 1 1
0 17 46 41 31 36 37 0 0 1 0 2 1 0 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
hegar
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 2
e= 0
f= 0
____
def = 2
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
2 gigi
0 gigi
INF
4 gigi
0 gigi
BANDUNG

NAMA: Joza Triyani Gender: 2P= 1 No. Resp.: J 12

W=2 Tanggal : 04 01 2017
ALAMAT: Jl. Cisaranten n0 99 Bandung RT,RW,Kelurahan: 02 04 Ujung Berung
KANAN
Keadaan gigi A A A B A A A A
DIAGNOSA DG 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 1 9 9 0
DIAGNOSA EA 1
Letak Caries L 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries B 0
DIAGNOSA EA 1
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 1 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS PS DA 0 0 2 0
Keadaan gigi A A A B A A A B 1 0 0 0

0 0 0 DI 0 0 0 CI M= 0
0 1 1 1 0.5 0 0 1 0 0.17 F= 0
OHI - S = 0.67 ____
CPITN
17 16 11 21 26 27 1 1 0 0 1 1 0
0 17 46 41 31 36 37 0 0 1 1 0 0 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
Berung
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
JumlahKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
1 gigi
1 gigi
INF
2 gigi
0 gigi
BANDUNG

NAMA: Gina Oktarina Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 22 12 2016
ALAMAT: Sukajadi bandung RT,RW,Kelurahan: 02 01 sukajadi
KANAN KIRI
Keadaan gigi - - B - - - - - - -
DIAGNOSA EA 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA EA EG 1 1 KMD-ART
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON


1 0 1 DI 1 0 1 CI M= 0 e= 0
0 1 0 1 0.67 0 0 0 1 0.5 F= 0 f= 0
OHI - S = 1.17 ____ ____
CPITN
16 11 26 1 0 2 1 2 0 2 2
46 31 36 2 0 1 2 2 1 0 0
0

- Tumpatan tanpa karies =3 0= D - Memerlukan scaling dan = 3 1
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
- Tak bersih satu segment =1 2.5. Dirujuk ke : Puskesmas Ciumbuleuit
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
2 1
0 0
BANDUNG

NAMA: Doni Gender: 1P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: Sukajadi bandung RT,RW,Kelurahan:
KANAN
Keadaan gigi - - B - - -
DIAGNOSA EA
Letak Caries O
55 54 53 52 51 61
Keadaan gigi 9 0 1 0 0 9 0 0 0
DIAGNOSA EA
Letak Caries O
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries
DIAGNOSA
Keadaan gigi 9 0 0 0 0 0 0 0 0
85 84 83 82 81 71
Letak Caries
DIAGNOSA
Keadaan gigi - - - - - -
Segment Segment

0 0 0 DI 0 0
0 1 0 1 0.3333 0 0 0
OHI - S = 0.333333
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26 0
0 46 31 36 0
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
22 12 2016
KIRI
- - - -
1 0 0 0
0 0 0 0
62 63 64 65 0
0 0 0 0 1 0 9 0 0 0 KODE:
EA 2 0
O 0 0 DIAGNOSA LETAK CARIES
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D

KMA = A RK = Rampan Kar
- - - - 0 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 2 d= 0
0 CI M= 0 e= 0
0 0 F= 0 f= 0
____ ____
DMF = 2 def = 0
Segmen JumlaKode
0 1 0 1 0 1 1
0 0 0 0 0 0 0
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Nur alfreda Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: Sukajadi bandung
KANAN
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 9 0 1 0 9 0 0
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries O
DIAGNOSA EA
Keadaan gigi 9 9 1 0 0 9 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Keadaan gigi - - A - -
Segment Segment

1 0 2 DI 1
0 2 0 2 1.17 0 1
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index Score
X 16 11 26 X X
0 X 46 31 36 X 0 X
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 23 12 2016
KIRI
- - B - -
DA 0 0 0 0
O 1 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 9 9 0 0 0 KODE:
0
1 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
1 0 KMD-ART = DA
0 0 9 0 0 0 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

KMA = A
- - - - - 0 0 0 0 GOYANG
Segment
0 1 CI M= 0 e= 0
0 1 0.666667 F= 0 f= 0
____ ____
DMF = 2 def = 1
Segmen JumlaKode
1 0 2 X - 1 2 0 2 2
1 0 2 X 0 1 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: Yogi saunan Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Sukajadi bandung
KANAN
Keadaan gigi - B - - -
DIAGNOSA EA
Letak Caries O
55 54 53 52 51
Keadaan gigi 9 9 0 0 9 0 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 0 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

2 0 0 DI 0
0 1 0 1 0.6667 0 1
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 04
Tanggal : 23 12 2016
KIRI
-
1 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 0 0 0 1 9 9 0 0 0 KODE:
DG 0 0
O 0 1 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
0 0 9 0 0 0 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

O KMA = A
EA 1 0 0 0 PERSISTENSI = PS
- - B - - 0 0 0 0 GOYANG
Segment
0 0 CI M= 0 e= 0
1 1 0.5 F= 0 f= 0
____ ____
DMF = 1 def = 2
Segmen JumlahKode
0 0 0 0 0 0 1 1
1 0 0 1 0 0 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 1
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Elycia effensi Gender: 2P=1

W=2
Umur: 11 tahun
ALAMAT: Sarijadi bandung
KANAN
DIAGNOSA DA
Letak Caries O
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 2 0 DI
0 1 0 2 1 0
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26 -
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 24 12 2016
RT,RW,Kelurahan: 05 03 Sarijadi bandung
- - - - - -
0 0 0 0
1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
B
EA 1 0 0 0
- - - B - - 0 0 0 0
Segment Segment
Calculus Score D= 0
1 0 0 CI M= 0
1 1 2 0.833333 F= 0
____
DMF = 0
Score Segmen
0 0 1 - 0 1 0
2 1 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
1 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
Jumlah ScKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
2 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Aris nuari Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Kurnia jaya manggar
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA -
85 84 83 82
Letak Caries O
DIAGNOSA EA
Segment
Plaque Score
1 0 1 DI
0 3 0 3 1.333333 0
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index
16 11 26 -
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 24 12 2016
Pekerjaan (orang tua/wali) : IRT
RT,RW,Kelurahan: 09 02 manggar
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 0 0 1 0 9 0
81 71 72 73 74 75 0
1 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 1
0 0 0 CI M= 0
2 0 2 0.666667 F= 0
____
DMF = 1
Score Segmen
2 0 2 - 2 2 0
1 0 2 0 1 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
1 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Rizki meidina Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: padang raya sukawarna
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries B
DIAGNOSA EA
Segment
Plaque Score
2 0 1 DI
0 2 1 1 1.166667 0
OHI - S = 1.666667
Artinya : SEDANG
CPITN
Gigi Index
16 11 26 -
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 25 12 2016
RT,RW,Kelurahan: 10 08 Sukawarna
- - - B - -
EA 1 0 0 0
O 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EA 1
0 0 0 0 0 0 1 0 9 0
81 71 72 73 74 75 0
1 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 1
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 1
Score Segmen
1 1 1 - 1 1 0
1 0 1 0 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
Jumlah ScKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
2 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Audisca gumilar Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Sarijadi bandung
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA DG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
0 1 0 DI
0 3 1 0 0.833333 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
16 11 26 -
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 25 12 2016
- - - B - -
EA 1 0 0 0
O 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 1 0 CI M= 0
2 1 0 0.666667 F= 0
____
DMF = 2
Score Segmen
0 0 1 - 0 1 0
1 1 0 0 1 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: Aprilianti Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: jalan sudirman no 4
KANAN
DIAGNOSA EA
Letak Caries O
55 54 53 52
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 0 1 DI
0 1 0 1 0.666667 0
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index
16 11 26 -
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 28 12 2016
RT,RW,Kelurahan: 02 01 gajah mada
- - - A - -
1 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0 0
0 0
1 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 0
0 0
0 0 0 9 0 0 0 0 9 0 0
81 71 72 73 74 75 0 >0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 1
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 1
Score Segmen
0 1 0 - 0 1 0
1 0 0 0 1 0
-
0= F 2.2. CPITN
2 - Tumpatan GI 0 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
JumlaKode
2 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: Reno Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: jalan sarijadi bandung
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 0 0 DI
0 2 1 0 0.67 0
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index
16 11 26 -
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 17
- Sealant =6 8
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 28 12 2016
ART GI
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 6 6 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EA 1
0 0 0 0 9 1 6 6 9 0
81 71 72 73 74 75 0
O
DA 0 0 0 0
- - - - B - 1 0 0 0
Segment Segment
Calculus Score D= 1
1 0 0 CI M= 0
1 0 1 0.5 F= 0
____
DMF = 1
Score Segmen
0 0 0 0 0 0
2 0 0 2 0 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Jihan H Gender: 2P= 1 No. Resp.: A001
W=2 Tanggal : 27 12 2016
ALAMAT: Jl. Eyckman no 40 RT,RW,Kelurahan: 08 03 Sukajadi
KANAN
Keadaan gigi B A A A
DIAGNOSA DA 0 0 0
Letak Caries M 1 0 0
55 54 53 52 51 61 62 63 64 65
Periodontal
Keadaan gigi 9 9 0 9 9 0 0 0 0 9 9 0 9 9
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 0 9 9 0 0 0 0 9 9 0 9 9
Periodontal
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA EG DA 0 1 0
Keadaan gigi B A A B 1 0 0

Plaque Score Calculus Score D=
1 0 0 DI 1 0 0 CI M=
0 1 0 1 0.5 0 1 0 2 0.67 F=
OHI - S = 1.167 ____
Artinya : BAIK DMF =
- Tumpatan tanpa karies =3 0 0= D - Memerlukan scaling dan
- Sealant =6 0 0= F 2.2. Konservasi :
- Mahkota khusus =7 0 0= G - Tumpatan ART
- Gigi tidak tumbuh =8 0 - - Tumpatan GI
di atas
2.3. Pencabutan :
1.2. Keadaan penyakit Periodental : - Gigi sulung
- Sehat =0 - Gigi tetap
- Gingivitis lebih satu segment =2 0 0 2.4. Observasi :

- Tak ada =0
- Ada =1
2.5. Dirujuk ke : Puskesmas Ciu
1.4. Kelainan Dentofacial : *Keterangan :
- Tak ada kelainan =0 Exo
- Ada kelainan =1 Endo
Konservasi
1.5. Kebersihan Mulut : Ortho
- Baik =0 2 Perio
- Tak bersih satu segment =1 Prosto
KIRI
0
0
0 0
0 0 0 0 0 0
0 0 0 KODE:
0 0
0 0 KMP VITAL = PV LABIAL = L
0 0 0 0 0 0
0 >0 0 KMP NONVITAL = PN PALATAL = P
0 PERSISTENSI = PS
0 GOYANG °3/°4 = G3/G4
0 d= 3
0 e= 0
0 f= 0
____
0 def = 3
= 0
= 1 3
= 2
= 3 1 3
1
GT GS
0 2 gigi
0 1 gigi
CE INF
0 0 gigi
0 0 gigi
Ciumbuleuit
BANDUNG

NAMA: Ilham R Gender: 2P= 1 No. Resp.: A002
W=2 Tanggal : 27 12 2016
ALAMAT: Jl. Muwardi no 1 RT,RW,Kelurahan: 16 20 Sukajadi
KANAN KIRI
Keadaan gigi B A A B
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
Keadaan gigi 9 9 0 0 0 9 01 0 0 9 0 0 0 9 9 0 0 0 KODE:
DIAGNOSA DG 0 0
Letak Caries L 0 1 DIAGNOSA
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O 0 0 0 KMD-GI = D
DIAGNOSA DG 0 0 KMD-ART =
Keadaan gigi 9 9 0 0 0 0 0 0 0 0 0 0 0 1 9 9 0 0 KMP VITAL
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
DIAGNOSA EA PN 1 0 0 0 PERSISTEN
Keadaan gigi B E 0 0 0 0 GOYANG

0 1 1 DI 0 0 0 CI M= 0 e= 1
0 2 0 1 0.83 0 2 0 2 0.67 F= 0 f= 0
OHI - S = 1.5 ____ ____
- Gigi lubang/karies =1 2 3= B - Memerlukan scaling = 1
3
- Sealant =6 0 0= F 2.2. Konservasi : GT GS
- Mahkota khusus =7 0 0= G - Tumpatan ART 0 1 gigi
- Gigi tidak tumbuh =8 0 - - Tumpatan GI 1 0 gigi
di atas
1.2. Keadaan penyakit Periodental : - Gigi sulung 0 0 gigi
- Sehat =0 - Gigi tetap 0 0 gigi
- Gingivitis lebih satu segment =2 0 2.4. Observasi :
0

- Tak ada =0
- Ada =1
2.5. Dirujuk ke : Puskesmas
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Meidiyani Gender: 1P= 1 No. Resp.: A003
W=2 Tanggal : 28 12 2016
ALAMAT: Jl. Kesehatan No 2 RT,RW,Kelurahan: 14 03 Sukajadi
KANAN KIRI
Keadaan gigi F A A B A B
DIAGNOSA EA DG DG 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
Letak Caries 0 0 DIAGNOSA
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA EA 1 0 KMD-ART =
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
Letak Caries MO KMA = A
DIAGNOSA DG 0 0 0 0 PERSISTEN
Keadaan gigi B A A A 0 1 0 0 GOYANG

1 0 1 DI 1 0 1 CI M= 0 e= 0
0 2 0 2 1 0 1 0 2 0.83 F= 1 f= 1
OHI - S = 1.83 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Dandi Gender: 1P= 1 No. Resp.: A004
W=2 Tanggal : 28 12 2016
ALAMAT: Jl. Solo no 1 RT,RW,Kelurahan: 05 01 Sukajadi
KANAN KIRI
Keadaan gigi B E
DIAGNOSA DG PN 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O O 0 0 0 KMD-GI = D
DIAGNOSA EA DA 1 0 KMD-ART =
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
DIAGNOSA DA 0 0 0 0 PERSISTEN
Keadaan gigi B 1 0 0 0 GOYANG

0 0 0 DI 0 0 0 CI M= 0 e= 1
0 1 0 1 0.33 0 1 0 1 0.33 F= 1 f= 0
OHI - S = 0.67 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Reysita Gender: 2P= 1 No. Resp.: A005
W=2 Tanggal : 29 12 2016
ALAMAT: Jl. Merak no 2 RT,RW,Kelurahan: 16 18 Mekarwangi
KANAN KIRI
Keadaan gigi
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
Keadaan gigi 9 0 0 1 0 9 0 0 0 KODE:
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries 0 0 0 KMD-GI = D
DIAGNOSA 0 0 KMD-ART =
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
DIAGNOSA 0 0 0 0 PERSISTEN

0 0 0 DI 1 1 0 CI M= 0 e= 0
0 1 0 1 0.33 0 0 0 0 0.33 F= 0 f= 0
OHI - S = 0.67 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Ari M Gender: 1P= 1 No. Resp.: A008
W=2 Tanggal : 30 12 2016
ALAMAT: jl.Eyckman no 3 RT,RW,Kelurahan: 01 02 sukajadi
KANAN KIRI
DIAGNOSA EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries M 0 0 0 KMD-GI = D
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV

0 0 0 DI 0 0 0 CI M= 0 e= 0
0 1 1 1 0.5 0 0 0 0 0 F= 0 f= 0
OHI - S = 0.5 ____ ____
2
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
7 81 71
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Riza G Gender: 1P= 1 No. Resp.: A007
W=2 Tanggal : 31 12 2016
ALAMAT: Sukajadi RT,RW,Kelurahan: 01 01 sukajadi
KANAN KIRI
Keadaan gigi
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA EG EG 0 2
Letak Caries O B 0 0 DIAGNOSA
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
DIAGNOSA EG EG 0 2 0 0 PERSISTEN

DI CI M= 0 e= 0
0 0 0 0 F= 0 f= 0
OHI - S = 0 ____ ____
0
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
0
7 81 71
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
0
BANDUNG

NAMA: Ida N Gender: 2P= 1 No. Resp.: A008
W=2 Tanggal : 03 01 2017
ALAMAT: Jl. Eyckman No 5 RT,RW,Kelurahan: 01 01 Sukajadi
KANAN KIRI
Keadaan gigi B A A A A A A A B A
DIAGNOSA EA DG 1 0 0 0
Letak Caries M O 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
Keadaan gigi A A A A A A 0 0 0 0 GOYANG

0 0 0 DI 0 0 0 CI M= 0 e= 0
0 1 0 1 0.33 0 0 0 0 0 F= 0 f= 0
OHI - S = 0.33 ____ ____
2
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
7 81 71
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Caca Gender: 2P= 1 No. Resp.: A009
W=2 Tanggal : 05 01 2017
ALAMAT: Sukajadi RT,RW,Kelurahan: 01 01 Sukajadi
KANAN KIRI
Keadaan gigi B A F A
DIAGNOSA EG EG 0 2 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV

0 0 1 DI 1 0 0 CI M= 0 e= 0
0 0 0 1 0.33 0 1 0 0 0.33 F= 0 f= 2
OHI - S = 0.67 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
7 81 71
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Ferdiansyah Gender: 1P= 1 No. Resp.: A010
W=2 Tanggal : 06 01 2017
ALAMAT: Sukajadi RT,RW,Kelurahan: 02 01 Sukajadi
KANAN KIRI
Keadaan gigi A B A B
Letak Caries P D 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV

0 1 0 DI 1 0 0 CI M= 0 e= 0
0 0 0 0 0.17 0 1 0 0 0.33 F= 0 f= 1
OHI - S = 0.5 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
1
7 81 71
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Pongky Gender: 1P= 1 No. Resp.: P001
W=2 Tanggal : 06 01 2017
ALAMAT: Jl.Sudirman NO.40 Bandung RT,RW,Kelurahan: 03 11 Sukabungah
KANAN KIRI
Keadaan gigi - - - - - - - A B E
DIAGNOSA DA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries MB 0 0 0 KMD-GI =
DIAGNOSA EG 0 1 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi - - - A - - - A A A 0 0 0 0 GOYANG

1 0 1 DI 2 1 1 CI M= 0 e= 1
0 1 1 0 0.67 0 0 0 1 0.83 F= 0 f= 0
OHI - S = 1.5 ____ ____
CPITN
17 16 11 21 26 27 X 1 1 0 0 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 0 1 0 0 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Ujang Gender: 1P= 1 No. Resp.: U002
W=2 Tanggal : 06 01 2017
ALAMAT: Kp.Sukamanah RT,RW,Kelurahan: 11 04 Majakerta
KANAN KIRI
Keadaan gigi - - A A A - - - - E
DIAGNOSA G3 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG G3 EG EA 1 2
Letak Caries L P O O 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DG DA 0 0 0 0 PERSISTE
Keadaan gigi - B A A A A A B 1 1 0 0 GOYANG

0 1 1 DI 2 1 2 CI M= 1 e= 1
0 1 1 1 0.83 0 0 2 1 1.33 F= 0 f= 0
OHI - S = 2.17 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 0 2 0 1 2 3 2
0 17 46 41 31 36 37 0 X 0 1 1 1 X 0 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Santi Gender: 2P= 1 No. Resp.: S003
W=2 Tanggal : 06 01 2017
ALAMAT: Margaraya RT,RW,Kelurahan: 05 12 Sukatani
KANAN KIRI
Keadaan gigi - - - - - - - B A B
Letak Caries P O 0 2 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DG 0 1
Letak Caries L O 0 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries OL 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi - B - - - A A B 1 1 0 0 GOYANG

0 0 0 DI 1 0 1 CI M= 0 e= 0
0 1 1 0 0.33 0 0 1 0 0.5 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
17 16 11 21 26 27 0 1 1 0 0 0 1 1 0 4 2
0 17 46 41 31 36 37 0 X 0 1 1 1 X 0 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Cinta Gender: 2P= 1 No. Resp.: C004
W=2 Tanggal : 06 01 2017
ALAMAT: Kp.Namicalung RT,RW,Kelurahan: 06 01 Panyadap
KANAN KIRI
Keadaan gigi A B A A A E A A B A
DIAGNOSA EG G3 DG 0 1 0 0
Letak Caries O OL 0 1 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries L KMA = A
DIAGNOSA DA G4 0 0 0 0 PERSISTE
Keadaan gigi B A A A E A A A A A 1 0 0 1 GOYANG

0 0 0 DI 1 0 1 CI M= 0 e= 2
0 1 1 0 0.33 0 0 1 0 0.5 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
17 16 11 21 26 27 0 1 1 0 1 2 1 1 2 3 2
0 17 46 41 31 36 37 0 0 2 1 1 2 0 2 1 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Gangan Gender: 1P= 1 No. Resp.: G005
W=2 Tanggal : 06 01 2017
ALAMAT: Majakerta RT,RW,Kelurahan: 01 10 Majasetra
KANAN KIRI
Keadaan gigi - - B A E - - - - A
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA G3 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi - A B A A A A B 1 1 0 0 GOYANG

0 0 1 DI 1 0 0 CI M= 1 e= 1
0 1 0 1 0.5 0 0 1 0 0.33 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 1 2 0 1 2 3 2
0 17 46 41 31 36 37 0 0 0 1 0 1 1 0 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Reza Gender: 1P= 1 No. Resp.: R006
W=2 Tanggal : 06 01 2017
ALAMAT: Kp.Bojong RT,RW,Kelurahan: 05 15 Bojong
KANAN KIRI
Keadaan gigi B A A A - - - A D A
DIAGNOSA DA PS 0 0 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DG 0 1
Letak Caries P O 0 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi B A A - - - A A A B 1 0 0 0 GOYANG

1 0 1 DI 2 1 1 CI M= 0 e= 0
0 1 1 1 0.83 0 0 2 1 1.17 F= 0 f= 1
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 1 0 1 0 0 1 1 1 1 5 2
0 17 46 41 31 36 37 0 1 0 2 0 0 1 1 2 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Pujiastuti Gender: 2P= 1 No. Resp.: P007
W=2 Tanggal : 06 01 2017
ALAMAT: Majasetra RT,RW,Kelurahan: 06 18 Majasetra
KANAN KIRI
Keadaan gigi A - - - - - - - - B
DIAGNOSA EA 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries B KMA = A
DIAGNOSA EG 0 1 0 0 PERSISTE
Keadaan gigi A - - - - - - - - B 0 0 0 0 GOYANG

1 2 1 DI 2 1 1 CI M= 0 e= 0
0 1 1 3 1.5 0 2 1 1 1.33 F= 0 f= 0
OHI - S = 2.83 ____ ____
CPITN
17 16 11 21 26 27 2 1 1 0 1 1 2 1 1 4 2
0 17 46 41 31 36 37 0 2 1 1 1 0 1 2 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Aday Gender: 1P= 1 No. Resp.: A008
W=2 Tanggal : 06 01 2017
ALAMAT: Cicalengka No.02 RT,RW,Kelurahan: 02 01 Padasuka
KANAN KIRI
Keadaan gigi E - - - - - - A A E
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi B A - - - - - A - - 0 0 0 0 GOYANG

1 0 1 DI 0 1 1 CI M= 0 e= 2
0 1 0 0 0.5 0 0 0 1 0.5 F= 1 f= 0
OHI - S = 1 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 0 1 0 1 1 3 2
0 17 46 41 31 36 37 0 0 0 0 0 0 1 0 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Zizan Gender: 1P= 1 No. Resp.: Z009
W=2 Tanggal : 06 01 2017
ALAMAT: Kp.Panggilingan RT,RW,Kelurahan: 06 13 Ibun
KANAN KIRI
Keadaan gigi - - - - - - - E A B
DIAGNOSA EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B 0 0 0 KMD-GI =
DIAGNOSA DG 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries OL KMA = A
Keadaan gigi - - - A - - - A A B 0 0 0 0 GOYANG

1 0 1 DI 1 0 1 CI M= 0 e= 1
0 0 0 1 0.5 0 0 0 0 0.33 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
17 16 11 21 26 27 1 1 0 1 1 1 1 1 1 3 2
0 17 46 41 31 36 37 0 0 0 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Sisxa Gender: 2P= 1 No. Resp.: S010
W=2 Tanggal : 06 01 2017
ALAMAT: Kp.Namicalung RT,RW,Kelurahan: 03 05 Bojong
KANAN KIRI
Keadaan gigi B - - - - - - - - A
DIAGNOSA DA 0 0 0 0
Letak Caries B 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi E - - - - - - - - A 0 0 0 0 GOYANG

1 0 1 DI 1 0 1 CI M= 0 e= 1
0 1 1 1 0.83 0 0 2 1 0.83 F= 1 f= 0
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 2 1 1 0 0 0 2 1 0 4 2
0 17 46 41 31 36 37 0 1 0 1 1 1 X 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Nabila Haura Autada Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 19 12 2016
ALAMAT: Jln. Pagarsih No. 20 RT,RW,Kelurahan: 04 01 Pagarsih
KANAN KIRI
Keadaan gigi - - A - - - - - - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON


1 0 2 DI 1 0 1 CI M= 0 e= 0
0 3 0 3 1.5 0 0 0 1 0.5 F= 0 f= 0
OHI - S = 2 ____ ____
CPITN
16 11 26 2 0 2 2 2 0 0 0
46 31 36 0 0 0 2 0 2 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
0 0
0 0
BANDUNG

NAMA: Sandi Iskandar Gender: 1P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: Jln. Sukajadi No.22 RT,RW,Kelurahan:
KANAN
DIAGNOSA
Letak Caries
55 54 53 52 51 61
Keadaan gigi 9 0 1 0 9 1 0 0 0
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries
DIAGNOSA
Keadaan gigi 9 0 0 0 0 0 0 0 0
85 84 83 82 81 71
Letak Caries
DIAGNOSA
Keadaan gigi
Segment Segment

1 0 0 DI 0 0
0 0 0 1 0.3333 0 0 0
OHI - S = 0.333333
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26 0 0
0 46 31 36 0 0 0
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
19 12 2016
KIRI
- A - -
0 0 0 0
0 0 0 0
62 63 64 65 0
0 0 0 0 0 0 9 0 0 0 KODE:
0 1
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D

0 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 1 d= 0
0 CI M= 0 e= 0
0 0 F= 0 f= 0
____ ____
DMF = 1 def = 0
Segmen JumlaKode
0 0 0 0 0 0
0 0 0 0 0 0
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Amelia Hendra Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Cianjur No.24
KANAN
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 9 0 0 1 0 0 0
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 0 0 0 9 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

3 0 3 DI 1
0 3 0 3 2 0 1
OHI - S = 2.666667
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 20 12 2016
RT,RW,Kelurahan: 05 03 Ahmad Yani
KIRI
- - - - -
0 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 0 1 0 0 9 9 0 0 0 KODE:
DA 0 0
O 1 1 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
0 0 0 0 0 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

KMA = A
- - A - - 0 0 0 0 GOYANG
Segment
0 1 CI M= 0 e= 0
0 1 0.666667 F= 0 f= 0
____ ____
DMF = 2 def = 0
Segmen JumlaKode
2 0 2 2 2 0 2 2
1 1 1 1 1 0 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: Yuliani Dwi Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Cikutra No. 41
KANAN
Keadaan gigi - - B - -
DIAGNOSA EG
Letak Caries D
55 54 53 52 51
Keadaan gigi 9 0 1 0 0 9 0 0
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 0 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

2 1 3 DI 2
0 1 1 1 1.5 0 3
OHI - S = 3
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 04
Tanggal : 20 12 2016
Pekerjaan (orang tua/wali) : PNS
RT,RW,Kelurahan: 09 01 Cikutra Lama
KIRI
- - B - -
EG 0 2 0 0
O 0 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 0 9 0 0 0 KODE:
0 0
1 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
0 0 0 0 0 0 0 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

KMA = A
- - - - - 0 0 0 0 GOYANG
Segment
0 1 CI M= 0 e= 0
1 2 1.5 F= 0 f= 1
____ ____
DMF = 1 def = 3
Segmen JumlahKode
2 0 1 - - 2 1 0 1 1
2 1 2 2 2 0 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Dhea Ananda Gender: 2P=1

W=2
Umur: 12 tahun
ALAMAT: Jln. Mekar Hegar 1 No.15
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 1 1 DI
0 1 1 1 1 0
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 21 12 2016
RT,RW,Kelurahan: 05 03 Cijerah
- - - B - -
A 0 0 0 0
MOD 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 1
1 1 1 CI M= 0
1 1 1 1 F= 0
____
DMF = 1
Score Segmen
2 2 2 2 2 0
2 2 2 2 2 0
19 -
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Sari Astuti Dewi Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Bukit Resik 1 No.05
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA PV
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 2 2 DI
0 2 2 2 2 0
OHI - S = 4
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 24
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 22 12 2016
RT,RW,Kelurahan: 02 01 Ciumbuleuit
- - A - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 9 9 0
DG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
PV 0
0 0 0 0 0 0 1 0 0 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 4
2 2 2 CI M= 0
2 2 2 2 F= 0
____
DMF = 4
Score Segmen
2 2 2 2 2 0
2 2 2 2 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Yuli Yulian Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. IR. H. Juanda NO.56
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries MOD
DIAGNOSA A
Segment
Plaque Score
3 3 3 DI
0 3 3 3 3 0
OHI - S = 5
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 22 12 2016
RT,RW,Kelurahan: 10 08 Dago
- - - A - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 1 0 0 0 0 1 0 0 0
EG DG 0
P L 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
MOD 0
A 0
0 0 0 0 0 0 1 0 9 0
81 71 72 73 74 75 0
OB MOD
PN A 0 0 0 0
- - - - E E 0 0 0 0
Segment Segment
Calculus Score D= 4
2 2 2 CI M= 0
2 2 2 2 F= 0
____
DMF = 4
Score Segmen
2 2 2 2 2 0
2 2 2 2 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 3
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 0
e= 3
f= 0
____
def = 3
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Farel Alif Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Kopo No.56
KANAN
Keadaan gigi E - A -
DIAGNOSA PN
Letak Caries MOD
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA DA
85 84 83 82
Letak Caries MOD
DIAGNOSA PN
Segment
Plaque Score
2 0 2 DI
0 1 0 1 1 0
OHI - S = 2.166667
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 23 12 2016
RT,RW,Kelurahan: 07 10 Kopo
- - - - - E
PN 0 0 0 0
MOD 0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O O 0
DA EG 0
0 0 0 0 0 0 1 1 9 2
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 3
3 0 3 CI M= 0
0 0 1 1.166667 F= 0
____
DMF = 3
Score Segmen
2 0 2 2 2 0
0 0 2 0 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
0 - Tumpatan GI 1
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 3
f= 0
____
def = 3
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: Risa Rismayani Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Sari Asih No.10
KANAN
DIAGNOSA A
Letak Caries MOD
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries MOD MOD
DIAGNOSA A A
Keadaan gigi E E - -
Segment
Plaque Score
3 2 1 DI
0 2 3 1 2 0
OHI - S = 2.666667
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 23 12 2016
RT,RW,Kelurahan: 01 02 Sarijadi
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0 0
0 1
0 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
D 0 0
DG 0 1
1 0 0 0 0 0 0 0 9 0 0
81 71 72 73 74 75 0 >0
MOD
A 0 0 0 0
- - - - - E 0 0 0 0
Segment Segment
Calculus Score D= 3
1 1 1 CI M= 0
0 0 1 0.666667 F= 0
____
DMF = 3
Score Segmen
2 1 1 2 1 0
0 0 0 0 0 0
-
0= F 2.2. CPITN
1 - Tumpatan GI 2 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 1
e= 3
f= 1
____
def = 5
JumlaKode
1 1
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: Wulan Permatasari Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Sukagalih No.15
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
0 0 1 DI
0 0 0 1 0.33 0
OHI - S = 0.5
Artinya : BAIK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 12
- Sealant =6 16
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 23 12 2016
ART GI
- - - A - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 6 6 6 6 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 6 6 6 6 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
0 0 1 0.1666667 F= 0
____
DMF = 0
Score Segmen
0 0 0 0 0 0
0 0 2 0 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Wawan Supriatna Gender: 1P= 1

W=2
Umur: 6 tahun
ALAMAT: SP.1 Tahap 1 Tana Lia
KANAN
Keadaan gigi D A B B
DIAGNOSA - - EA A
Letak Caries - - D MO
55 54 53 52
DIAGNOSA - - - - - - -
Letak Caries - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries O O - -
DIAGNOSA EA EA - -
Keadaan gigi B B A -
Segment
Plaque Score
3 1 2 DI
0 2 1 3 2 0
OHI - S = 4.1666667
Artinya : BURUK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 6
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 01
Tanggal : 23 12 2016
RT,RW,Kelurahan: 07 01 Tanah Merah
B B B A A F
A A A - - - 1 0 0 0
MOD MOD MO - - - 0 0 0 0
51 61 62 63 64 65
9 9 9 9 9 9 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 9 9 9 0 9 9 0
81 71 72 73 74 75 0
- - - - - O
- - - - - DA 2 0 0 0
- - - A A B 1 0 0 0
Segment Segment
Calculus Score D= 0
2 0 3 CI M= 0
3 2 3 2.1666667 F= 0
____
DMF = 0
Score Segmen
X 2 0 2 1 X 2 2 1
X 1 3 1 2 X 1 3 2
-
1= F 2.2. CPITN
0 - Tumpatan ART 0
3 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 8
e= 0
f= 0
____
def = 8
Jumlah ScKode
2 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
4 gigi 0 4
0 gigi
INF
0 gigi 0 0
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Ade Sukarsih Gender: 2P= 1

W=2
Umur: 13 tahun
KANAN
DIAGNOSA - - - -
Letak Caries - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries - - M - - - -
DIAGNOSA - - DG - - - -
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
3 2 3 DI
0 3 2 3 2.6666667 0
OHI - S = 5.1666667
Artinya : BURUK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 02
Tanggal : 23 12 2016
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - D - O - - 0
- - - - EA - DG - - 1
0 0 0 0 1 0 2 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
3 1 3 CI M= 0
3 2 3 2.5 F= 0
____
DMF = 2
Score Segmen
X 1 0 2 3 X 1 2 3
X 3 0 2 1 X 3 2 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
4 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
2 4
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Lia Agustina Gender: 2P= 1

W=2
Umur: 10 tahun
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries - - O - - - -
DIAGNOSA - - EG - - - -
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
1 0 1 DI
0 2 0 2 1 0
OHI - S = 1.8333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 17
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 03
Tanggal : 24 12 2016
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - EG - - 0
0 0 0 9 0 0 1 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
1 0 1 CI M= 0
1 1 1 0.8333333 F= 0
____
DMF = 2
Score Segmen
X 4 0 0 3 X 4 0 3
X 3 2 0 2 X 3 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
4 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
0 0
2 4
1
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 4
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Lisa Rosalina Gender: 2P= 1

W=2
Umur: 8 tahun
ALAMAT: Jalan Dermaga
KANAN
Keadaan gigi B A - -
DIAGNOSA EA - G3 -
Letak Caries M - - -
55 54 53 52
DIAGNOSA - - EA - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries - - M - - - -
DIAGNOSA - - DA - - - -
85 84 83 82
Letak Caries DO M - -
DIAGNOSA DA EA - -
Segment
Plaque Score
0 0 0 DI
0 1 0 1 0.3333333 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 04
Tanggal : 24 12 2016
- - - - C F
- - - - DA - 1 0 0 0
- - - - O O 1 0 1 0
51 61 62 63 64 65
0 0 0 9 9 9 6 9 9 0
- - - - - - - - - 1
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - DA - - 0
0 0 0 9 9 9 1 9 9 2
81 71 72 73 74 75 0
- - - - O O
- - - G4 DA PN 1 0 0 0
- - - - B B 2 0 0 1
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
2 1 2 0.8333333 F= 0
____
DMF = 3
Score Segmen
X 2 0 0 1 X 2 0 1
X 2 3 0 2 X 2 3 2
-
1= F 2.2. CPITN
0 - Tumpatan ART 3
3 - Tumpatan GI 0
- Gigi sulung 2
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 6
e= 0
f= 1
____
def = 7
Jumlah ScKode
1 1
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
5 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Ricco Maholtra Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Jalan Anggur langgar Al-Aamiin
KANAN
DIAGNOSA - - PS -
Letak Caries - - MOD -
55 54 53 52
DIAGNOSA - - PV - - - EG
Letak Caries - - MO - - - B
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
0 0 0 DI
0 1 0 1 0.3333333 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 24 12 2016
RT,RW,Kelurahan: 01 01 tanah merah
- - - - - -
- - - - - - 0 0 1 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 1 0 0 3 9 9 0
- - - DA - - - - - 0
- - - D - - - - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- M - - - - - - - 0
- EG - - - - - - - 0
0 1 0 0 0 0 0 0 9 1
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 5
0 0 0 CI M= 0
2 1 2 0.8333333 F= 1
____
DMF = 6
Score Segmen
X 1 0 0 2 X 1 0 2
X 1 2 0 2 X 1 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 2
e= 0
f= 1
____
def = 3
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Eman Sulaeman Gender: 1P= 1

W=2
Umur: 11 tahun
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - EA - -
Letak Caries - - - - P - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries - - MOD - - - -
DIAGNOSA - - PV - - - -
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
1 0 1 DI
0 2 1 2 1.1666667 0
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 24 12 2016
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 9 9 0
- - - - - - EG - - 1
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - DG - - 0
0 0 0 0 0 0 1 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 4
0 0 0 CI M= 0
2 1 2 0.8333333 F= 1
____
DMF = 5
Score Segmen
X 2 0 2 3 X 2 2 3
X 1 0 1 2 X 1 1 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Rukinah Gender: 2P= 1

W=2
Umur: 8 tahun
ALAMAT: Pangkalan 1
KANAN
Keadaan gigi B C A -
DIAGNOSA EA DA G3 -
Letak Caries MB O - -
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries D O - -
DIAGNOSA EG DA - -
Segment
Plaque Score
2 0 1 DI
0 1 1 1 1 0
OHI - S = 1.3333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 24 12 2016
RT,RW,Kelurahan: 04 06 Tanah Marah
- - - A B A
- - - - PN - 1 0 0 0
- - - - M - 1 0 1 0
51 61 62 63 64 65
0 0 0 9 9 9 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - EG - - 0
0 0 0 9 9 9 2 9 9 0
81 71 72 73 74 75 0
- - - - O -
- - - - EA - 1 1 0 0
- - - A C A 1 0 0 0
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
1 0 1 0.3333333 F= 1
____
DMF = 4
Score Segmen
X 3 1 0 2 X 3 1 2
X 1 2 1 1 X 1 2 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 2
- Gigi sulung 1
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 6
e= 0
f= 1
____
def = 7
Jumlah ScKode
3 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
4 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Dwi Arianto Gender: 1P= 1

W=2
Umur: 7 tahun
ALAMAT: Jalan Setia
KANAN
Keadaan gigi C D A B
DIAGNOSA DA - - EG
Letak Caries O - - M
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
Letak Caries - O - MOD
DIAGNOSA - DA - PN
Keadaan gigi D C A B
Segment
Plaque Score
0 0 0 DI
0 2 0 2 0.6666667 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 4
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 25 12 2016
- - A A C C
- - - - EG EG 0 3 0 0
- - - - D M 1 0 0 0
51 61 62 63 64 65
0 0 9 9 9 9 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - MOD - - 0
- - - - - - PN - - 0
0 0 9 9 9 9 1 9 9 0
81 71 72 73 74 75 0
- - M - - -
- - EA - - - 1 0 0 0
- - B A D D 1 0 0 0
Segment Segment
Calculus Score D= 4
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 4
Score Segmen
X 2 1 0 1 X 2 1 1
X 1 0 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 7
e= 0
f= 5
____
def = 12
Jumlah ScKode
5 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
3 gigi
3 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: LIZA NURTIKA Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: JL. DERMAGA 1 NO. 24
KANAN
Keadaan gigi - - A B
DIAGNOSA - - - PS
55 54 53 52
Letak Caries - - P - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
2 0 1 DI
0 1 0 1 0.8333333 0
OHI - S = 1.3333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 16
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 30 12 2016
RT,RW,Kelurahan: 01 01 TANAH MERAH
- - - A - -
- - - - - - 0 0 1 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 9 3 0 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 0 0 9 0 9 9 1
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
1 1 1 0.5 F= 1
____
DMF = 4
Score Segmen
X 2 0 0 1 X 2 0 1
X 2 0 0 1 X 2 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: FITRI Gender: 2P= 1

W=2
Umur: 8 tahun
ALAMAT: JALAN JATI NO.123
KANAN
Keadaan gigi D C A -
DIAGNOSA - DA - -
Letak Caries - M - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries O - - -
DIAGNOSA EG - - -
Keadaan gigi C D A -
Segment
Plaque Score
0 0 0 DI
0 2 1 0 0.5 0
OHI - S = 0.8333333
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 10
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 30 12 2016
RT,RW,Kelurahan: 07 01 TANAH MERAH
ART GI
- - - A C C
- - - - DA DA 0 0 0 0
- - - - M M 3 0 0 0
51 61 62 63 64 65
0 0 0 9 9 9 3 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 9 9 9 0 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 1 0 0
- - - A D A 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
1 0 1 0.3333333 F= 0
____
DMF = 0
Score Segmen
X 3 0 1 1 X 3 1 1
X 2 1 0 3 X 2 1 3
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
4 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 4
e= 0
f= 3
____
def = 7
Jumlah ScKode
3 2
2 4
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
3 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Diandra Putri Gender: 2P= 1 No. Resp.: D15
W=2 Tanggal : 01 12 2016
ALAMAT: Jl. Soma No.41 Bandung RT,RW,Kelurahan: 04 03 Kiaracondong
KANAN KIRI
Keadaan gigi B A A A A B A A A E
DIAGNOSA DA PS DG G3 0 0 1 0
Letak Caries M M 1 1 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG DA DG 0 0
Letak Caries O O O 1 2 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi B A A B A A A A A B 1 1 0 1 GOYANG

DI CI M= 0 e= 1
0 1 0.17 0 1 0.17 F= 0 f= 0
OHI - S = 0.33 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 1
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Nathasya Aljazira Gender: 2P= 1 No. Resp.: N12
W=2 Tanggal : 02 12
ALAMAT: Jl. Ahmad Yani No.23 Bandung RT,RW,Kelurahan: 02 03 Babakan Surabaya
KANAN KIRI
Keadaan gigi B A B B B B B B A B
DIAGNOSA DA A DG DG DG EG A DA 0 1 0 0
Letak Caries O RK RK RK RK RK RK O 2 3 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 KODE:
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Keadaan gigi 0 0 KMP VITA
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O M D O KMA = A
DIAGNOSA EA DG DG G3 DA 1 0 0 0 PERSISTE
Keadaan gigi B A A B B A A A A B 1 2 1 0 GOYANG

2 1 1 DI 0 0 0 CI M= 0 e= 0
0 2 1 2 1.5 0 1 0 0 0.17 F= 0 f= 1
1.67 ____ ____
CPITN
16 11 26 1 1 1 1 1 1 5 2
0 46 31 36 0 2 1 1 2 1 1 0 0
0

- Gigi lubang/karies =1 0 12 = B - Memerlukan scaling = 1 3
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Yonash Immanuel Gender: 1P= 1 No. Resp.: Y23
W=2 Tanggal : 03 12 2016
ALAMAT: Jl. Soma No.4B Bandung RT,RW,Kelurahan: 03 02 Kiaracondong
KANAN KIRI
Keadaan gigi A B A A A A A A A B
DIAGNOSA DA G3 G4 DG 0 0 0 0
Letak Caries O DO 1 1 1 1
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA EA DG PS G4 A 1 0 1 0 PERSISTE
Keadaan gigi A B A B A A A A A B 0 1 0 1 GOYANG

2 2 1 DI 1 0 1 CI M= 0 e= 0
0 2 1 1 1.5 0 0 0 2 0.67 F= 0 f= 0
OHI - S = 2.17 ____ ____
CPITN
16 11 26 1 1 1 1 1 1 5 2
0 46 31 36 0 1 1 2 1 1 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Cikal Aji Sakti 1P= 1
Gender: No. Resp.: C15
W=2 Tanggal : 04 12 2016
ALAMAT: Jl. Lengkong Barat NO.12 Bandung RT,RW,Kelurahan: 04 04 Lengkong
KANAN KIRI
Keadaan gigi B B B A B B A A A A
DIAGNOSA DA DA A DG DG G4 0 0 0 0
Letak Caries O O D M 2 2 0 1
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries D M D O KMA = A
DIAGNOSA DG DA PS DA A 0 0 1 0 PERSISTE
Keadaan gigi A B A B A B A A A B 2 1 0 0 GOYANG

2 1 1 DI 1 0 2 CI M= 0 e= 0
0 2 1 0 1.17 0 1 0 0 0.67 F= 0 f= 3
OHI - S = 1.83 ____ ____
CPITN
16 11 26 1 0 3 1 0 3 2 2
0 46 31 36 0 1 0 0 1 0 0 1 3
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Vaiza Fairus Gender: 2P= 1 No. Resp.: V24
W=2 Tanggal : 05 12 2016
ALAMAT: Jl. Purwakarta Timur No.2A RT,RW,Kelurahan: 01 06 Antapani
KANAN KIRI
Keadaan gigi B A E A B B A E B B
DIAGNOSA A EG DG DG PN 0 1 0 0
Letak Caries O M M D O 0 2 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DA DG 0 1
Letak Caries B O O 1 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B M 0 0 0 KMD-GI =
DIAGNOSA EG EG 0 2 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O O B KMA = A
DIAGNOSA DG EG PS G4 G4 DA 0 1 1 0 PERSISTE
Keadaan gigi B B A B A A A A A B 1 1 0 2 GOYANG

1 0 2 DI 1 0 0 CI M= 0 e= 2
0 2 1 2 1.33 0 0 1 0 0.33 F= 0 f= 1
OHI - S = 1.67 ____ ____
CPITN
16 11 26 1 0 0 1 0 0 3 2
0 46 31 36 0 1 1 1 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
GI = DG OCLUSAL = O
RT = DA BUCCAL = B
ITAL = PV LABIAL = L
0
STENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Reyhan Valdema Gender: 1P= 1 No. Resp.: R27
W=2 Tanggal : 06 12 2016
ALAMAT: Jl. Cimenyan No. 23 RT,RW,Kelurahan: 03 04 Cimenyan
KANAN KIRI
Keadaan gigi B B B B A A A A A B
DIAGNOSA A A DA G3 PS PS DA 0 0 2 0
Letak Caries O O P O 2 0 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG EG 0 2
Letak Caries P M 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries L 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DA DG G4 PS DA 0 0 1 0 PERSISTE

1 1 1 DI 2 0 1 CI M= 0 e= 0
0 1 1 1 1 0 1 1 1 1 F= 0 f= 0
OHI - S = 2 ____ ____
CPITN
16 11 26 2 0 1 2 0 1 4 2
0 46 31 36 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Devina Nur C Gender: 2P= 1 No. Resp.: D16
W=2 Tanggal : 07 12 2016
ALAMAT: Jl. Gatot Soebroto No.14 Bandung RT,RW,Kelurahan: 05 02 Maleer
KANAN KIRI
Keadaan gigi B A A B B B A A B A
DIAGNOSA DA DA G4 G4 DA G3 0 0 0 0
Letak Caries O D O 3 0 1 2
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O O O O 0 0 0 KMD-GI =
DIAGNOSA EG EG EG EG 0 4 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O D M O KMA = A
DIAGNOSA EA DA DA G4 DA 1 0 0 0 PERSISTE

3 2 3 DI 2 1 2 CI M= 0 e= 0
0 3 1 3 2.5 0 1 0 1 1.17 F= 0 f= 2
OHI - S = 3.67 ____ ____
CPITN
16 11 26 2 1 2 2 1 2 3 2
0 46 31 36 0 1 0 1 1 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Alveo Ramadhan Gender: 1P= 1 No. Resp.: A13
W=2 Tanggal : 08 12 2016
ALAMAT: Jl. Senam VII No. 8 RT,RW,Kelurahan: 10 11 Antapani
KANAN KIRI
DIAGNOSA DA PS PS G3 0 0 2 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DG EG 0 2
Letak Caries O MB M 0 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B B 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O O O O KMA = A
DIAGNOSA A A PS G4 PV DA 0 0 1 0 PERSISTE
Keadaan gigi B B A A A A A A B B 1 0 0 1 GOYANG

1 0 1 DI 0 0 1 CI M= 0 e= 1
0 1 1 1 0.83 0 0 0 1 0.33 F= 0 f= 0
OHI - S = 1.17 ____ ____
CPITN
16 11 26 0 0 0 0 0 0 1 1
0 46 31 36 0 0 0 1 0 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Viorel Lawiana Gender: 1P= 1 No. Resp.: V25
W=2 Tanggal : 09 12 2016
ALAMAT: JL. Laswi No.43 RT,RW,Kelurahan: 04 03 Cikudapateuh
KANAN KIRI
Keadaan gigi B B A A A A A A A B
DIAGNOSA A PV PV 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG DG EG EG 0 2
Letak Caries O P M O 0 2 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries M O O M D O O 0 0 0 KMD-GI =
DIAGNOSA EG DG EG EG EG EG EG 0 6 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA A A 0 0 0 0 PERSISTE
Keadaan gigi B A A A A A A A A B 0 0 0 0 GOYANG

2 1 2 DI 0 0 1 CI M= 0 e= 0
0 1 1 1 1.33 0 1 0 1 0.5 F= 0 f= 1
OHI - S = 1.83 ____ ____
CPITN
16 11 26 0 0 1 0 0 1 3 2
0 46 31 36 0 1 0 1 1 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Andika Melody Gender: 1P= 1 No. Resp.: A14
W=2 Tanggal : 10 12 2016
ALAMAT: Jl. Pacuan Kuda No.12 RT,RW,Kelurahan: 05 12 Antapani
KANAN KIRI
Keadaan gigi A A A A A A A A B E
DIAGNOSA A G4 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DG EG DG EG DG 0 3
Letak Caries B O O P M O 0 3 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O O M M O B 0 0 0 KMD-GI =
DIAGNOSA DG EG EG EG EG EG 0 5 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA A PN PS 0 0 1 0 PERSISTE
Keadaan gigi B B A A A A A A A A 0 0 0 0 GOYANG

3 1 3 DI 0 0 0 CI M= 0 e= 1
0 3 2 3 2.5 0 1 2 1 0.67 F= 0 f= 0
OHI - S = 3.17 ____ ____
CPITN
16 11 26 1 1 1 1 1 1 5 2
0 46 31 36 0 1 2 1 1 2 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Deva Nedia Sari Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 10 10 2016
ALAMAT: Bojong Soang RT,RW,Kelurahan: 01 03 Cianjur
KANAN KIRI
Keadaan gigi - - B - - - - - - -
DIAGNOSA DG 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON


3 2 2 DI 2 1 2 CI M= 0 e= 0
0 3 1 3 2.33 0 3 3 3 2.33 F= 0 f= 0
OHI - S = 4.67 ____ ____
CPITN
16 11 26 2 1 2 - 2 2 0 0 0
0 46 31 36 0 2 1 2 2 2 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
1 1
0 0
BANDUNG

NAMA: Della Imaisa Gender: 2P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: Tanjung Raya RT,RW,Kelurahan:
KANAN
DIAGNOSA
Letak Caries
55 54 53 52 51 61
Keadaan gigi 9 0 0 0 0 0 0 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries O M
DIAGNOSA PV PN
Keadaan gigi 9 1 1 0 0 9 0 0 0
85 84 83 82 81 71
Letak Caries
DIAGNOSA
Keadaan gigi - - A - - -
Segment Segment

1 2 0 DI 0 0
0 0 2 3 1.3333 0 2 0
OHI - S = 2.166667
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26 27 2
0 46 31 36 0 3
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
10 10 2016
RT,RW,Kelurahan: 03 04 Sukau
KIRI
- - - -
0 0 0 0
0 0 0 0
62 63 64 65 0
0 0 0 0 1 0 9 0 0 0 KODE:
DG 0 0
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D

- - - - 0 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 3 d= 1
2 CI M= 0 e= 0
1 0.833333 F= 0 f= 0
____ ____
DMF = 3 def = 1
Segmen JumlaKode
2 2 2 2 0 0 0
3 2 3 3 0 2 4
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Andica Utama Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Kembahang
KANAN
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 9 0 0 0 0 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries O
DIAGNOSA EG
Keadaan gigi 9 9 1 0 0 9 0 0
85 84 83 82 81
Letak Caries M
DIAGNOSA EG
Keadaan gigi - - B - -
Segment Segment

1 0 2 DI 1
0 0 0 3 1 0 2
OHI - S = 3.166667
Artinya : BURUK
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 10 10 2016
RT,RW,Kelurahan: 07 01 Balik Bukit
KIRI
- - - - -
0 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 9 9 0 0 0 KODE:
0 0
0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
O 0 0 0 KMD-GI = DG
EG 0 2 KMD-ART = DA
0 0 9 0 0 1 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

KMA = A
- - - - - 0 0 0 0 GOYANG
Segment
3 3 CI M= 0 e= 0
1 3 2.166667 F= 0 f= 0
____ ____
DMF = 2 def = 1
Segmen JumlaKode
2 1 2 2 2 0 0 0
2 1 2 0 2 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: Fajar Ramadhan Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Tanjung Kemala
KANAN
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 0 1 0 0 0 0 0
DIAGNOSA EA
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries O O
DIAGNOSA EA DA
Keadaan gigi 9 1 1 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

1 0 2 DI 2
0 2 1 1 1.1667 0 3
OHI - S = 2.666667
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 04
Tanggal : 10 10 2016
KIRI
- - - - -
0 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 0 0 0 1 0 9 0 0 0 KODE:
EA 2 0
O 0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
O O 0 0 0 KMD-GI = DG
DA EA 2 0 KMD-ART = DA
0 0 9 0 0 1 9 9 2 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

D O KMA = A
EA EG 1 1 0 0 PERSISTENSI = PS
- - B - B 0 0 0 0 GOYANG
Segment
0 1 CI M= 0 e= 0
1 2 1.5 F= 0 f= 0
____ ____
DMF = 6 def = 2
Segmen JumlahKode
1 0 2 1 2 0 1 1
2 0 2 0 2 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Intan Febriani Gender: 1P=1

W=2
Umur: 11 tahun
ALAMAT: Gg.Eme no.5
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA -
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA - EA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 1 2 DI
0 2 0 2 1.333333 0
OHI - S = 2.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 2
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 24 12 2016
- - - A - B
A 0 0 0 0
MOD 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 9 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
- 1
0 0 0 0 0 0 6 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 1
2 1 1 CI M= 0
2 1 2 1.5 F= 0
____
DMF = 1
Score Segmen
1 0 0 1 0 0
2 2 1 2 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
1 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Desta Meliana Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Tanjung Raya
KANAN
DIAGNOSA A
Letak Caries MOD
55 54 53 52
DIAGNOSA DG
Letak Caries M
17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries MOD
DIAGNOSA PV
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 0 1 DI
0 2 1 2 1.166667 0
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 10 10 2016
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0
EG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 4
0 0 0 CI M= 0
2 1 2 0.833333 F= 0
____
DMF = 4
Score Segmen
0 0 0 0 0 0
1 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Ani Rahmayani Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Tanjung Raya
KANAN
DIAGNOSA A
Letak Caries MOD
55 54 53 52
DIAGNOSA DG
Letak Caries M
17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries MOD
DIAGNOSA PV
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 0 1 DI
0 2 1 2 1.166667 0
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 10 10 2016
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0
EG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 4
0 0 0 CI M= 0
2 1 2 0.833333 F= 0
____
DMF = 4
Score Segmen
0 0 0 0 0 0
1 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Agus Setia Boma Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Jalan Setia
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries OL O
DIAGNOSA PV DG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 0 0 DI
0 1 0 2 0.666667 0
OHI - S = 2.333333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 20
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 10 10 2016
- - - B - B
PV A 0 0 0 0
O O 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 0 9 0
DG 0
O 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
MOD MO 0
PN DG 0
0 0 0 0 0 0 1 1 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 6
2 1 2 CI M= 0
1 1 3 1.666667 F= 0
____
DMF = 6
Score Segmen
1 1 1 1 1 0
2 0 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 2
e= 0
f= 0
____
def = 2
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: Elsa Rahmatika Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Hanakau
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA -
85 84 83 82
Letak Caries D
DIAGNOSA EG
Segment
Plaque Score
2 0 1 DI
0 1 0 1 0.833333 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 24
- Sealant =6 2
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 10 10 2016
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0 0
DG 0 0
O 1 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 0
- 0 0
0 0 0 0 0 0 6 0 9 0 0
81 71 72 73 74 75 0 >0
0 1 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
1 0 1 CI M= 0
1 0 1 0.666667 F= 0
____
DMF = 2
Score Segmen
0 1 0 0 1 0
1 0 0 0 1 0
-
0= F 2.2. CPITN
2 - Tumpatan GI 1 1

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 1
e= 0
f= 1
____
def = 2
JumlaKode
2 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: Ega Mawarni Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jalan Cinta no.05
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
0 0 0 DI
0 2 1 0 0.5 0
OHI - S = 0.833333
Artinya : BAIK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 10 10 2016
RT,RW,Kelurahan: 10 11 Sukarame
ART GI
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0
DG 0
O 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 9 9 0
81 71 72 73 74 75 0
MOD
A 0 0 0 0
- - - A - B 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
1 0 1 0.3333333 F= 0
____
DMF = 2
Score Segmen
1 2 1 1 2 0
2 1 2 2 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
1 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Devy Budi Pertiwi Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 02 12 2016
ALAMAT: Jln. Raya Tanjungsari No.256 RT,RW,Kelurahan: 02 04 Tanjungsari
KANAN KIRI
Keadaan gigi - - - - - - - - - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON


0 1 0 DI 0 0 0 CI M= 0 e= 0
0 1 0 1 0.5 0 2 1 2 0.83 F= 0 f= 0
OHI - S = 1.33 ____ ____
CPITN
16 11 26 0 0 0 0 0 0 0 0
0 46 31 36 0 2 2 2 0 2 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
2 1
0 0
BANDUNG

NAMA: Putri Budi Winarti Gender: 2P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: Jln. Raya Tanjungsari No.256 RT,RW,Kelurahan:
KANAN
Keadaan gigi
DIAGNOSA
55 54 53 52 51 61
Keadaan gigi 9 0 0 0 0 9 0 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries O M
DIAGNOSA EG EG
Keadaan gigi 9 1 1 0 0 0 0 0 0
85 84 83 82 81 71
DIAGNOSA
Keadaan gigi
Segment Segment

1 0 0 DI 0 0
0 3 1 1 1 0 2 1
OHI - S = 1.666667
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26 0
0 46 31 36 0
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
15 12 2016
KIRI
0 0 0 0
- - - - 0 0 0 0
62 63 64 65 0
0 0 0 0 0 0 9 0 0 0 KODE:
0 0
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D

O 1 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 2 d= 1
0 CI M= 0 e= 0
1 0.666667 F= 0 f= 0
____ ____
DMF = 2 def = 1
Segmen JumlaKode
0 0 0 0 0 0 0
3 2 2 0 3 2 1 3
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Atit Tajmiati Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Raya Tanjungsari No.256
KANAN
DIAGNOSA EA
Letak Caries B
55 54 53 52 51
Keadaan gigi 9 0 1 0 0 9 0 0
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries O
DIAGNOSA EA
Keadaan gigi 9 0 6 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

1 1 1 DI 1
0 2 0 2 1.17 0 2
OHI - S = 2.5
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 1 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 20 12 2016
KIRI
- - - - -
1 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 0 0 0 0 0 9 0 0 0 KODE:
0 1
0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
1 0 KMD-ART = DA
0 0 9 0 0 0 0 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

MOD KMA =KMA
- - B - - 0 0 0 0 GOYANG
Segment
0 1 CI M= 0 e= 0
1 3 1.333333 F= 0 f= 0
____ ____
DMF = 1 def = 2
Segmen JumlaKode
2 0 2 2 2 0 0 0
2 2 3 0 2 3 1 3
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: Eristia Pradina Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jalan sukajadi gang eme
KANAN
Keadaan gigi
DIAGNOSA
55 54 53 52 51
Keadaan gigi 9 1 1 0 0 9 0 0
DIAGNOSA EG EG
Letak Caries O O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 0 0 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

0 1 0 DI 1
0 2 0 2 0.8333 0 1
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 1 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
9
No. Resp.: 04
Tanggal : 24 12 2016
KIRI
O
DA 0 0 0 0
- - B - - 1 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 0 9 0 0 0 KODE:
0 2
- 0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
O 0 0 0 KMD-GI = DG
EA 1 0 KMD-ART = DA
0 0 0 0 0 6 0 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

KMA = A
- - - - - 0 0 0 0 GOYANG
Segment
0 0 CI M= 0 e= 0
2 3 1.166667 F= 0 f= 0
____ ____
DMF = 2 def = 1
Segmen JumlahKode
2 0 0 2 0 0 0 0
2 2 2 0 2 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Bambang Gender: 1P=1

W=2
Umur: 11 tahun
ALAMAT: Jalan sarijadi no.22
KANAN
DIAGNOSA EA
Letak Caries O
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
0 0 0 DI
0 2 1 3 1 0
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 22
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 26 12 2016
- - - A - -
1 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EG 0
0 0 0 9 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
2 1 2 0.833333 F= 0
____
DMF = 2
Score Segmen
0 0 0 0 0 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Iwan Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: Jl. Raya Antapani no.24
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
3 1 2 DI
0 2 1 3 2 0
OHI - S = 4.166667
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 24
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 27 12 2016
RT,RW,Kelurahan: 10 02 Antapani
- - - B - -
DA 0 0 0 0
O 1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EA 1
0 0 0 0 0 0 6 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 0 3 CI M= 0
3 2 3 2.166667 F= 0
____
DMF = 2
Score Segmen
2 0 2 2 2 0
3 2 2 0 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Amanda Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Sungai Liat
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O
DIAGNOSA EA
Segment
Plaque Score
2 1 1 DI
0 1 1 1 1.166667 0
OHI - S = 2.5
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 28 12 2016
RT,RW,Kelurahan: 04 06 sungaliat
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0
EA 1
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
1 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 0 2 CI M= 0
2 1 1 1.333333 F= 0
____
DMF = 2
Score Segmen
2 0 2 2 2 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Ridho Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: Jalan Sungai liat
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 2 2 2 1.666667 0
OHI - S = 2.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 16
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 25 12 2016
RT,RW,Kelurahan: 02 06 sungai liat
- - - A - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 9 9 0
DG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
M 0
EG 0
1 0 0 9 0 0 0 9 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 4
1 0 1 CI M= 0
2 1 2 1.166667 F= 0
____
DMF = 4
Score Segmen
1 0 1 1 1 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 2
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: Rifky Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jalan Sungai liat
KANAN
DIAGNOSA DA
Letak Caries O
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 0 1 DI
0 1 0 1 0.833333 0
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 30 12 2016
RT,RW,Kelurahan: 02 01 Sungai liat
- - - - - -
0 0 0 0
1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0 0
0 1
0 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 0
0 0
0 0 0 9 0 0 0 0 9 0 0
81 71 72 73 74 75 0 >0
B
EA 1 0 0 0
- - - B - - 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
2 2 2 1 F= 1
____
DMF = 1
Score Segmen
1 0 1 1 1 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
2 - Tumpatan GI 1 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
JumlaKode
2 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: Ariel Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jalan Sungai Liat
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries MOD
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 2 1 1 1.33 0
OHI - S = 3.166667
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 30 12 2016
RT,RW,Kelurahan: 07 01 Sungai liat
ART GI
- - - B - -
KMA 0 0 0 1
MOD 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 0 0 0
EG 0
- - - - - - O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 9 0 1 0 0 0
81 71 72 73 74 75 0
O
DA 0 0 0 0
- - - - B - 1 0 0 0
Segment Segment
Calculus Score D= 4
2 1 1 CI M= 0
3 1 3 1.8333333 F= 0
____
DMF = 4
Score Segmen
2 1 1 2 1 0
3 2 2 0 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
3 - Tumpatan GI 3
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 2
e= 0
f= 0
____
def = 2
Jumlah ScKode
1 1
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
1 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Jessica Gender: 2P= 1 No. Resp.: J001
W=2 Tanggal : 09 01 2017
ALAMAT: Jalan Ibrahim No 34 Bandung RT,RW,Kelurahan: 01 01 Sukabungah
KANAN KIRI
Keadaan gigi - - - - - - - - E -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries MD 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi - A - - - - - A A - 0 0 0 0 GOYANG

1 0 1 DI 2 1 1 CI M= 0 e= 1
0 1 1 0 0.67 0 0 0 1 0.83 F= 0 f= 0
OHI - S = 1.5 ____ ____
CPITN
17 16 11 21 26 27 X 1 1 0 0 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 0 1 0 0 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Abraham Gender:1P= 1 No. Resp.: A005
W=2 Tanggal : 09 01 2017
ALAMAT: Jalan Adjie Mubarok No 12 Bandung RT,RW,Kelurahan: 04 02 Sukahati
KANAN KIRI
Keadaan gigi - - - - - A A A - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG EA EG 1 2
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries D M L KMA = A
DIAGNOSA EG DG DG 0 1 0 0 PERSISTE
Keadaan gigi - B B A A A A B A 0 2 0 0 GOYANG

0 1 1 DI 2 1 2 CI M= 0 e= 0
0 1 1 1 0.83 0 0 2 1 1.33 F= 0 f= 1
OHI - S = 2.17 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 0 2 0 1 2 3 2
0 17 46 41 31 36 37 0 X 0 1 1 1 X 0 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0 KODE:
:
NOSA LETAKKME-ART= EA MESIAL = M
ART= EA MESIAKME-GI= EG DISTAL = D
GI= EG DISTAKMD-GI = DG OCLUSAL = O
GI = DG OCLUSKMD-ART = DA BUCCAL = B
ART = DA BUCCAKMP VITAL = PV LABIAL = L
VITAL = PV LABIA 0 0 0
NONVITAL = PN PALATKMA = A RK = Rampan Karies
=A RK = PERSISTENSI = PS
ISTENSI = PS GOYANG °3/°4 = G3/G4
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Srikandi Gender: 2P= 1 No. Resp.: S011
W=2 Tanggal : 09 01 2017
ALAMAT: Margajaya Bandung RT,RW,Kelurahan: 08 06 Sukarajin
KANAN KIRI
Keadaan gigi A A A - - - - B F
DIAGNOSA DA 0 0 0 0
Letak Caries MD 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG 0 0
Letak Caries L 0 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA G3 EG 0 1 0 0 PERSISTE
Keadaan gigi B F A A - - - A A B 0 0 1 0 GOYANG

0 0 0 DI 1 0 1 CI M= 0 e= 0
0 1 1 0 0.33 0 0 1 0 0.5 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
17 16 11 21 26 27 0 1 1 0 0 0 1 1 0 4 2
0 17 46 41 31 36 37 0 X 0 1 1 1 X 0 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Asep Gender: 1P= 1 No. Resp.: A008
W=2 Tanggal : 09 01 2017
ALAMAT: Sukamalas RT,RW,Kelurahan: 10 14 Haurkuning
KANAN KIRI
Keadaan gigi B E
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 KODE:
DIAGNOSA A A A A A A A A A A A PS DG A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

0 0 0 DI 1 0 1 CI M= 0 e= 1
0 1 1 0 0.33 0 0 1 0 0.5 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
17 16 11 21 26 27 0 1 1 0 1 2 1 1 2 3 2
0 17 46 41 31 36 37 0 0 2 1 1 2 0 2 1 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Ismail Gender: 1P= 1 No. Resp.: I005
W=2 Tanggal : 09 01 2017
ALAMAT: Sukamakan RT,RW,Kelurahan: 05 10 Cijambu
KANAN KIRI
Keadaan gigi E B A - - - - A E E
DIAGNOSA DA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DG EG 0 1 0 0 PERSISTE
Keadaan gigi B E A - - - - A E B 0 1 0 0 GOYANG

0 0 1 DI 1 0 0 CI M= 0 e= 5
0 1 0 1 0.5 0 0 1 0 0.33 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 1 2 0 1 2 3 2
0 17 46 41 31 36 37 0 0 0 1 0 1 1 0 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Nurdian Gender: 2P= 1 No. Resp.: N006
W=2 Tanggal : 09 01 2017
ALAMAT: Karasak RT,RW,Kelurahan: 05 15 Rawabinong
KANAN KIRI
Keadaan gigi B B A A A A A A F B
DIAGNOSA DA DG EA 1 0 0 0
Letak Caries M O D 1 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA A A 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A PS A A 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O O O KMA = A
Keadaan gigi B F A A - A A A B 1 0 1 0 GOYANG

1 0 1 DI 2 1 1 CI M= 0 e= 0
0 1 1 1 0.83 0 0 2 1 1.17 F= 0 f= 1
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 1 0 1 0 0 1 1 1 1 5 2
0 17 46 41 31 36 37 0 1 0 2 0 0 1 1 2 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Rajby Gender: 1P= 1 No. Resp.: R007
W=2 Tanggal : 06 01 2017
ALAMAT: Tanjungsari RT,RW,Kelurahan: 01 01 Situ
KANAN KIRI
Keadaan gigi A - - - - - - - - B
DIAGNOSA EA 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries B KMA = A
Keadaan gigi A - - - - - - - - B 0 0 0 0 GOYANG

1 2 1 DI 2 1 1 CI M= 0 e= 0
0 1 1 3 1.5 0 2 1 1 1.33 F= 0 f= 0
OHI - S = 2.83 ____ ____
CPITN
17 16 11 21 26 27 2 1 1 0 1 1 2 1 1 4 2
0 17 46 41 31 36 37 0 2 1 1 1 0 1 2 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Keisa Gender: 2P= 1 No. Resp.: K008
W=2 Tanggal : 09 01 2017
ALAMAT: Cipayung RT,RW,Kelurahan: 08 09 Bojong Nangka
KANAN KIRI
Keadaan gigi A A
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 KODE:
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA A A A A A A A A A A 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O M KMA = A
DIAGNOSA EA EA 2 0 0 0 PERSISTE

1 0 1 DI 0 1 1 CI M= 0 e= 0
0 1 0 0 0.5 0 0 0 1 0.5 F= 0 f= 0
OHI - S = 1 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 0 1 0 1 1 3 2
0 17 46 41 31 36 37 0 0 0 0 0 0 1 0 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Raisa Gender: 1P= 1 No. Resp.: R009
W=2 Tanggal : 09 01 2017
ALAMAT: Depok RT,RW,Kelurahan: 09 10 Lanjung
KANAN KIRI
Keadaan gigi C B
DIAGNOSA DA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 0 1 DI 1 0 1 CI M= 0 e= 0
0 0 0 1 0.5 0 0 0 0 0.33 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
17 16 11 21 26 27 1 1 0 1 1 1 1 1 1 3 2
0 17 46 41 31 36 37 0 0 0 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Kholila Gender: 2P= 1 No. Resp.: K010
W=2 Tanggal : 09 01 2017
ALAMAT: Gudang RT,RW,Kelurahan: 11 12 Kenanga
KANAN KIRI
Keadaan gigi
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA DG DG 0 0 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 0 1 DI 1 0 1 CI M= 0 e= 0
0 1 1 1 0.83 0 0 2 1 0.83 F= 0 f= 0
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 2 1 1 0 0 0 2 1 0 4 2
0 17 46 41 31 36 37 0 1 0 1 1 1 X 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0 KODE:
:
NOSA LETAKKME-ART= EA MESIAL = M
ART= EA MESIAKME-GI= EG DISTAL = D
GI= EG DISTAKMD-GI = DG OCLUSAL = O
GI = DG OCLUSKMD-ART = DA BUCCAL = B
ART = DA BUCCAKMP VITAL = PV LABIAL = L
VITAL = PV LABIA 0 0 0
NONVITAL = PN PALATKMA = A RK = Rampan Karies
=A RK = PERSISTENSI = PS
ISTENSI = PS GOYANG °3/°4 = G3/G4
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Reysita A F Gender: 2P= 1 No. Resp.: R005
W=2 Tanggal : 16 12 2016
ALAMAT: Jalan Cinunuk no 107 RT,RW,Kelurahan: 12 02 Cileunyi
KANAN
Keadaan gigi B E
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0
DIAGNOSA A A PS A A A A A A A A PS DG A 0 0
Letak Caries O 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A EA PS A A A A A A A A PS A A 1 0
Keadaan gigi 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O O
DIAGNOSA EA DA 1 0 0 0
Keadaan gigi B B 1 0 0 0

Plaque Score Calculus Score D= 2 d=
1 0 0 DI 1 0 0 CI M= 0 e=
0 1 0 1 0.5 0 0 0 1 0.33 F= 0 f=
OHI - S = 0.833 ____ ____
Artinya : BAIK DMF = 2 def =
CPITN
Gigi Index Score Segmen Jumlah
17 16 11 21 26 27 1 0 1 0 0 1 1 1 1 6
0 17 46 41 31 36 37 0 1 0 1 0 0 1 1 1 1 0
0

- Tumpatan tanpa karies =3 0= D - Memerlukan scaling dan = 3
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
KMP NONVITAL = PN PALATAL = P
PERSISTENSI = PS
3
1
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Neisya K N Gender: 2P= 1 No. Resp.: N001
W=2 Tanggal : 16 12 2016
ALAMAT: Jalan Cileunyi RT,RW,Kelurahan: 05 06 Cinunuk
KANAN
Keadaan gigi B B A - A A A
DIAGNOSA DA EG G4 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 0 0 0 0 0 0 0 0 0
DIAGNOSA A PS A 0 0
Letak Caries 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A A 0 0
Keadaan gigi 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O O
Keadaan gigi B A A A A B 1 0 0 0

1 0 1 DI 1 0 1 CI M= 0 e=
0 1 1 1 0.83 0 1 0 1 0.67 F= 0 f=
OHI - S = 1.5 ____ ____
Artinya : SEDANG DMF = 0 def =
CPITN
17 16 11 21 26 27 1 1 1 0 0 1 1 1 1 6
0 17 46 41 31 36 37 0 1 0 1 0 0 1 1 1 1 0
0

- Gigi lubang/karies =1 0 4=B - Memerlukan scaling = 1
- Tumpatan dgn karies =2 0 0=C - Instruksi menyikat gigi = 2
- Tumpatan tanpa karies =3 0=D - Memerlukan scaling dan = 3
- Gigi dicabut karena karies =4 0 0=E intruksi menyikat gigi
- Sealant =6 0 0=F 2.2. CPITN
- Mahkota khusus =7 0 0=G - Tidak memerlukan perawatan
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
4
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Reynaldi A F Gender: 1P= 1 No. Resp.: R007
W=2 Tanggal : 18 12 2016
ALAMAT: Jl. Marga asih RT,RW,Kelurahan: 06 03 Sukabungah
KANAN
Keadaan gigi B B A A A A B B
DIAGNOSA EG DG DG DG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
DIAGNOSA A A 0 0
Letak Caries 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A A 0 0
Keadaan gigi 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O M O
DIAGNOSA EA DG DA 1 0 0 0
Keadaan gigi B A A B A A A B 1 1 0 0

2 1 2 DI 1 0 1 CI M= 0 e=
0 2 1 2 1.67 0 1 0 1 0.67 F= 0 f=
OHI - S = 2.33 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 0 0 1 1 1 1 6
0 17 46 41 31 36 37 0 1 1 1 0 1 1 1 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
7
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Annisa Rahma Gender: 2P= 1 No. Resp.: A002
W=2 Tanggal : 18 12 2016
ALAMAT: Jl. Cileunyi Raya RT,RW,Kelurahan: 02 01 Cileunyi
KANAN
Keadaan gigi A A A A A A A B
DIAGNOSA EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
DIAGNOSA A A 0 0
Letak Caries 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA EG A 0 1
Keadaan gigi 1 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O O
DIAGNOSA EA EG EG 1 2 0 0
Keadaan gigi B B A A A B 0 0 0 0

1 0 1 DI 0 0 0 CI M= 0 e=
0 0 0 0 0.33 0 0 0 0 0 F= 0 f=
OHI - S = 0.33 ____ ____
CPITN
17 16 11 21 26 27 1 0 1 0 0 1 1 1 1 6
0 17 46 41 31 36 37 0 1 0 1 0 0 1 1 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
4
0
0
Kode
2
0
2 2
0
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Yoga Ardiansyah Gender: 1P= 1 No. Resp.: Y009
W=2 Tanggal : 18 12 2016
ALAMAT: Jl. Manisi RT,RW,Kelurahan: 08 01 Ujungberung
KANAN
Keadaan gigi A
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 0 0 0 0 0 0 0 0 1 0 0 0
DIAGNOSA DA A A A A A A A A DG 0 0
Letak Caries O O 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0 0 0
DIAGNOSA A A A A A A A A A EG 0 1
Keadaan gigi 0 0 0 0 0 0 0 0 0 1 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O
DIAGNOSA EG 0 1 0 0
Keadaan gigi B 0 0 0 0

1 0 1 DI 0 0 0 CI M= 0 e=
0 1 0 0 0.5 0 0 0 1 0.17 F= 0 f=
OHI - S = 0.67 ____ ____
CPITN
17 16 11 21 26 27 1 0 0 0 0 0 1 0 0 3
0 17 46 41 31 36 37 0 1 0 0 0 0 1 1 0 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
1
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Ruhi Aurora Gender: 2P= 1 No. Resp.: R003
W=2 Tanggal : 19 12 2016
ALAMAT: Jl. Jambina RT,RW,Kelurahan: 10 04 Bandung
KANAN
Keadaan gigi - -
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0
DIAGNOSA DA EG A PS A A A A PS PN DG 0 1
Letak Caries O O O 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A EG A A A A A A A A A A A A 0 1
Keadaan gigi 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries
DIAGNOSA 0 0 0 0

1 0 1 DI 1 0 0 CI M= 0 e=
0 1 0 1 0.67 0 0 0 1 0.33 F= 0 f=
OHI - S = 1 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 0 0 1 1 1 1 6
0 17 46 41 31 36 37 0 1 1 1 0 0 1 1 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
0
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Abhisek Sigh Gender: 1P= 1 No. Resp.: A005
W=2 Tanggal : 19 12 2016
ALAMAT: Jl. Peta RT,RW,Kelurahan: 06 04 Bandung
KANAN
Keadaan gigi A A A A A B
DIAGNOSA EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 0 0 0 0 1 0 0 0
DIAGNOSA EG A A A A DG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A A A A A A A A PS A 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O
DIAGNOSA G3 DA 0 0 0 0
Keadaan gigi A - B 1 0 1 0

0 0 0 DI 0 0 CI M= 0 e=
0 0 0 0 0 0 0 0 1 0.17 F= 0 f=
OHI - S = 0.17 ____ ____
CPITN
17 16 11 21 26 27 1 0 0 0 0 0 1 0 0 2
0 17 46 41 31 36 37 0 1 0 0 0 0 0 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 0
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
2
0
0
Kode
2
0
1 1
3
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Ishita Iyer Gender: 2P= 1 No. Resp.: I002
W=2 Tanggal : 19 12 2016
ALAMAT: Jl. Rumah Sakit RT,RW,Kelurahan: 03 07 Ujung Berung
KANAN
Keadaan gigi B A A A A A A A
DIAGNOSA DA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
DIAGNOSA DA A A DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O O

2 1 2 DI 1 0 0 CI M= 0 e=
0 1 1 2 1.5 0 0 0 1 0.33 F= 0 f=
OHI - S = 1.83 ____ ____
CPITN
17 16 11 21 26 27 1 0 1 0 0 1 1 1 1 5
0 17 46 41 31 36 37 0 1 1 0 0 0 1 1 0 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
3
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Mihika Gender: 2P= 1 No. Resp.: M002
W=2 Tanggal : 20 12 2016
ALAMAT: Jl. Caringin RT,RW,Kelurahan: 08 01 Cibiru
KANAN
Keadaan gigi B A A A A A
DIAGNOSA DG 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 0 0 0 0 1 0 0 0
DIAGNOSA DA A A A A DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries
DIAGNOSA 0 0 0 0
Keadaan gigi A A 0 0 0 0

2 0 0 DI 1 0 0 CI M= 0 e=
0 2 1 2 1.17 0 1 0 1 0.5 F= 0 f=
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 1 1 0 0 1 1 1 0 1 4
0 17 46 41 31 36 37 0 1 1 0 0 1 1 1 0 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
1
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Aditya Bhala Gender: 1P= 1 No. Resp.: A007
W=2 Tanggal : 20 12 2016
ALAMAT: Jl. India RT,RW,Kelurahan: 12 06 Sukamiskin
KANAN
Keadaan gigi B A A A A B
DIAGNOSA DG EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 0 0 0 0 0 1 0 0 0
DIAGNOSA A A A A EG 0 1
Letak Caries O 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA DG A A A A A A A A A 0 0
Keadaan gigi 1 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries
DIAGNOSA 0 0 0 0

1 0 0 DI 2 0 1 CI M= 0 e=
0 2 1 1 0.83 0 1 0 1 0.83 F= 0 f=
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 1 1 0 0 1 1 1 0 1 4
0 17 46 41 31 36 37 0 1 1 0 0 1 1 1 0 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
2
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG

NAMA: Andhika Rachmadi Gender: 1P= 1 No. Resp.: A 01
W=2 Tanggal : 14 11 2016
ALAMAT: Komp. Citra no. 17A RT,RW,Kelurahan: 05 15 Antapani Kidul
KANAN KIRI
Keadaan gigi B A A A F B
55 54 53 52 51 61 62 63 64 65 0 0
0 0
DIAGNOSA 0 0
Letak Caries 0 0 DIAGNO
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-AR
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI
Letak Caries 0 0 0 KMD-GI
DIAGNOSA 0 0 KMD-AR
Keadaan gigi 9 0 9 9 9 9 0 0 0 0 9 9 9 9 0 9 0 0 KMP VIT
0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NO
DIAGNOSA DA 0 0 0 0 PERSIS
Keadaan gigi A F A C F D 1 0 0 0 GOYAN

2 1 1 DI 2 0 2 CI M= 0 e= 0
0 1 1 2 1.33 0 1 1 1 1.17 F= 0 f= 1
OHI - S = 2.5 ____ ____
CPITN
Gigi Index Score Segmen Jumlah SKode
X 16 11 21 26 X X 2 0 1 2 X 2 1 2 4 2
0 X 46 41 31 36 X 0 X 1 1 1 1 X 1 1 1 0 0
0

- Mahkota khusus =7 0 0= G - Tidak memerlukan perawatan =
- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan mulut =
- Gigi tidak termasuk kriteria =9 0 - - Memerlukan Scaling dan EIKM =
di atas - Memerlukan Scaling dan EIKM =
- Memerlukan Perawatan Khusus dan EIKM =
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
RI
0 0
DE:
AGNOSA LETAK CARIES

E-ART= EA MESIAL = M
E-GI= EG DISTAL = D
D-GI = DG OCLUSAL = O
D-ART = DA BUCCAL = B
P VITAL = PV LABIAL = L
0 0
P NONVITAL = PN PALATAL = P
A=A RK = Rampan Karies
RSISTENSI = PS
YANG °3/°4 = G3/G4
de
0
1
2 2
3
4
BANDUNG

NAMA: Mozes Rein Gender: 1P= 1 No. Resp.: M 02

W=2 Tanggal : 14 11 2016
ALAMAT: Jl. Kadipaten 11 no. 265 RT,RW,Kelurahan: 04 14 Sulaksana
KANAN
Keadaan gigi C A A B A C B A
DIAGNOSA G3 EA DA EA 2 0 0 0
Letak Caries L O MO 1 0 1 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 9 9 9 9 9 2 0 9 9 9 9 9 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 9 9 9 0 0 9 9 0 0 9 9 9 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O DO
DIAGNOSA DG EA G4 G3 PS 1 0 1 0
Keadaan gigi C B E E C A 0 1 1 1

3 1 3 DI 3 2 3 CI M= 0
0 2 2 1 2 0 0 1 2 1.83 F= 0
OHI - S = 3.83 ____
Artinya : BURUK DMF = 1
CPITN
17 16 11 21 26 27 3 2 0 0 2 2 3 0 2
0 17 46 41 31 36 37 0 2 1 0 0 0 1 2 0 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 7
e= 2
f= 0
____
def = 9
JumlahKode
1 1
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
4 gigi
1 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Sherin Aprilia Gender: 2P= 1 No. Resp.: S 12

W=2 Tanggal : 14 11 2016
ALAMAT: Jl. Cigadung no. 167 Bandung RT,RW,Kelurahan: 03 04 Rancabolang
KANAN
Keadaan gigi A A C E
Letak Caries MO 0 1 0 1
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 4 0 0 9 0 0 0 0 9 0 9 1 9 9 0
DIAGNOSA PN PV 0
Letak Caries OP O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries MB 0
DIAGNOSA DG 0
Keadaan gigi 9 9 1 0 9 0 0 0 0 0 0 0 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA G3 PS DA 0 0 1 0
Keadaan gigi E B D 1 0 1 0

2 0 1 DI 1 0 1 CI M= 1
0 1 1 2 1.17 0 1 0 1 0.67 F= 0
OHI - S = 1.83 ____
CPITN
17 16 11 21 26 27 0 0 1 2 0 1 2
0 17 46 41 31 36 37 0 2 0 1 2 2 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
abolang
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 2
e= 2
f= 1
____
def = 5
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
1 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Ariesta Arfani Gender: 2P= 1 No. Resp.: A 02

W=2 Tanggal : 14 11 2016
ALAMAT: Jl. Gumuruh VII no. 19 Bandung RT,RW,Kelurahan: 06 05 Sukamaju
KANAN
Keadaan gigi B C B
DIAGNOSA A PS A 0 0 1 0
Letak Caries MD 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 6 1 0 0 0 0 0 0 0 0 0 0 3 0 9 0
DIAGNOSA DG DG 0
Letak Caries O O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O MP L 0
DIAGNOSA PV DG EA 1
Keadaan gigi 9 6 1 1 0 0 0 1 0 0 0 0 0 0 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries MO
DIAGNOSA PV G4 0 0 0 0
Keadaan gigi C E 0 0 0 1

2 0 0 DI 2 0 0 CI M= 0
0 2 1 1 1 0 0 1 0 0.5 F= 0
OHI - S = 1.5 ____
CPITN
17 16 11 21 26 27 0 2 0 0 2 0 2 0 2
0 17 46 41 31 36 37 0 0 1 2 2 2 0 1 2 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
maju
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 1
f= 0
____
def = 5
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Dinda Ayu Gender: 2P= 1 No. Resp.: D 19

W=2 Tanggal : 14 11 2016
ALAMAT: Jl. Margahayu Raya blok. 1 no. 109 Bandung RT,RW,Kelurahan: 04 09 Rancabolang
KANAN
Keadaan gigi A A C B B B B C A B
DIAGNOSA EG EA EA EA PS EG EA 4 2 1 0
Letak Caries M RK RK RK RK M P 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries L MB
DIAGNOSA DA G3 A DA A 0 0 0 0
Keadaan gigi B A E B B B A A A A 2 0 1 0

1 0 1 DI 1 0 0 CI M= 0
0 0 1 1 0.67 0 1 2 0 0.67 F= 0
OHI - S = 1.33 ____
CPITN
17 16 11 21 26 27 2 0 0 0 2 0 0
0 17 46 41 31 36 37 0 1 2 2 0 1 2 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
abolang
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 11
e= 1
f= 0
____
def = 12
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
6 gigi
2 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Fatimah Azzahra Gender: 2P= 1 No. Resp.: F 31

W=2 Tanggal : 14 11 2016
ALAMAT: Jl. Kemangi no. 154C Bandung RT,RW,Kelurahan: 18 10 Padasuka
KANAN
Keadaan gigi
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 0 0 0 0 0 0 1 1 0 0 0 0 2 0 9 0
DIAGNOSA EG EG PV 0
Letak Caries M M O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries M M B 0
DIAGNOSA DG DA EG 0
Keadaan gigi 9 0 0 0 0 0 0 2 2 0 0 0 0 3 0 9 1
85 84 83 82 81 71 72 73 74 75 0
Letak Caries
DIAGNOSA 0 0 0 0

2 1 3 DI 0 0 2 CI M= 0
0 0 0 2 1.33 0 0 0 0 0.33 F= 0
OHI - S = 1.67 ____
CPITN
17 16 11 21 26 27 0 2 2 0 3 0 2 2 3
0 17 46 41 31 36 37 0 0 0 0 0 2 2 0 0 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
suka
KIRI
0
0 0 0 0
0 0 KODE:
2
0 0 0 0
PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
JumlahKode
0 0
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Sofyan Kevin Gender: 1P= 1 No. Resp.: K 01

W=2 Tanggal : 14 11 2016
ALAMAT: Komp. Setiabudhi no. 1A Bandung RT,RW,Kelurahan: 07 09 Setiabudhi
KANAN
Keadaan gigi A A A B A
DIAGNOSA EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 9 9 9 0 0 0 9 9 9 0 3 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 0 9 9 0 3 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries MB OB O
DIAGNOSA EA EG G3 DA 1 1 0 0
Keadaan gigi C C B E A B 1 0 1 0

2 0 1 DI 3 0 2 CI M= 0
0 1 1 2 1.17 0 1 2 0 1.33 F= 0
OHI - S = 2.5 ____
CPITN
17 16 11 21 26 27 2 0 0 0 0 2 2 0 2
0 17 46 41 31 36 37 0 2 0 2 1 1 2 2 2 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
budhi
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 5
e= 1
f= 1
____
def = 7
JumlahKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
2 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Rifqi Akaresyawa Gender: 1P= 1 No. Resp.: R 10

W=2 Tanggal : 14 11 2016
ALAMAT: JL. Gurame no. 15 Bandung RT,RW,Kelurahan: 03 04 Buahbatu
KANAN
Keadaan gigi C C E
DIAGNOSA DG DA G4 0 0 0 0
Letak Caries DO O 1 1 0 1
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 3 0 0 0 0 0 0 0 0 9 9 0 4 0 9 0
DIAGNOSA DG 0
Letak Caries O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O B B 0
DIAGNOSA PV DG DA 0
Keadaan gigi 9 3 2 9 0 0 0 1 1 0 0 0 0 3 3 9 1
85 84 83 82 81 71 72 73 74 75 0
Letak Caries
DIAGNOSA 0 0 0 0
Keadaan gigi A 0 0 0 0

2 2 3 DI 2 1 2 CI M= 1
0 3 1 1 2 0 2 0 1 1.33 F= 0
OHI - S = 3.33 ____
CPITN
17 16 11 21 26 27 0 3 1 0 3 2 3 1 3
0 17 46 41 31 36 37 0 1 3 0 2 2 1 3 2 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
batu
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 1
f= 0
____
def = 5
JumlahKode
1 1
3 4
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
1 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Bogi Satrio Gender: 1P= 1 No. Resp.: B 01

W=2 Tanggal : 14 11 2016
ALAMAT: JL. Kawaluyaan no 29 Bandung RT,RW,Kelurahan: 02 07 Cidurian
KANAN
Keadaan gigi C C A
Letak Caries MB O 0 2 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 3 0 0 9 0 0 0 0 9 0 0 3 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 0 0 0 9 9 0 0 0 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O

0 0 3 DI 0 0 2 CI M= 0
0 2 1 1 1.17 0 0 1 1 0.67 F= 0
OHI - S = 1.83 ____
CPITN
17 16 11 21 26 27 0 1 1 1 1 1 1 1 1
0 17 46 41 31 36 37 0 0 0 1 0 2 1 0 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ian
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 0
f= 0
____
def = 4
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
2 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Firman Ramadhan Gender: 1P= 1 No. Resp.: F 12

W=2 Tanggal : 14 11 2016
ALAMAT: Jl. Semarang no. 21 Bandung RT,RW,Kelurahan: 02 04 Antapani
KANAN
Keadaan gigi A A B A E C
DIAGNOSA DG G4 DG 0 0 0 0
Letak Caries M MO 0 2 0 1
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 3 9 9 9 0 0 9 9 9 3 1 9 9 0
DIAGNOSA EA 1
Letak Caries L 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries B 0
DIAGNOSA EA 1
Keadaan gigi 9 9 0 3 9 9 9 9 0 0 9 9 3 1 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O OB MB O
DIAGNOSA A DG PS DA EA 1 0 1 0
Keadaan gigi C A B A C B 1 1 0 0

2 0 1 DI 1 0 1 CI M= 0
0 0 0 3 1 0 0 1 0 0.5 F= 0
OHI - S = 1.5 ____
CPITN
17 16 11 21 26 27 1 1 0 0 1 1 0
0 17 46 41 31 36 37 0 0 1 1 0 0 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ani
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 6
e= 1
f= 0
____
def = 7
JumlahKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
2 gigi
3 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: AKILA Gender: 2P= 1 No. Resp.: A001
W=2 Tanggal : 04 01 2017
ALAMAT: JL. ANGGREK N0.2 RT,RW,Kelurahan: 02 06 SUKAJADI
KANAN KIRI
Keadaan gigi B - - - - - - - - A
DIAGNOSA DA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 KODE:
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi A - - - - - - - - A 0 0 0 0 GOYANG

1 0 1 DI 0 0 0 CI M= 0 e= 0
0 1 1 1 0.83 0 1 0 1 0.33 F= 0 f= 0
OHI - S = 1.17 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 2 2
0 17 46 41 31 36 37 0 1 0 0 1 1 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL/VESTIBULAR = V
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG
KARTU SURVEY KESE

USAHA KESEHAT
NAMA: ADI RAHMAT Gender: 2P= 1

W=2
Umur: 7 tahun
ALAMAT: JL. KENCANA NO.18
KANAN
Keadaan gigi A A A B
DIAGNOSA EG
Letak Caries M
55 54 53 52
Keadaan gigi 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
Keadaan gigi 0 0
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi A A A
Segment
Plaque Score
1 0 1 DI
0 1 1 1 0.83 0
OHI - S = 1.17
Artinya : BAIK
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 10
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A002

Tanggal : 05 01 2017
RT,RW,Kelurahan: 05 08 CIBUBUR
A A A A
0 1 0 0
0 0 0 0
51 61 62 63 64 65 0
0 0 0 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0
81 71 72 73 74 75 0
V
EG 0 1 0 0
A C A 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
1 0 1 0.33 F= 0
____
DMF = 0
Score Segmen
0 0 0 0 0 0 0
1 0 0 1 1 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 KMD-ART = DA BUCCAL/VESTIBULAR = V
0 0 0 0
PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: ISYANA KUSUMAH Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: JL. KENCANA NO.22
KANAN
Keadaan gigi A
DIAGNOSA PS
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries V
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
1 0 1 DI
0 1 0 1 0.67 0
OHI - S = 1.17
Artinya : BAIK
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A003

Tanggal : 05 01 2017
RT,RW,Kelurahan: 08 08 CIBUBUR
0 0 1 0
0 0 0 0
51 61 62 63 64 65 0
0 0 0 0 0 0 0 0 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 6 0 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 1
1 0 0 CI M= 0
1 0 1 0.50 F= 0
____
DMF = 1
Score Segmen
0 0 0 0 0 0 0
1 0 0 1 1 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 1
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: BILLY FUAD Gender: 1P= 1

W=2
Umur: 9 tahun
ALAMAT: JL. CITARUM NO.25A
KANAN
Keadaan gigi A - A -
DIAGNOSA
Letak Caries
55 54 53 52
Keadaan gigi 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O
DIAGNOSA EG
Keadaan gigi C -
Segment
Plaque Score
1 0 1 DI
0 1 0 1 0.67 0
OHI - S = 1.17
Artinya : BAIK
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 16
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A004

Tanggal : 08 02 2017
RT,RW,Kelurahan: 09 12 CIBEUNYING KIDUL
- - - A - A
0 0 0 0
0 0 0 0
51 61 62 63 64 65 0
0 0 0 0 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0
81 71 72 73 74 75 0
0 1 0 0
- D 0 0 0 0
Segment Segment
Calculus Score D= 0
1 0 0 CI M= 0
1 0 1 0.50 F= 0
____
DMF = 0
Score Segmen
0 0 0 0 0 0 0
1 0 0 1 1 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 1
e= 0
f= 1
____
def = 2
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: AYU NASYID Gender: 2P= 1

W=2
Umur: 9 tahun
ALAMAT: JL. BANJARAN NO 12
KANAN
Keadaan gigi A - A -
DIAGNOSA
Letak Caries
55 54 53 52
Keadaan gigi 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O
DIAGNOSA PV
Keadaan gigi B -
Segment
Plaque Score
2 0 1 DI
0 1 0 2 1.00 0
OHI - S = 1.50
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 15
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A005

Tanggal : 14 01 2017
RT,RW,Kelurahan: 12 01 BALEENDAH
- - - A - A
0 0 0 0
0 0 0 0
51 61 62 63 64 65 0
0 0 0 0 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0
81 71 72 73 74 75 0
0 0 0 0
- F 0 0 0 0
Segment Segment
Calculus Score D= 0
1 0 0 CI M= 0
1 0 1 0.50 F= 0
____
DMF = 0
Score Segmen
1 0 0 0 1 0 0
1 0 0 1 1 0 1
-
1= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: EDWIN SUPONO Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: JL. PADASUKA NO 25
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA G3
Keadaan gigi A
Segment
Plaque Score
1 1 1 DI
0 2 0 2 1.17 0
OHI - S = 1.67
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 2
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A006

Tanggal : 18 02 2017
A
G3 0 0 0 0
0 0 1 0
51 61 62 63 64 65 0
0 0 0 0 0 0 0 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 6 0 0
81 71 72 73 74 75 0
0 0 0 0
0 0 1 0
Segment Segment
Calculus Score D= 0
1 0 0 CI M= 0
1 0 1 0.50 F= 0
____
DMF = 0
Score Segmen
0 0 0 0 0 0 0
1 0 0 1 1 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 2
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: LUTHFI AULIA Gender: 1P= 1

W=2
Umur: 13 tahun
ALAMAT: JL. PADASUKA NO 15
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
2 1 1 DI
0 1 0 2 1.17 0
OHI - S = 1.83
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 20
- Sealant =6 6
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A007

Tanggal : 18 02 2017
A
PS 0 0 1 0
0 0 0 0
51 61 62 63 64 65 0
1 1 0 0 0 0 6 0 0
EG EG 0
M M 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 6 6 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 2
2 0 0 CI M= 0
1 0 1 0.67 F= 0
____
DMF = 2
Score Segmen
1 0 0 0 1 0 0
1 0 0 1 1 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 2
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
2
0 0 0 0
PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: IKHSAN MUHAMMAD Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: JL. CIMUNCANG NO.085
KANAN
Keadaan gigi B
DIAGNOSA A
Letak Caries L
55 54 53 52
Keadaan gigi 6 0 0 0 1
DIAGNOSA EG
Letak Caries D
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
1 0 1 DI
0 1 0 2 0.83 0
OHI - S = 1.50
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 4
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A008

Tanggal : 25 02 2017
RT,RW,Kelurahan: 14 05 CIBEUNYING KALER
C
EG 0 1 0 0
L 0 0 0 0
51 61 62 63 64 65 0
1 0 0 0 0 6 0
EG 0
M 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 6 0 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 2
1 0 1 CI M= 0
1 0 1 0.67 F= 0
____
DMF = 2
Score Segmen
1 0 0 1 1 0 1
1 0 0 1 1 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 2
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
2
0 0 0 0
PERSISTENSI = PS
d= 2
e= 0
f= 1
____
def = 3
Jumlah ScKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: ILYAS HASYIM Gender: 1P= 1

W=2
Umur: 8 tahun
ALAMAT: JL. JATINANGOR NO. 32
KANAN
Keadaan gigi B A A
DIAGNOSA A
Letak Caries L
55 54 53 52
Keadaan gigi 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
Keadaan gigi 6 0
85 84 83 82
Letak Caries O
DIAGNOSA DA
Keadaan gigi B F A
Segment
Plaque Score
1 0 1 DI
0 1 0 2 0.83 0
OHI - S = 1.50
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 9
- Sealant =6 2
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A009

Tanggal : 27 02 2017
RT,RW,Kelurahan: 09 04 JATINANGOR
A A C
EG 0 1 0 0
L 0 0 0 0
51 61 62 63 64 65 0
0 0 0 6 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0
81 71 72 73 74 75 0
V
EG 0 1 0 0
A A B 1 0 0 0
Segment Segment
Calculus Score D= 0
1 0 1 CI M= 0
1 0 1 0.67 F= 0
____
DMF = 0
Score Segmen
1 0 0 1 1 0 1
1 0 0 1 1 0 1
-
1= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 0
f= 0
____
def = 4
Jumlah ScKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
1 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: ANGEL ELIZABETH Gender: 2P= 1

W=2
Umur: 7 tahun
ALAMAT: JL. SUNDA NO. 09
KANAN
DIAGNOSA A EG
Letak Caries L D
55 54 53 52
Keadaan gigi 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
Keadaan gigi 0 0
85 84 83 82
Letak Caries O
DIAGNOSA DA
Keadaan gigi B F A
Segment
Plaque Score
1 0 1 DI
0 2 0 1 0.83 0
OHI - S = 1.33
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 21 26 27
0 17 46 41 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 10
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: A010

Tanggal : 30 02 2017
RT,RW,Kelurahan: 12 10 CIDURIAN
A A A C
EG 0 2 0 0
L 0 0 0 0
51 61 62 63 64 65 0
0 0 0 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0
81 71 72 73 74 75 0
V
EG 0 1 0 0
A F B 1 0 0 0
Segment Segment
Calculus Score D= 0
1 0 0 CI M= 0
1 0 1 0.50 F= 0
____
DMF = 0
Score Segmen
1 0 0 0 1 0 0
1 0 0 1 1 0 1
-
2= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke :
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 5
e= 0
f= 1
____
def = 6
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
1 gigi
3 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Natasya Salsa. N 2P= 1
Gender: No. Resp.: N01
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Terusan Perintis No. 13, Sarijadi-Bandung RT,RW,Kelurahan: 05 03 Cijerokaso
KANAN KIRI
Keadaan gigi B A B B B
DIAGNOSA DA DG PS DA 0 0 1 0
Letak Caries O O M O 2 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DA DG DG 0 0 0 0 PERSISTE
Keadaan gigi C C E B 1 2 0 0 GOYANG

1 1 DI 0 1 CI M= 0 e= 1
0 0 0 1 0.5 0 1 1 0 0.5 F= 0 f= 0
OHI - S = 1 ____ ____
CPITN
11 21 26 2 1 0 0 2 0 1 1
0 41 31 0 1 0 0 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
VITAL = PVLABIAL = L
0
NONVITALPALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Anita Fujiawati Gender: 2P= 1 No. Resp.: A02
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Babakan Loa No.04 RT,RW,Kelurahan: 06 02 Gunung Batu
KANAN
Keadaan gigi C E B B
DIAGNOSA DG PS DG 0 0 1 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 0 0 9 0 0 0 0 0 9 9 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O M O
DIAGNOSA EA DG G3 1 0 0 0
Keadaan gigi B C B 0 1 1 0

2 0 2 DI 1 0 0 CI M= 0
0 1 0 0.83 0 0 1 0.33 F= 0
OHI - S = 1.17 ____
CPITN
16 11 21 26 1 1 0 0 1 1 0
0 46 41 31 0 1 1 0 1 1 0

- Gigi sehat = 0 16 0=A - Tak memerlukan scaling
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 1
f= 1
____
def = 6
Jumlah SKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
1 gigi
3 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Yandi Purnama Gender: 1P= 1 No. Resp.: Y03
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Soekarno Hatta No.04 Bandug RT,RW,Kelurahan: 18 04 Cibatu
KANAN
Keadaan gigi B C C E
DIAGNOSA PS DG DA 0 0 1 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 9 0 0 0 0 0 0 9 0 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 0 9 0 0 0 0 0 0 0 0 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA DA 0 0 0 0

1 1 0 DI 0 0 0 CI M= 0
0 0 0 0 0.33 0 1 1 1 0.5 F= 0
OHI - S = 0.83 ____
CPITN
16 11 21 26 0 1 1 1 0 1 1
0 46 41 31 36 0 1 1 0 0 1 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 1
f= 0
____
def = 5
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
2 gigi
1 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Cahya Gumilar Gender: 1P= 1 No. Resp.: C04
W=2 Tanggal : 09 01 2017
ALAMAT: jln. Sukajadi No.20- Bandung RT,RW,Kelurahan: 12 01 Sukajadi
KANAN
Keadaan gigi B A D B A A B B
DIAGNOSA DA DG EA DG 1 0 0 0
Letak Caries O D M O 1 2 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O M O
Keadaan gigi C D A B D B 1 1 0 0

0 0 0 DI 0 0 0 CI M= 0
0 1 1 2 0.67 0 1 0 2 0.5 F= 0
OHI - S = 1.17 ____
CPITN
16 11 21 26 0 1 0 1 0 1 1
0 46 41 31 36 0 0 1 1 2 0 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 KMP VITAL = P LABIAL = L
0 0 0 0
>0 0 KMP NONVITALPALATAL = P
PERSISTENSI = PS
d= 7
e= 0
f= 4
____
def = 11
JumlahKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
4 gigi
3 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Anti Purwanti Gender: 2P= 1 No. Resp.: A05
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Jendral Ahmad Yani No.12-Bandung RT,RW,Kelurahan: 04 07 Cicadas
KANAN
Keadaan gigi C B B A
DIAGNOSA DA DG 0 0 0 0
Letak Caries O M 1 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 0 9 0 0 0 0 9 9 0 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 0 9 0 0 0 0 9 9 0 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries D O O
DIAGNOSA DG EA DA 1 0 0 0
Keadaan gigi C B A B 1 1 0 0

2 0 2 DI 1 0 0 CI M= 0
0 0 1 0 0.83 0 0 0 1 0.33 F= 0
OHI - S = 1.17 ____
CPITN
16 11 21 26 1 1 0 0 1 1 0
0 46 41 31 36 0 0 0 1 1 0 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
>0 0 KMP NONVITAL =PALATAL = P
PERSISTENSI = PS
d= 6
e= 0
f= 1
____
def = 7
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
3 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Nia Komalasari Gender: 2P= 1 No. Resp.: N06
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Utama No.28 Sukajadi, Bandung RT,RW,Kelurahan: 13 05 Sukajadi
KANAN
Keadaan gigi B B C B
DIAGNOSA A
DG DG EA 1 0 0 0
Letak Caries M O D 0 2 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 9 9 0 0 0 0 9 9 0 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 0 0 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA EA 1 0 0 0
Keadaan gigi B D E 0 0 0 0

2 0 1 DI 2 0 1 CI M= 0
0 2 2 2 1.5 0 0 0 2 0.83 F= 0
OHI - S = 2.33 ____
CPITN
16 11 21 26 1 1 2 0 1 2 0
0 46 41 31 36 0 0 1 0 0 0 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
>0 0 KMP NONVITAL = PALATAL = P
PERSISTENSI = PS
d= 5
e= 1
f= 2
____
def = 8
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
2 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Andi Rustandi Gender: 1P= 1 No. Resp.: A07
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Cijerokaso No.14-Bandung RT,RW,Kelurahan: 08 05 Sarijadi
KANAN
Keadaan gigi C D B E B B
DIAGNOSA DA DG PS G3 0 0 1 0
Letak Caries M O O M 1 1 1 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 0 0 9 9 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 0 9 0 9 0 0 0 0 0 0 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries M
DIAGNOSA DG 0 0 0 0
Keadaan gigi D E B 0 1 0 0

3 0 DI 0 0 CI M= 0
0 0 1 1 0.83 0 1 2 0 0.5 F= 0
OHI - S = 1.33 ____
CPITN
16 11 21 26 0 1 0 1 0 1 1
0 46 41 31 36 0 0 1 1 1 0 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
>0 0 KMP NONVITAL = PNPALATAL = P
PERSISTENSI = PS
d= 5
e= 2 s
f= 2
____
def = 9
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
1 gigi
2 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Ilfa Nurrahmah. P 2P= 1
Gender: No. Resp.: I08
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Jendral Sudirmah No.05-Bandung RT,RW,Kelurahan: 02 06 Cimahi
KANAN
Keadaan gigi B
DIAGNOSA DG 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 9 0 0 0 0 0 0 0 9 0 0 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 0 0 0 0 0 0 0 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O D O
DIAGNOSA DA DG DG 0 0 0 0
Keadaan gigi B C B 1 2 0 0

0 0 DI 1 0 0 CI M= 0
0 1 2 2 0.83 0 2 0 0 0.5 F= 0
OHI - S = 1.33 ____
CPITN
11 21 26 1 1 0 0 1 1 0
0 46 41 31 36 0 2 1 2 0 2 2 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
>0 0 KMP NONVITAL = PNPALATAL = P
PERSISTENSI = PS
d= 4
e= 0
f= 1
____
def = 5
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
3 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Asep Jaelani Gender: 1P= 1 No. Resp.: A09
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Sukajadi N0.12-Bandung RT,RW,Kelurahan: 06 05 Sukajadi
KANAN
Keadaan gigi C B
Letak Caries B M 0 1 1 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 9 0 0 0 0 0 9 0 0 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 0 0 9 0 0 0 0 9 0 0 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O M
DIAGNOSA DA PS 0 0 1 0
Keadaan gigi D B B 1 0 0 0

0 0 1 DI 1 0 0 CI M= 0
0 1 1 2 0.83 0 1 2 0 0.67 F= 0
OHI - S = 1.5 ____
CPITN
16 11 21 26 2 1 0 0 2 1 0
0 46 41 31 36 0 1 1 2 0 1 2 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 5
e= 0
f= 1
____
def = 6
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
1 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Rizky Setiadi 1P= 1
Gender: No. Resp.: R10
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Babakan Loa No. 30-Bandung RT,RW,Kelurahan: 13 09 Gunung Batu
KANAN
Keadaan gigi B C D E
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 9 9 0 0 0 0 0 9 0 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 0 9 0 0 0 0 0 9 0 0 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries D O
DIAGNOSA DG DA 0 0 0 0
Keadaan gigi C E B 1 1 0 0

1 1 1 DI 0 0 2 CI M= 0
0 1 1 1 1 0 2 2 1 1.17 F= 0
OHI - S = 2.17 ____
CPITN
16 11 21 26 2 1 2 2 2 2 2
0 46 41 31 36 0 1 1 0 0 1 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 2
f= 3
____
def = 9
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Neng Susi 2P= 1
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Terusan Perintis No.50 , Sarijadi-Bandung RT,RW,Kelurahan: 13 03 sarijadi
KANAN KIRI
Keadaan gigi B A B B A
DIAGNOSA DA EG PS 0 1 1 0
Letak Caries O O M 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA - 0 0
Letak Caries - 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DA DG PS DG 0 0 1 0 PERSISTE
Keadaan gigi C C A B 1 2 0 0 GOYANG

1 1 1 DI 0 0 1 CI M= 0 e= 0
0 1 0 0 0.67 0 1 1 0 0.5 F= 0 f= 0
OHI - S = 1.17 ____ ____
CPITN
11 21 26 2 1 0 0 2 0 1 1
0 46 41 31 0 2 1 0 2 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
VITAL = PVLABIAL = L
0
NONVITALPALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Iran Sutiawan Gender: 1P= 1 No. Resp.: I002
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Sarijadi No 10 RT,RW,Kelurahan: 06 02 Sarijadi
KANAN
Keadaan gigi C B B
DIAGNOSA EG - G3 DG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 0 0 0 0 0 0 0 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 0 0 0 0 0 0 0 0 9 9 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O
DIAGNOSA EA G3 1 0 0 0

1 0 1 DI 1 0 0 CI M= 0
0 1 0 0 0.5 0 0 1 1 0.5 F= 0
OHI - S = 1 ____
CPITN
16 11 21 26 1 1 0 0 1 1 0
0 46 41 31 0 1 1 0 1 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 0
f= 1
____
def = 5
Jumlah SKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
1 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Cep Muhidin 1P= 1
Gender: No. Resp.: C003
W=2 Tanggal : 09 01 2017
ALAMAT: kp. Gelarmulya Desa. Sukamulya Leles Cianjur SelRT,RW,Kelurahan: 13 04 Cianjur
KANAN
Keadaan gigi
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 0 0 0 0 0 0 0 0 0 1 9 9 0
DIAGNOSA EG 0
Letak Caries O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 0 9 0 0 0 0 0 0 0 0 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA DA 0 0 0 0
Keadaan gigi D 1 0 0 0

1 1 2 DI 0 0 1 CI M= 0
0 0 0 0 0.67 0 1 1 1 0.67 F= 0
OHI - S = 1.33 ____
CPITN
16 11 21 26 0 1 1 2 0 1 2
0 46 41 31 36 0 1 1 0 0 1 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 0
e= 0
f= 1
____
def = 1
JumlahKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Ratna Octaviana Gender: 2P= 1 No. Resp.: R004
W=2 Tanggal : 09 01 2017
ALAMAT: jln. Sukajadi No. 6- Bandung RT,RW,Kelurahan: 12 01 Sukajadi
KANAN
Keadaan gigi B A D B A A B B
DIAGNOSA DA EG DG DG 0 1 0 0
Letak Caries O D M O 1 2 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O M O
Keadaan gigi C D A B D B 1 1 0 0

0 0 0 DI 0 0 0 CI M= 0
0 1 1 2 0.67 0 1 0 2 0.5 F= 0
OHI - S = 1.17 ____
CPITN
16 11 21 26 1 1 1 0 1 1 0
0 46 41 31 36 0 1 1 0 0 1 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 KMP VITAL = P LABIAL = L
0 0 0 0
>0 0 KMP NONVITALPALATAL = P
PERSISTENSI = PS
d= 7
e= 0
f= 4
____
def = 11
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
3 gigi
4 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Henny Gender: 2P= 1 No. Resp.: H005
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Jendral Ahmad Yani No.12-Bandung RT,RW,Kelurahan: 04 07 Cicadas
KANAN
Keadaan gigi B A A A A A A A B B
DIAGNOSA EG PS DA DG 0 1 1 0
Letak Caries D O O 1 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 9 9 9 0 9 9 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O
Keadaan gigi B A A A A A A B 1 0 0 0

2 0 2 DI 1 0 1 CI M= 0
0 0 1 2 1.17 0 0 0 1 0.5 F= 0
OHI - S = 1.67 ____
CPITN
16 11 26 1 1 0 1 1 0
0 46 41 31 36 0 0 0 1 1 0 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
>0 0 KMP NONVITAL =PALATAL = P
PERSISTENSI = PS
d= 5
e= 0
f= 1
____
def = 6
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
2 gigi
3 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Riki Muladi Gender: 1P= 1 No. Resp.: R006
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Cibolang Parigi Cianjur Selatan RT,RW,Kelurahan: 02 04 Parigi
KANAN
Keadaan gigi B A A B A A E
DIAGNOSA DA PS G3 0 0 1 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 9 9 9 9 0 0 0 0 9 9 9 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O

1 0 1 DI 0 0 0 CI M= 0
0 1 0 1 0.67 0 1 0 1 0.33 F= 0
OHI - S = 1 ____
CPITN
16 11 21 26 1 0 0 1 1 0 1
0 46 41 31 36 0 1 0 0 1 1 0 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 DIAGNOSLETAK CARIES
KME-ART= MESIAL = M
KME-GI= DISTAL = D
0 0 KMD-GI = OCLUSAL = O
0 KMD-ARTBUCCAL = B
0 KMP VITALLABIAL = L
0 0 0 0
>0 0 KMP NONV PALATAL = P
PERSISTENSI = PS
d= 4
e= 1
f= 0
____
def = 5
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
3 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Mardiana Keysha V.P Gender: 2P= 1 No. Resp.: M007
W=2 Tanggal : 09 01 2017
ALAMAT: Jln. Sukamulya Desa. Sukamulya Leles Cianjur SeRT,RW,Kelurahan: 03 05 Leles
KANAN
Keadaan gigi B A B A B B
DIAGNOSA DA PS EG PV 0 1 1 0
Letak Caries M P O O 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O

1 0 2 DI 0 0 0 CI M= 0
0 2 0 1 1 0 0 0 0 0 F= 0
OHI - S = 1 ____
CPITN
16 11 21 26 1 0 0 1 1 0 1
0 46 41 31 36 0 1 0 0 1 1 0 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
T
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 6
e= 0
f= 0
____
def = 6
JumlahKode
4 2
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
= 0
esehatan mulut = 1
= 2 1
= 3
GS
3 gigi
1 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Tya Halimatul Sadiah Gender: 2P= 1 No. Resp.: T008
W=2 Tanggal : 09 01 2017
ALAMAT: Gg. Utama No. 2 Sukajadi Bandung RT,RW,Kelurahan: 01 01 Sukajadi
KANAN
Keadaan gigi B A A A A A A A B B
DIAGNOSA DA PS EG DG 0 1 1 0
Letak Caries O M O 1 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 9 9 9 0 9 9 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O
Keadaan gigi B A A A A A A B 1 0 0 0

1 0 1 DI 0 0 0 CI M= 0
0 1 0 2 0.83 0 0 0 1 0.17 F= 0
OHI - S = 1 ____
CPITN
16 11 26 1 0 1 1 0 1
0 46 41 31 36 0 1 0 0 1 1 0 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 5
e= 0
f= 0
____
def = 5
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
2 gigi
3 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Yusuf Bahtiar Gender: 1P= 1 No. Resp.: Yoo9
W=2 Tanggal : 09 01 2017
ALAMAT: Cibolang Padangsari Leles Cianjur Selatan RT,RW,Kelurahan: 04 03 Padang Sari
KANAN
DIAGNOSA DA PS PS DG 0 0 2 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O

1 1 1 DI 0 0 0 CI M= 0
0 1 1 1 1 0 0 0 0 0 F= 0
OHI - S = 1 ____
CPITN
16 11 21 26 1 1 1 1 1 1 1
0 46 41 31 36 0 1 1 1 1 1 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
T
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 0
f= 0
____
def = 4
JumlahKode
6 2
0 0
0
= 0
= 1 2
= 2
= 3 2 2
0
= 0
esehatan mulut = 1
= 2 1
= 3
GS
3 gigi
1 gigi
INF
2 gigi
0 gigi
BANDUNG

NAMA: Herni Damayanti Gender: 2P= 1 No. Resp.: H010
W=2 Tanggal : 09 01 2017
ALAMAT: Cibogo Karawang RT,RW,Kelurahan: 07 06 Teluk Jambe
KANAN
Keadaan gigi B A A A A A A B
DIAGNOSA DA PV 0 0 0 0
Letak Caries DO O 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O B
Keadaan gigi C A A A A C 0 0 0 0

0 0 0 DI 0 0 0 CI M= 0
0 1 1 1 0.5 0 0 0 1 0.17 F= 0
OHI - S = 0.67 ____
CPITN
16 11 21 26 1 0 0 1 1 0 1
0 46 41 31 36 0 1 0 0 1 1 0 1

- Gigi sehat = 0 10 10 = A - Tak memerlukan scaling
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
>0 0 KMP NONVITAL = P PALATAL = P
PERSISTENSI = PS
d= 5
e= 0
f= 0
____
def = 5
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 1
= 3
GS
1 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Nia Komalasari Gender: 2P= 1 No. Resp.: N.201
W=2 Tanggal : 08 01 2017
ALAMAT: Sukajadi RT,RW,Kelurahan: 05 02 Pasteur
KANAN KIRI
Keadaan gigi D A A A B E
DIAGNOSA PS DG 0 0 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries D O KMA = A
DIAGNOSA DG DG 0 0 0 0 PERSISTE
Keadaan gigi E B A A B E 0 2 0 0 GOYANG

2 0 2 DI 1 0 0 CI M= 0 e= 3
0 2 1 2 1.5 0 2 0 1 0.67 F= 0 f= 2
OHI - S = 2.17 ____ ____
CPITN
16 11 21 26 1 0 0 0 1 0 0 2 2
0 46 41 31 36 0 2 0 0 1 2 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Arini Putri Gender: 2P= 1 No. Resp.: A.355
W=2 Tanggal : 08 01 2017
ALAMAT: Sukagalih RT,RW,Kelurahan: 08 02 Pasteur
KANAN
Keadaan gigi B D A A B A B C
DIAGNOSA DA EA DA DA 1 0 0 0
Letak Caries O D O M 3 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 2 9 9 0
DIAGNOSA EG 0
Letak Caries M 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0
DIAGNOSA DG 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 1 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O B

0 0 0 DI 0 0 0 CI M= 0
0 1 0 2 0.5 0 2 1 1 0.67 F= 0
OHI - S = 1.17 ____
CPITN
16 11 21 26 0 0 0 2 0 0 2
0 46 41 31 36 0 0 1 0 2 0 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 7
e= 0
f= 2
____
def = 9
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
6 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Hanif Wijaya Gender: 1P= 1 No. Resp.: H.555
W=2 Tanggal : 08 01 2017
ALAMAT: Jl.Bojong Kenyot RT,RW,Kelurahan: 06 01 Bojong Koneng
KANAN
Keadaan gigi A A B A A A A
DIAGNOSA PS PS EG PS PS PS G4 0 1 5 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 0 9 0 0 0 0 9 0 0 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O M 0
DIAGNOSA DG EG 0
Keadaan gigi 9 9 1 0 0 9 0 1 0 0 9 0 0 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries D
DIAGNOSA PS DG PS G4 G3 0 0 2 0
Keadaan gigi A B A A D A 0 1 1 1

0 0 1 DI 0 0 0 CI M= 0
0 3 1 1 1 0 3 1 0 0.67 F= 0
OHI - S = 1.67 ____
CPITN
16 11 21 26 0 0 0 1 0 0 1
0 46 41 31 36 0 3 1 0 1 3 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 2
e= 0
f= 2
____
def = 4
JumlahKode
3 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
2 gigi
INF
7 gigi
0 gigi
BANDUNG

NAMA: Anang Somantri Gender: 1P= 1 No. Resp.: A.300
W=2 Tanggal : 08 01 2017
ALAMAT: Jl. Terusan Perintis RT,RW,Kelurahan: 03 01 Sarijadi
KANAN
Keadaan gigi D A B A A A C
DIAGNOSA PS DG PS PS DG 0 0 3 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 0 9 0 0 0 0 9 0 9 1 9 9 0
DIAGNOSA EG 0
Letak Caries O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS PS PS PN 0 0 3 0
Keadaan gigi A A A A A A B 0 0 0 0

0 0 2 DI 0 0 0 CI M= 0
0 1 1 3 1.17 0 1 2 3 1 F= 0
OHI - S = 2.17 ____
CPITN
16 11 21 26 0 1 0 0 1 0 1 1
0 46 41 31 36 0 1 1 2 3 1 1 2 3

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 2
____
def = 5
JumlahKode
3 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
2 gigi
INF
6 gigi
0 gigi
BANDUNG

NAMA: Fahrizal Zulfiqar Gender: 1P= 1 No. Resp.: F.165
W=2 Tanggal : 08 01 2017
ALAMAT: Cibogo RT,RW,Kelurahan: 05 02 Margamulya
KANAN
DIAGNOSA DG PS PS G3 0 0 2 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 3 9 0 0 0 0 0 0 0 0 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 0 0 0 9 0 0 0 0 0 0 9 9 2 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS G4 EG 0 1 1 0
Keadaan gigi C A A C A 0 0 0 1

1 0 1 DI 0 0 0 CI M= 0
0 2 1 3 1.33 0 1 0 1 0.33 F= 0
OHI - S = 1.67 ____
CPITN
16 11 21 26 0 0 0 0 0 0 0
0 46 41 31 36 0 2 1 0 2 2 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 1
____
def = 4
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
2 gigi
INF
3 gigi
0 gigi
BANDUNG

NAMA: Helmina Dwiyani Gender: 2P= 1 No. Resp.: H.228
W=2 Tanggal : 08 01 2017
ALAMAT: Jl.Jendral Sudirman RT,RW,Kelurahan: 13 08 Palawati
KANAN
Keadaan gigi A D A A C C
Letak Caries O D 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O M
Keadaan gigi B A A B A D 0 1 0 0

0 0 1 DI 0 0 0 CI M= 0
0 0 1 1 0.5 0 0 1 2 0.5 F= 0
OHI - S = 1 ____
CPITN
16 11 21 26 1 0 0 2 1 0 2
0 46 41 31 36 0 1 1 0 0 1 1 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 0
f= 3
____
def = 7
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
4 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Maelan Sri Gender: 2P= 1 No. Resp.: M.124
W=2 Tanggal : 08 01 2017
ALAMAT: Jl.Cikeris RT,RW,Kelurahan: 07 04 Bojong Sawit
KANAN
Keadaan gigi A A C A A A A B
DIAGNOSA PS EG PS G4 G3 DG 0 1 2 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 2 9 0 0 0 0 9 0 9 0 9 9 0
DIAGNOSA EG 0
Letak Caries O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries M 0
DIAGNOSA DG 0
Keadaan gigi 9 0 0 9 0 0 0 0 0 0 0 0 9 2 3 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA EG PS PS 0 1 2 0
Keadaan gigi B A A A 0 0 0 0

1 1 1 DI 1 0 0 CI M= 0
0 0 0 2 0.83 0 1 1 3 1 F= 1
OHI - S = 1.83 ____
CPITN
16 11 21 26 0 1 1 1 0 1 1
0 46 41 31 36 0 1 0 1 3 1 1 3

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
JumlahKode
4 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
3 gigi
INF
4 gigi
0 gigi
BANDUNG

NAMA: Tasya Febriana Gender: 2P= 1 No. Resp.: T.200
W=2 Tanggal : 08 01 2017
ALAMAT: Jl. Sawit RT,RW,Kelurahan: 10 03 Darangdan
KANAN
Keadaan gigi A D B A A A A C
DIAGNOSA EG PS PS EG 0 2 2 0
Letak Caries M D 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 2 9 9 9 0 0 0 0 9 9 9 0 9 9 0
DIAGNOSA DG 0
Letak Caries OB 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS G4 DA 0 0 1 0
Keadaan gigi D A A A A B 1 0 0 1

1 0 0 DI 1 0 0 CI M= 0
0 1 1 0 0.5 0 2 2 1 1 F= 0
OHI - S = 1.5 ____
CPITN
16 11 21 26 1 0 0 0 1 0 0
0 46 41 31 36 0 2 1 1 0 2 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 3
____
def = 6
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
2 gigi
INF
3 gigi
0 gigi
BANDUNG

NAMA: Dino Andalisto Gender: 1P= 1 No. Resp.: D.176
W=2 Tanggal : 08 01 2017
ALAMAT: Jl.Tunggakjati RT,RW,Kelurahan: 06 03 Tanjung Pura
KANAN
Keadaan gigi B A A A A A C
DIAGNOSA EG PS PS G4 EG 0 2 2 0
Letak Caries B O 0 0 0 1
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 0 9 0 0 0 0 9 0 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0
DIAGNOSA DG 0
Keadaan gigi 9 0 2 9 0 0 0 0 0 0 0 0 9 0 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries
Keadaan gigi D A A A 0 0 0 0

0 0 0 DI 0 0 0 CI M= 0
0 1 1 0 0.33 0 1 1 0 0.33 F= 0
OHI - S = 0.67 ____
CPITN
16 11 21 26 0 0 0 0 0 0 0
0 46 41 31 36 0 2 1 0 1 2 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 1
____
def = 4
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
2 gigi
INF
4 gigi
0 gigi
RESP
BANDUNG

NAMA: Muhammad Toyib Gender: 1P= 1 No. Resp.: M.205
W=2 Tanggal : 08 01 2017
ALAMAT: Gang Sawo RT,RW,Kelurahan: 17 05 Klari
KANAN
DIAGNOSA EG PS PS G4 PS 0 1 3 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 1 3 9 0 0 0 0 0 0 0 0 9 0 0 9 0
DIAGNOSA EG 0
Letak Caries M 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries MOD 0
DIAGNOSA PV 0
Keadaan gigi 9 0 1 9 0 0 0 0 0 0 0 0 9 1 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS PS DG 0 0 2 0
Keadaan gigi A A A B 0 1 0 0

1 1 1 DI 1 0 1 CI M= 0
0 1 1 3 1.33 0 1 1 3 1.17 F= 1
OHI - S = 2.5 ____
CPITN
16 11 21 26 1 0 0 1 1 0 1
0 46 41 31 36 0 1 2 2 3 1 2 3

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 2
e= 0
f= 0
____
def = 2
JumlahKode
3 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
2 gigi
INF
5 gigi
0 gigi
BANDUNG

NAMA: Dini Widiya Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 22 12 2016
ALAMAT: Jln. Waluran No. 15 RT,RW,Kelurahan: 02 01 Waluran
KANAN KIRI
Keadaan gigi - - - - - - - A - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON


2 0 2 DI 2 0 1 CI M= 0 e= 0
0 2 0 2 1.33 0 3 0 3 1.5 F= 0 f= 0
OHI - S = 2.83 ____ ____
CPITN
16 11 26 2 0 2 2 2 0 0 0
46 31 36 0 2 0 2 2 2 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
0 0
0 0
BANDUNG

NAMA: Sandi Ruswanda Gender: 1P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: Jln. Sukaraja No.27 RT,RW,Kelurahan:
KANAN
Keadaan gigi - - A - - -
DIAGNOSA
Letak Caries
55 54 53 52 51 61
Keadaan gigi 9 0 1 0 1 9 0 0 0
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries
DIAGNOSA
Keadaan gigi 9 0 0 0 0 0 0 0 0
85 84 83 82 81 71
Letak Caries
DIAGNOSA
Keadaan gigi
Segment Segment

0 0 1 DI 0 0
0 0 0 1 0.3333 0 0 0
OHI - S = 0.333333
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26 0 0
0 46 31 36 0 0 0
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
22 12 2016
RT,RW,Kelurahan: 03 02 Sukaraja
KIRI
- - - -
0 0 0 0
0 0 0 0
62 63 64 65 0
0 0 0 0 0 0 9 0 0 0 KODE:
0 1
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D

0 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 1 d= 0
0 CI M= 0 e= 0
0 0 F= 0 f= 0
____ ____
DMF = 1 def = 0
Segmen JumlaKode
0 0 0 0 0 0
0 0 0 0 0 0
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Lastri Andini Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jln. Gagak No.20
KANAN
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 9 0 0 1 0 0 0
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 0 0 0 9 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

3 2 2 DI 1
0 2 0 3 2 0 1
OHI - S = 2.666667
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 23 12 2016
RT,RW,Kelurahan: 04 05 Sukamulya
KIRI
- - - - -
0 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 0 0 0 0 9 9 0 0 0 KODE:
0 0
0 1 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
0 0 0 0 0 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

KMA = A
- - - - - 0 0 0 0 GOYANG
Segment
0 1 CI M= 0 e= 0
0 1 0.666667 F= 0 f= 0
____ ____
DMF = 1 def = 0
Segmen JumlaKode
2 0 2 2 2 0 0 0
2 1 2 2 2 0 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: Rani Febyani Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Sukaralang No. 45
KANAN
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 0 1 0 0 0 0 0
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 0 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

2 0 0 DI 0
0 1 0 1 0.6667 0 1
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 04
Tanggal : 23 12 2016
RT,RW,Kelurahan: 06 02 Sukalarang
KIRI
- - B
EG 0 1 0 0
M 0 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 0 9 0 0 0 KODE:
0 0
1 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
0 0 0 0 0 0 0 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

KMA = A
- - - - - 0 0 0 0 GOYANG
Segment
0 0 CI M= 0 e= 0
1 1 0.5 F= 0 f= 0
____ ____
DMF = 1 def = 1
Segmen JumlahKode
0 0 0 - - 0 0 0 0 0
2 2 2 2 2 0 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Rio Muhsyal Gender: 1P=1

W=2
Umur: 12 tahun
ALAMAT: Jln.
KANAN
DIAGNOSA A
Letak Caries MOD
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA DG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 1 3 DI
0 1 2 1 1.5 0
OHI - S = 2.666667
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 24 12 2016
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 1
1 0 3 CI M= 0
1 1 1 1.166667 F= 0
____
DMF = 1
Score Segmen
2 0 2 2 2 0
2 2 2 2 2 0
19 -
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Ai Nuraini Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Sukaraj No.34
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 1 1 DI
0 0 0 2 0.833333 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 24 12 2016
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 9 9 0
DG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
PV 0
0 0 0 0 0 0 1 0 0 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
2 0 2 0.666667 F= 0
____
DMF = 2
Score Segmen
0 0 2 0 2 0
2 0 2 2 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Lisna Hidayat Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Pasir No. 23
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries MOD
DIAGNOSA A
Segment
Plaque Score
2 1 3 DI
0 2 1 2 1.833333 0
OHI - S = 3.333333
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 28
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 25 12 2016
RT,RW,Kelurahan: 10 08 Sukawarna
- - - A - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 0 0
DG 0
L 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
MOD 0
A 0
0 0 0 0 0 0 1 0 9 0
81 71 72 73 74 75 0
OB MOD
PN A 0 0 0 0
- - - - E E 0 0 0 0
Segment Segment
Calculus Score D= 2
3 0 3 CI M= 0
1 1 1 1.5 F= 0
____
DMF = 2
Score Segmen
2 0 2 2 2 0
2 2 2 2 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 3
f= 0
____
def = 3
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Nida Hapiani Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Merpati No.56
KANAN
Keadaan gigi E - A -
DIAGNOSA PN
Letak Caries MOD
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA DA
85 84 83 82
Letak Caries MOD
DIAGNOSA PN
Segment
Plaque Score
1 1 2 DI
0 1 1 1 1.166667 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 25 12 2016
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O O 0
DA EG 0
0 0 0 0 0 0 1 1 9 2
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 3
0 0 1 CI M= 0
0 0 1 0.333333 F= 0
____
DMF = 3
Score Segmen
0 0 2 0 2 0
0 0 2 0 2 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
0 - Tumpatan GI 1
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 2
f= 0
____
def = 2
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: Ayu Fitri Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Bunga No. 09
KANAN
DIAGNOSA A
Letak Caries MOD
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries MOD MOD
DIAGNOSA A A
Keadaan gigi E E - -
Segment
Plaque Score
3 2 1 DI
0 2 0 1 1.5 0
OHI - S = 1.666667
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 28 12 2016
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0 0
0 1
0 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
D 0 0
DG 0 1
1 0 0 0 0 0 0 0 9 0 0
81 71 72 73 74 75 0 >0
MOD
A 0 0 0 0
- - - - - E 0 0 0 0
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
0 0 1 0.166667 F= 0
____
DMF = 3
Score Segmen
0 0 0 0 0 0
0 0 2 0 2 0
-
0= F 2.2. CPITN
0 - Tumpatan GI 2 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 1
e= 3
f= 1
____
def = 5
JumlaKode
0 0
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: Mila Rosa Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Waluran No.15
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 0 0 DI
0 1 0 0 0.33 0
OHI - S = 0.5
Artinya : BAIK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 12
- Sealant =6 16
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 28 12 2016
ART GI
- - - A - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 6 6 6 6 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 6 6 6 6 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
1 0 0 0.1666667 F= 0
____
DMF = 0
Score Segmen
0 0 0 0 0 0
2 0 0 2 0 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Erlangga Gender: 1P= 1 No. Resp.: 01

W=2 Tanggal : 08 01
ALAMAT: Pasanggrahan indah blok 28 no.7 ujungberung bandung RT,RW,Kelurahan: 04
KANAN
DIAGNOSA DA G3
Letak Caries O
55 54 53 52 51 61 62 63 64 65
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12 11 21 22 23 24 25
48 47 46 45 44 43 42 41 31 32 33 34 35
Letak Caries
DIAGNOSA
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA EA DA

1 0 1 DI 0 0 0 CI
0 1 0 0 0.5 0 1 0 1 0.33
OHI - S = 0.833
Artinya : BAIK
CPITN
Gigi Index Score
- 16 11 21 26 - - 0 1 0 0 -
2 - 46 41 31 36 - 2 - 1 1 0 1 -
- Mahkota khusus =7 0 0= G - Tidak memerlukan peraw
- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Keseh
- Gigi tidak termasuk kriteria =9 0 - - Memerlukan Scaling dan
di atas - Memerlukan Scaling dan
- Memerlukan Perawatan
- Sehat =0 2.2. Konservasi :
- Gingivitis pada satu segment =1 0 0 - Tumpatan ART
- Gingivitis lebih satu segment =2 0 2 - Tumpatan GI
2.3. Pencabutan :
1.3. Keadaan Pathologi Mulut : - Gigi sulung
- Tak ada =0 0 - Gigi tetap
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
N GIGI DAN MULUT
MASYARAKAT
2017
g tua/wali) : Wiraswasta
14 Pasanggrahan
KIRI
0 0 0 0
1 0 1 0
0 0
0 0 0 0
1 0 0 0 KODE:
DG 0 0
26 27 28 KME-ART= EA MESIAL = M
36 37 38 KME-GI= EG DISTAL = D
0 0 0 KMP VITAL = PV LABIAL = L
0 0 0 0
1 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 2 d= 3
M= 0 e= 0
F= 0 f= 0
____ ____
DMF = 2 def = 3
Segmen Jumlah ScKode

0 1 0 4 2
1 1 1 0 0
0
CANA PERAWATAN
Kebersihan Mulut :

Konservasi : GT GS
Pencabutan : CE INF
Observasi :
Dirujuk ke : Puskesmas
*Keterangan :
Konservasi
pan Karies
BANDUNG

NAMA: Novia Oktaviani Gender: 2P=1 No. Resp.: 02

W=2 Tanggal : 08 01 2017
ALAMAT: Tubagus Ismail no.3 B Dago RT,RW,Kelurahan: 10 02
KANAN
Keadaan gigi B A A A A A A A A A
DIAGNOSA DA 0
Letak Caries O 1
55 54 53 52 51 61 62 63 64 65
Keadaan gigi 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26
48 47 46 45 44 43 42 41 31 32 33 34 35 36
Letak Caries O
DIAGNOSA PS EA
Keadaan gigi 0 1 0
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA EA PS EA 2
Keadaan gigi B A A A A A A A A B 0

0 - 1 DI 0 - 0 CI
1 1 1 0 0.6 1 0 0 0 0
OHI - S = 0.6
Artinya : BAIK
CPITN
Gigi Index Score
- 16 - - 26 - - 0 - - 0 -
4 - 46 - 31 36 - 4 - 1 - 1 1 -

- Mahkota khusus =7 0 0= G - Tidak memerlukan perawa
- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehat
- Gigi tidak termasuk kriteria =9 0 - - Memerlukan Scaling dan E
di atas - Memerlukan Scaling dan E
- Memerlukan Perawatan Kh
2.3. Pencabutan :
- Tak ada =0 - Gigi tetap
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
GI DAN MULUT
YARAKAT
2017
Swasta
Dago
KIRI
0 0 0
0 0 0
0 0
0 0 0 0
0 0 0 KODE:
0 0
27 28 KME-ART= EA MESIAL = M
37 38 KME-GI= EG DISTAL = D
0 0 0 0
0 1 0 PERSISTENSI = PS
0 0 0 GOYANG °3/°4 = G3/G4
D= 1 d= 3
M= 0 e= 0
F= 0 f= 0
____ ____
DMF 1 def = 3
0 0 0 3 2
1 1 1 0 0
0
A PERAWATAN
ersihan Mulut :
k memerlukan scaling = 0
emerlukan scaling = 1 2
struksi menyikat gigi = 2
emerlukan scaling dan = 3 2 2
ruksi menyikat gigi 0
dak memerlukan perawatan = 0

ukasi Instruksi Kesehatan mulut = 1
emerlukan Scaling dan EIKM = 2 1
emerlukan Scaling dan EIKM = 3
emerlukan Perawatan Khusus dan EIKM = 4
GT GS
mpatan ART 1 3 gigi
0 0 gigi
CE INF
0 1 gigi
0 0 gigi
Puskesmas
BANDUNG

NAMA: Risal Salman Gender: 1P=1 No. Resp.: 03

W=2 Tanggal : 08 01 2017
ALAMAT: Cibiru hilir no.87 bandung RT,RW,Kelurahan: 10 02 Cileunyi
KANAN
Keadaan gigi B A A A A A A
DIAGNOSA DA 0 0
Letak Caries O 1 0
55 54 53 52 51 61 62 63 64 65
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
Letak Caries O
DIAGNOSA PS PS EA
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA DA PS PS DA 0 0
Keadaan gigi B A A A A A A B 2 0

0 - 1 DI 0 - 0 CI
1 0 1 0 0.4 1 0 0 0 0
OHI - S = 0.4
Artinya : BAIK
CPITN
- 16 - - 26 - - 0 - - - 0
4 - 46 - 31 36 - 3 - 1 1 0 1 - 1

- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan m
- Memerlukan Perawatan Khusus
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
I DAN MULUT
ARAKAT
Swasta
Cileunyi
KIRI
0 0
0 0
0 0
0 0 0 0
0 0 0 KODE:
0 0
28 KME-ART= EA MESIAL = M
38 KME-GI= EG DISTAL = D
0 0 0 0
2 0 PERSISTENSI = PS
0 0 GOYANG °3/°4 = G3/G4
D= 0 d= 3
M= 0 e= 0
F= 0 f= 0
____ ____
DMF 0 def = 3
0 0 3 2
1 1 0 0
0
ERAWATAN
han Mulut :
emerlukan scaling = 0
rlukan scaling = 1 2
ksi menyikat gigi = 2
rlukan scaling dan = 3 2 2
si menyikat gigi 0
memerlukan perawatan = 0
si Instruksi Kesehatan mulut = 1
rlukan Scaling dan EIKM = 2 1
rlukan Scaling dan EIKM = 3
rlukan Perawatan Khusus dan EIKM = 4
GT GS
1 3 gigi
0 0 gigi
CE INF
0 2 gigi
0 0 gigi
Puskesmas
BANDUNG

NAMA: Ulfah Fauziah Gender: 2P= 1 No. Resp.: 04

W=2 Tanggal : 08 01 2017
ALAMAT: Cilengkrang 2 no.30 RT,RW,Kelurahan: 01 05 Cisurupan
KANAN
Keadaan gigi A A A A B B
DIAGNOSA EA EA 2 0
55 54 53 52 51 61 62 63 64 65
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
Letak Caries
DIAGNOSA PS
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA DA PS EA 1 0
Keadaan gigi B A A A A A B 1 0

0 0 1 DI 0 0 0 CI
0 1 1 0 0.5 0 0 0 0 0
OHI - S = 0.5
Artinya : BAIK
CPITN
- 16 11 21 26 - - 0 1 0 0 - 0
2 - 46 41 31 36 - 2 - 1 1 0 0 - 1

- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan
- Memerlukan Perawatan Khus
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
DAN MULUT
RAKAT
Cisurupan
KIRI
0 0
0 0
0 0
0 0 0 0
0 0 0 KODE:
0 0
0 0 0 0
0 0 GOYANG °3/°4 = G3/G4
D= 0 d= 4
M= 0 e= 0
F= 0 f= 0
____ ____
DMF 0 def = 4
1 0 3 2
1 0 0 0
0
ERAWATAN
han Mulut :
emerlukan scaling = 0
lukan scaling = 1 2
ksi menyikat gigi = 2
lukan scaling dan = 3 2 2
si menyikat gigi 0
lukan Scaling dan EIKM = 2 1
lukan Scaling dan EIKM = 3
lukan Perawatan Khusus dan EIKM = 4
GT GS
0 4 gigi
0 0 gigi
CE INF
0 1 gigi
0 0 gigi
Puskesmas
BANDUNG

NAMA: Tiya Utari Gender: 2P= 1 No. Resp.: 05

W=2 Tanggal : 08 01 2017
ALAMAT: Jl. AH Nasution no.54 RT,RW,Kelurahan: 01 08
KANAN
Keadaan gigi A A A A B F
DIAGNOSA EA 1
Letak Caries O 0
55 54 53 52 51 61 62 63 64 65
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26
48 47 46 45 44 43 42 41 31 32 33 34 35 36
Letak Caries
DIAGNOSA PS
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA DA PS EA 1
Keadaan gigi B F A A A A B 1

0 0 1 DI 0 0 0 CI
0 1 1 0 0.5 0 0 0 0 0
OHI - S = 0.5
Artinya : BAIK
CPITN
Gigi Index Score
- 16 11 21 26 - - 0 0 0 0 -
2 - 46 41 31 36 - 2 - 0 1 1 1 -

2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
AN GIGI DAN MULUT
I MASYARAKAT
2017
Swasta
Ujungberung
KIRI
0 0 0
0 0 0
0 0
0 0 0 0
0 0 0 KODE:
0 0
0 0 0 0
0 0 0 GOYANG °3/°4 = G3/G4
D= 0 d= 3
M= 0 e= 0
F= 0 f= 0
____ ____
DMF = 0 def = 3
0 0 0 2 2
0 1 1 0 0
0
ERAWATAN
merlukan scaling = 0
ukan scaling = 1 2
si menyikat gigi = 2
ukan scaling dan = 3 2 2
i menyikat gigi 0
ukan Scaling dan EIKM = 2 1
ukan Scaling dan EIKM = 3
ukan Perawatan Khusus dan EIKM = 4
GT GS
0 3 gigi
0 0 gigi
CE INF
0 1 gigi
0 0 gigi
Puskesmas
pan Karies
BANDUNG

NAMA: Yudhistira Gender: 1P= 1 No. Resp.: 06

W=2 Tanggal : 06 01 2017
ALAMAT: Jl,ciporeat no.28, Ujungberung RT,RW,Kelurahan: 07 18 Pasirjati
KANAN
Keadaan gigi B A A A A A A
DIAGNOSA DA PS 0 0
Letak Caries O 1 0
55 54 53 52 51 61 62 63 64 65
DIAGNOSA DA DG
Letak Caries O O
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
Letak Caries
DIAGNOSA
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA EA DA 1 0
Keadaan gigi B A A A A B 1 0

1 0 DI 0 0 0 CI
0 1 0 0 0.33 0 1 0 1 0.33
OHI - S = 0.7
Artinya : BAIK
CPITN
- 16 11 21 26 - - 0 1 0 0 - 0
2 - 46 41 31 36 - 2 - 1 0 0 1 - 1

2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
DAN MULUT
ARAKAT
Pasirjati
KIRI
1 0
0 0
0 0
0 0 0 0
0 0 0 KODE:
0 0
0 0 0 0
0 0 GOYANG °3/°4 = G3/G4
D= 2 d= 3
M= 0 e= 0
F= 0 f= 0
____ ____
DMF 2 def = 3
1 0 3 2
0 1 0 0
0
lukan scaling = 1 3
si menyikat gigi = 2
lukan scaling dan = 3 1 3
i menyikat gigi 1
lukan Scaling dan EIKM = 2 1
lukan Scaling dan EIKM = 3
lukan Perawatan Khusus dan EIKM = 4
GT GS
1 3 gigi
1 0 gigi
CE INF
0 1 gigi
0 0 gigi
Puskesmas
BANDUNG

NAMA: Rona Gusmawarni Gender: 2P=1 No. Resp.: 07

W=2 Tanggal : 08 01 2017
ALAMAT: Jl. Gegerkalong no.40 RT,RW,Kelurahan: 16 07 Lembang
KANAN
Keadaan gigi B A A A A A A A A A
DIAGNOSA DA 0 0
Letak Caries O 1 0
55 54 53 52 51 61 62 63 64 65
Keadaan gigi 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
Letak Caries O
DIAGNOSA PS EA
Keadaan gigi 0 1 0
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA EA PS EA 2 0
Keadaan gigi B A A A A A A A A B 0 0

0 - 1 DI 0 - 0 CI
1 1 1 0 0.6 1 0 0 0 0
OHI - S = 0.6
Artinya : BAIK
CPITN
- 16 - - 26 - - 0 - - 0 - 0
4 - 46 - 31 36 - 3 1 - 0 1 - 1

- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan mu
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
DAN MULUT
RAKAT
Swasta
Lembang
KIRI
0 0
0 0
0 0
0 0 0 0
0 0 0 KODE:
0 0
0 0 0 0
0 0 GOYANG °3/°4 = G3/G4
D= 1 d= 3
M= 0 e= 0
F= 0 f= 0
____ ____
DMF = 1 def = 3
0 0 2 2
0 1 0 0
0
ukan scaling = 1 2
i menyikat gigi = 2
ukan scaling dan = 3 2 2
menyikat gigi 0
emerlukan perawatan = 0
Instruksi Kesehatan mulut = 1
ukan Scaling dan EIKM = 2 1
ukan Scaling dan EIKM = 3
ukan Perawatan Khusus dan EIKM = 4
GT GS
1 3 gigi
0 0 gigi
CE INF
0 1 gigi
0 0 gigi
Puskesmas
BANDUNG

NAMA: M. Hardiansyah Gender: 1P=1 No. Resp.: 08

W=2 Tanggal : 08 01 2017
ALAMAT: Taman Kopo Indah 3 no.15 A RT,RW,Kelurahan: 14 01
KANAN
Keadaan gigi F A A A A A A
DIAGNOSA 0
Letak Caries 0
55 54 53 52 51 61 62 63 64 65
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26
48 47 46 45 44 43 42 41 31 32 33 34 35 36
Letak Caries O
DIAGNOSA PS PS EA
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA DA PS PS DA 0
Keadaan gigi B A A A A A A B 2

0 0 0 DI 0 0 0 CI
0 1 1 0 0.33 0 0 0 0 0
OHI - S = 0.33
Artinya : BAIK
CPITN
Gigi Index Score
- 16 11 21 26 - - 0 0 0 0 -
2 - 46 41 31 36 - 2 - 1 0 0 1 -

- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan
- Memerlukan Perawatan Khus
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
IGI DAN MULUT
SYARAKAT
2017
Swasta
Kopo
KIRI
0 0 0
0 0 0
0 0
0 0 0 0
0 0 0 KODE:
0 0
0 0 0 0
0 0 0 GOYANG °3/°4 = G3/G4
D= 0 d= 2
M= 0 e= 0
F= 0 f= 0
____ ____
DMF 0 def = 2
0 0 0 2 2
1 0 1 0 0
0
A PERAWATAN
ersihan Mulut :
memerlukan scaling = 0
merlukan scaling = 1 2
truksi menyikat gigi = 2
merlukan scaling dan = 3 2 2
uksi menyikat gigi 0
ak memerlukan perawatan = 0
merlukan Scaling dan EIKM = 2 1
merlukan Scaling dan EIKM = 3
merlukan Perawatan Khusus dan EIKM = 4
GT GS
mpatan ART 1 2 gigi
0 0 gigi
CE INF
0 2 gigi
0 0 gigi
Puskesmas
BANDUNG

NAMA: Adi Muhammad Gender: 1P= 1 No. Resp.: 09

W=2 Tanggal : 08 01 2017
ALAMAT: Jl. Alun Alun Utara no,90 RT,RW,Kelurahan: 13 05
KANAN
DIAGNOSA EA 1
Letak Caries O O 0
55 54 53 52 51 61 62 63 64 65
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26
48 47 46 45 44 43 42 41 31 32 33 34 35 36
Letak Caries
DIAGNOSA PS PS
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA DA PS PS DA 0
Keadaan gigi B A A A A A A B 2

0 0 1 DI 0 0 0 CI
0 1 0 1 0.5 0 0 0 0 0
OHI - S = 0.5
Artinya : BAIK
CPITN
Gigi Index Score
- 16 11 21 26 - - 0 1 - 0 -
2 - 46 41 31 36 - 2 - 1 1 1 1 -

- Memerlukan Perawatan Khusu
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
AN GIGI DAN MULUT
GI MASYARAKAT
2017
Swasta
Cigending
KIRI
0 0 0
0 0 0
0 0
0 0 0 0
0 0 0 KODE:
0 0
0 0 0 0
0 0 0 GOYANG °3/°4 = G3/G4
D= 0 d= 3
M= 0 e= 0
F= 0 f= 0
____ ____
DMF = 0 def = 3
0 1 0 4 2
1 1 1 0 0
0
A PERAWATAN
ersihan Mulut :
uksi menyikat gigi 0
ak memerlukan perawatan = 0
GT GS
mpatan ART 0 3 gigi
0 0 gigi
CE INF
0 2 gigi
0 0 gigi
Puskesmas
pan Karies
BANDUNG

NAMA: Anastya Hana Gender: 2P=1 No. Resp.: 10

W=2 Tanggal : 08 01
ALAMAT: Panghegar permai 12 no.3 RT,RW,Kelurahan: 05
KANAN
Keadaan gigi A A A A B F
DIAGNOSA DA
Letak Caries O
55 54 53 52 51 61 62 63 64 65
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25
48 47 46 45 44 43 42 41 31 32 33 34 35
Letak Caries
DIAGNOSA PS
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA DA PS EA
Keadaan gigi B F A A A A B

0 1 1 DI 0 0 0 CI
0 1 1 0 0.67 0 0 0 0 0
OHI - S = 0.67
Artinya : BAIK
CPITN
Gigi Index Score
- 16 11 21 26 - - 0 1 1 0 -
2 - 46 41 31 36 - 2 - 1 1 1 1 -

- Gigi lubang/karies =1 0 3=B - Memerlukan scaling
- Tumpatan dgn karies =2 0 0=C - Instruksi menyikat gigi
- Tumpatan tanpa karies =3 0=D - Memerlukan scaling dan
- Mahkota khusus =7 0 0=G - Tidak memerlukan perawa
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
AN GIGI DAN MULUT
GI MASYARAKAT
2017
Swasta
08 Gede Bage
KIRI
0 0 0 0
1 0 0 0
0 0
0 0 0 0
0 0 0 0 KODE:
0 0
0 0 0 0
1 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 0 d= 3
M= 0 e= 0
F= 0 f= 0
____ ____
DMF = 0 def = 3
0 1 0 4 2
1 1 1 0 0
0
ANA PERAWATAN
Kebersihan Mulut :

Konservasi : GT GS
Pencabutan : CE INF
*Keterangan :
Konservasi
pan Karies
BANDUNG

NAMA: Ahmad Gender: 1P= 1 No. Resp.: 01
W=2 Tanggal : 01 01 2017
ALAMAT: Jl. Sukajadi 1 RT,RW,Kelurahan: 01 01 Sukajadi
KANAN KIRI
Keadaan gigi - - - - - - - - - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA DG EG 0 1 KMD-ART
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON


0 1 0 DI 0 0 0 CI M= 0 e= 0
0 2 0 1 0.67 0 2 1 2 0.83 F= 0 f= 0
OHI - S = 1.5 ____ ____
CPITN
16 11 26 0 0 0 0 0 0 0 0
0 46 31 36 0 2 2 2 0 2 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
1 1
0 0
BANDUNG
KARTU SURVEY KESEHATAN GIGI DAN

USAHA KESEHATAN GIGI MASYARAKA
NAMA: Bambang Gender: 1P= 1 No. Resp.:

W=2 Tanggal :
Umur: 12 tahun Pekerjaan (orang tua/wali)
ALAMAT: Jl. Sukajadi 2 RT,RW,Kelurahan:
KANAN
Keadaan gigi
DIAGNOSA
55 54 53 52 51 61
Keadaan gigi 9 0 0 0 0 9 0 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries O M
DIAGNOSA EG EG
Keadaan gigi 9 1 1 0 0 0 0 0 0
85 84 83 82 81 71
DIAGNOSA
Keadaan gigi
Segment Segment

1 0 0 DI 0 0
0 1 1 1 0.6667 0 1 1
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26 0
0 46 31 36 0
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
01 01 2017
KIRI
0 0 0 0
- - - - 0 0 0 0
62 63 64 65 0
0 0 0 0 0 0 9 0 0 0 KODE:
0 0
0 0 DIAGNOSA
22 23 24 25 26 27 28 KME-ART= EA
32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
0 2 KMD-ART = DA
0 9 0 0 0 0 9 0 0 KMP VITAL = PV
72 73 74 75 0 >0 0 KMP NONVITAL = PN

- B - - KMA = A
O 1 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 2 d= 1
0 CI M= 0 e= 0
1 0.5 F= 0 f= 0
____ ____
DMF = 2 def = 1
Segmen JumlaKode
0 0 0 0 0 0 0
3 2 2 0 3 2 1 3
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
3/°4 = G3/G4
3
BANDUNG
KARTU SURVEY KESEHATAN

USAHA KESEHATAN GIGI M
NAMA: Cepi Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA EA
Letak Caries B
55 54 53 52 51
Keadaan gigi 9 0 1 0 0 9 0 0
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries O
DIAGNOSA EA
Keadaan gigi 9 0 6 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

1 1 1 DI 1
0 1 0 1 0.83 0 2
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 1 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 01 01 2017
- - - - -
1 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 0 0 0 0 0 9 0 0 0
0 1
0 0
21 22 23 24 25 26 27 28
31 32 33 34 35 36 37 38
0 0 0
1 0
0 0 9 0 0 0 0 9 0 0
71 72 73 74 75 0 >0 0
MOD
KMA 0 0 0 1
- - B - - 0 0 0 0
Segment
Calculus Score D= 1 d=
0 1 CI M= 0 e=
1 1 1 F= 0 f=
____ ____
DMF = 1 def =
Segmen Jumla
2 0 2 2 2 0 0
2 2 3 0 2 3 1
0
=B - Memerlukan scaling = 1
=D - Memerlukan scaling dan = 3
=E intruksi menyikat gigi
-
=F 2.2. CPITN
- Tumpatan ART 1 1
- Tumpatan GI 1 0

- Gigi sulung 0 1
- Gigi tetap 0 0
2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
KODE:


PERSISTENSI = PS
2
0
0
Kode
0
3
3
1 3
1
= 0
= 1
= 2 3
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KESEHATAN G

USAHA KESEHATAN GIGI MAS
NAMA: Deden Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
Keadaan gigi
DIAGNOSA
55 54 53 52 51
Keadaan gigi 9 1 1 0 0 9 0 0
DIAGNOSA EG EG
Letak Caries O O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 0 0 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

0 1 0 DI 1
0 1 0 1 0.5 0 1
OHI - S = 1.3333333
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Sealant =6 1 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
9
No. Resp.: 04
Tanggal : 01 01 2017
O
DA 0 0 0 0
- - B - - 1 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 0 9 0 0 0
0 2
- 0 0
21 22 23 24 25 26 27 28
31 32 33 34 35 36 37 38
O 0 0 0
EA 1 0
0 0 0 0 0 6 0 9 0 0
71 72 73 74 75 0 >0 0
0 0 0 0
- - - - - 0 0 0 0
Segment
Calculus Score D= 2 d=
0 0 CI M= 0 e=
2 1 0.8333333 F= 0 f=
____ ____
DMF = 2 def =
Segmen Jumlah
2 0 0 2 0 0 0
2 2 2 0 2 2 0
0
=B - Memerlukan scaling = 1
=D - Memerlukan scaling dan = 3
=E intruksi menyikat gigi
-
=F 2.2. CPITN
- Tumpatan ART 1 1
- Tumpatan GI 2 0

- Gigi sulung 0 0
- Gigi tetap 0 0
2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
KODE:


PERSISTENSI = PS
1
0
0
Kode
0
0
3
1 3
1
= 0
= 1
= 2 2
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY K
USAHA KES
NAMA: Encep Gender: 1P= 1

W=2
Umur: 11 tahun
KANAN
DIAGNOSA EA
Letak Caries O
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
0 0 0 DI
0 2 1 3 1 0
OHI - S = 1.8333333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 22
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 01 01 2017
- - - A - -
1 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EG 0
0 0 0 9 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
2 1 2 0.8333333 F= 0
____
DMF = 2
Score Segmen
0 0 0 0 0 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Farel Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
3 1 2 DI
0 2 1 3 2 0
OHI - S = 4.1666667
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 24
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 01 01 2017
- - - B - -
DA 0 0 0 0
O 1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EA 1
0 0 0 0 0 0 6 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 0 3 CI M= 0
3 2 3 2.1666667 F= 0
____
DMF = 2
Score Segmen
2 0 2 2 2 0
3 2 2 0 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Gunawan Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O
DIAGNOSA EA
Segment
Plaque Score
2 1 1 DI
0 1 1 1 1.1666667 0
OHI - S = 2.5
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 01 01 2017
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0
EA 1
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
1 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 0 2 CI M= 0
2 1 1 1.3333333 F= 0
____
DMF = 2
Score Segmen
2 0 2 2 2 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Hadi Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 2 2 2 1.6666667 0
OHI - S = 2.8333333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 16
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 01 01 2017
- - - A - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 9 9 0
DG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
M 0
EG 0
1 0 0 9 0 0 0 9 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 4
1 0 1 CI M= 0
2 1 2 1.1666667 F= 0
____
DMF = 4
Score Segmen
1 0 1 1 1 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 2
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESE

USAHA KESEHATA
NAMA: Ibnu Gender: 1P= 1

W=2
Umur: 11 tahun
KANAN
DIAGNOSA DA
Letak Caries O
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 0 1 DI
0 1 0 1 0.8333333 0
OHI - S = 1.8333333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 01 01 2017
- - - - - -
0 0 0 0
1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0 0
0 1
0 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 0
0 0
0 0 0 9 0 0 0 0 9 0 0
81 71 72 73 74 75 0 >0
B
EA 1 0 0 0
- - - B - - 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
2 2 2 1 F= 1
____
DMF = 1
Score Segmen
1 0 1 1 1 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
2 - Tumpatan GI 1 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
JumlaKode
2 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY
USAHA KE
NAMA: Jajang Gender: 1P= 1

W=2
Umur: 11 tahun
KANAN
Keadaan gigi - - -
DIAGNOSA
Letak Caries
55 54 53
DIAGNOSA DG
Letak Caries M - - - -
18 17 16 15 14 13
48 47 46 45 44 43
Letak Caries MOD
DIAGNOSA EG
85 84 83
Letak Caries
DIAGNOSA
Keadaan gigi - - A
Segment
Plaque Score
2 1 1 DI
0 2 1 1 1.33
OHI - S = 3.166667
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36
1. DIAGNOSA
1.1. Keadaan gigi :
- Gigi sehat =0
- Gigi lubang/karies =1
- Tumpatan dgn karies =2
- Gigi dicabut karena karies =4
- Gigi dicabut karena sebab lain =5
- Sealant =6
- Mahkota khusus =7
- Gigi tidak tumbuh =8
- Gigi tidak termasuk kriteria =9
di atas

- Sehat =0
- Gingivitis pada satu segment =1
- Gingivitis lebih satu segment =2
- Pocket pada satu segment =3
- Pocket lebih dari satu segment =4

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
- Tak bersih lebih satu segment =2
No. Resp.: 10
Tanggal : 01 01 2017
ART GI
- - - - B - -
KMA 0 0 0
MOD 0 0 0
52 51 61 62 63 64 65
0 0 0 0 9 0 0 1 0 0
EG
- - - - - - - O
12 11 21 22 23 24 25 26 27 28
42 41 31 32 33 34 35 36 37 38
O
DG
0 0 0 0 0 9 0 1 0 0
82 81 71 72 73 74 75
O
DA 0 0 0
- - - - - B - 1 0 0
Segment Segment
Calculus Score D=
2 1 1 CI M=
0 3 1 3 1.8333333 F=
____
DMF =
Score Segmen
2 1 1 2 1
0 3 2 2 0 3
GT GS 2.1. Kebersihan Mulut :
25 1=A - Tak memerlukan scaling
4 2=B - Memerlukan scaling
0 0=C - Instruksi menyikat gigi
0 0=D - Memerlukan scaling dan
0 0=E intruksi menyikat gigi
0 -
0 0=F 2.2. CPITN
0 0=G - Tidak memerlukan perawatan
0 - - Edukasi Instruksi Kesehatan mulut
3 - - Memerlukan Scaling dan EIKM
2.2. Konservasi :
0 0 - Tumpatan ART
0 3 - Tumpatan GI
0
0
2.3. Pencabutan :
- Gigi sulung
0 - Gigi tetap
2.4. Observasi :
2
6 *Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
1
0
0
0 0 0 KODE:
0 1

0 PERSISTENSI = PS
0 GOYANG °3/°4 = G3/G4
4 d= 2
0 e= 0
0 f= 0
____
4 def = 2
Jumlah ScKode
0 1 1
2 1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GT GS
0 1 gigi
3 0 gigi
CE INF
0 1 gigi
0 0 gigi
as Sukajadi
BANDUNG

NAMA: Fahmi Fachrezy Gender: 1P= 1 No. Resp.: F01
W=2 Tanggal : 08 01 2017
ALAMAT: Komplek Permata Biru Blok I no 10 RT,RW,Kelurahan: 04 15 Cinunuk Cibiru Kabupaten Bandung
KANAN KIRI
Keadaan gigi A A A A A B A A A A
DIAGNOSA G4 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG 0 0
18 17 16 15 14 13 12 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries M O 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi A A A B A A A A A A 0 0 1 0 GOYANG

1 0 0 DI 1 0 0 CI M= 0 e= 0
0 0 1 0 0.33 0 1 1 0 0.5 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
16 11 26 1 1 0 1 1 0 2 2
0 46 31 36 0 0 0 0 0 0 0 0 0
0

- Tumpatan dgn karies =2 0= C - Instruksi menyikat gigi = 2
- Tumpatan tanpa karies =3 0 0= D - Memerlukan scaling dan = 3 1 3
- Gigi dicabut karena sebab lain =5 0 0-
- Gigi tidak tumbuh =8 0 0- - Edukasi Instruksi Kesehatan mulut = 1
- Gigi tidak termasuk kriteria =9 0 0- - Memerlukan Scaling dan EIKM = 2
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 1
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Nafis Rizqullah Gender:1P= 1 No. Resp.: N01
W=2 Tanggal : 08 01 2017
KANAN KIRI
Keadaan gigi A A A A A A A A A A
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG EG 0 1
Letak Caries O M 0 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA PS 0 0 1 0 PERSISTE
Keadaan gigi A A A A A A A A A A 0 0 0 0 GOYANG

0 0 0 DI 1 0 0 CI M= 0 e= 0
0 0 1 0 0.17 0 0 1 0 0.33 F= 0 f= 0
OHI - S = 0.5 ____ ____
CPITN
16 11 26 1 1 0 1 1 0 2 2
0 46 31 36 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 1
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Kief Luthfi Abdul Ra Gender: 1P= 1 No. Resp.: K01
W=2 Tanggal : 08 01 2017
KANAN KIRI
Keadaan gigi A A A B A A A A A A
DIAGNOSA DG 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

0 0 0 DI 1 0 0 CI M= 0 e= 0
0 0 1 0 0.17 0 0 1 0 0.33 F= 0 f= 0
OHI - S = 0.5 ____ ____
CPITN
16 11 26 1 1 0 1 1 0 2 2
0 46 31 36 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 1
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Rama Karisma Putra Gender: 1P= 1 No. Resp.: R01
W=2 Tanggal : 08 01 2017
ALAMAT: Manglayang Regency 1A no 22 RT,RW,Kelurahan: 05 08 Cinunuk Cibiru Kabupaten Bandung
KANAN KIRI
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG 0 1
Letak Caries P 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DA 0 0 0 0 PERSISTE
Keadaan gigi B A A A A A A A A A 1 0 0 0 GOYANG

0 0 0 DI 1 0 0 CI M= 0 e= 0
0 0 1 0 0.17 0 0 0 0 0.17 F= 0 f= 0
OHI - S = 0.33 ____ ____
CPITN
16 11 26 1 0 0 1 0 0 2 2
0 46 31 36 0 0 1 0 0 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 0
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Iqbal Dicky Setiawan Gender: 1P= 1 No. Resp.: I01
W=2 Tanggal : 08 01 2017
KANAN KIRI
Keadaan gigi B A A A A B A B A A
DIAGNOSA DA DG 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA PS 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi B A A A A A A A A A 0 0 0 0 GOYANG

0 0 0 DI 1 0 1 CI M= 0 e= 0
0 1 1 1 0.5 0 0 1 0 0.5 F= 0 f= 0
OHI - S = 1 ____ ____
CPITN
16 11 26 0 0 0 0 0 0 2 2
0 46 31 36 0 1 1 0 1 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Cahyadin Gender: 1P= 1 No. Resp.: C01
W=2 Tanggal : 08 01 2017
KANAN KIRI
Keadaan gigi A A A A A A A B A A
DIAGNOSA G4 EA A 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA PV EG PS 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi B A A B A A A A A A 0 0 0 0 GOYANG

0 1 1 DI 1 0 0 CI M= 0 e= 0
0 0 1 0 0.5 0 1 1 0 0.5 F= 0 f= 0
OHI - S = 1 ____ ____
CPITN
16 11 26 1 1 0 1 1 0 3 2
0 46 31 36 0 0 1 0 0 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
4
BANDUNG

NAMA: Nazibullah 1P= 1
W=2 Tanggal : 08 01 2017
KANAN KIRI
Keadaan gigi A A A A A A A A A A
DIAGNOSA G3 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG G4 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DA DG 0 0 0 0 PERSISTE
Keadaan gigi B A A A A A A A B A 1 1 0 0 GOYANG

0 1 0 DI 1 0 0 CI M= 0 e= 0
0 0 1 0 0.33 0 1 0 0 0.33 F= 0 f= 0
OHI - S = 0.67 ____ ____
CPITN
16 11 26 0 1 1 0 1 1 2 2
0 46 31 36 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Nazibulloh Bachir 1P= 1
W=2 Tanggal : 08 01 2017
KANAN KIRI
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG PS 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries M KMA = A
DIAGNOSA DG 0 0 0 0 PERSISTE
Keadaan gigi A A A A A A A A B A 0 1 0 0 GOYANG

0 0 0 DI 1 0 0 CI M= 0 e= 0
0 1 1 0 0.33 0 1 1 0 0.5 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
16 11 26 1 1 0 1 1 0 2 2
0 46 31 36 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Wisnu Al Kautsar 1P= 1
Gender: No. Resp.: W01
W=2 Tanggal : 08 01 2017
KANAN KIRI
Keadaan gigi A B A A A B A A A A
DIAGNOSA DG 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA PS EG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries D 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

0 1 0 DI 1 0 0 CI M= 0 e= 0
0 0 1 1 0.5 0 0 1 1 0.5 F= 0 f= 1
OHI - S = 1 ____ ____
CPITN
16 11 26 1 1 0 1 1 0 2 2
0 46 31 36 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 1
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Timmy Daifa 1P= 1
Gender: No. Resp.: T01
W=2 Tanggal : 08 01 2017
ALAMAT: Komplek Permata Biru Blok H no 11 RT,RW,Kelurahan: 02 15 Cinunuk Cibiru Kabupaten Bandung
KANAN KIRI
Keadaan gigi B A A A A B A A A A
DIAGNOSA PV G3 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries M KMA = A
DIAGNOSA DG G4 0 0 0 0 PERSISTE
Keadaan gigi A B A B A A A A A A 0 1 0 1 GOYANG

0 0 1 DI 1 0 0 CI M= 0 e= 0
0 0 1 0 0.33 0 0 1 1 0.5 F= 0 f= 0
OHI - S = 0.83 ____ ____
CPITN
16 11 26 1 1 0 1 1 0 2 2
0 46 31 36 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 0
Exo
Endo
Konservasi
Ortho
Perio
Prosto
ng
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Silvia Gender: 2P= 1 No. Resp.: A01
W=2 Tanggal : 27 12 2016
ALAMAT: Jl. Mawar No.5 RT,RW,Kelurahan: 08 03 Sukajadi
KANAN
DIAGNOSA DA 0 0 0
Letak Caries M 1 0 0
55 54 53 52 51 61 62 63 64 65
Periodontal
Keadaan gigi 9 9 0 9 9 0 0 0 0 9 9 0 9 9
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 0 9 9 0 0 0 0 9 9 0 9 9
Periodontal
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA EG DA 0 1 0
Keadaan gigi B A A B 1 0 0

Plaque Score Calculus Score D=
1 0 0 DI 1 0 0 CI M=
0 1 0 1 0.5 0 1 0 2 0.67 F=
OHI - S = 1.167 ____
Artinya : BAIK DMF =
- Sealant =6 0 0= F 2.2. Konservasi :
- Mahkota khusus =7 0 0= G - Tumpatan ART
- Gigi tidak tumbuh =8 0 - - Tumpatan GI
di atas
2.3. Pencabutan :
1.2. Keadaan penyakit Periodental : - Gigi sulung
- Sehat =0 - Gigi tetap
- Gingivitis lebih satu segment =2 0 0 2.4. Observasi :

- Tak ada =0
- Ada =1
2.5. Dirujuk ke : Puskesmas Ciu
Konservasi
- Baik =0 2 Perio
KIRI
0
0
0 0
0 0 0 0 0 0
0 0 0 KODE:
0 0
0 0 0 0 0 0
0 PERSISTENSI = PS
0 GOYANG °3/°4 = G3/G4
0 d= 3
0 e= 0
0 f= 0
____
0 def = 3
= 0
= 1 3
= 2
= 3 1 3
1
GT GS
0 2 gigi
0 1 gigi
CE INF
0 0 gigi
0 0 gigi
Ciumbuleuit
BANDUNG

NAMA: Anggita Gender: 2P= 1 No. Resp.: A02
W=2 Tanggal : 27 12 2016
ALAMAT: Jl. Anggur No.17 RT,RW,Kelurahan: 16 20 Sukajadi
KANAN KIRI
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA DG 0 0
Letak Caries L 0 1 DIAGNOSA
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA DG 0 0 KMD-ART =
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
DIAGNOSA EA PN 1 0 0 0 PERSISTEN
Keadaan gigi B E 0 0 0 0 GOYANG

0 1 1 DI 0 0 0 CI M= 0 e= 1
0 2 0 1 0.83 0 2 0 2 0.67 F= 0 f= 0
OHI - S = 1.5 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Andrea Gender: 1P= 1 No. Resp.: A003
W=2 Tanggal : 28 12 2016
ALAMAT: Jl. Anggrek No.40 RT,RW,Kelurahan: 14 03 Sukajadi
KANAN KIRI
Keadaan gigi F A A B A B
DIAGNOSA EA DG DG 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
DIAGNOSA DG 0 0 0 0 PERSISTEN

1 0 1 DI 1 0 1 CI M= 0 e= 0
0 2 0 2 1 0 1 0 2 0.83 F= 1 f= 1
OHI - S = 1.83 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Dika Gender: 1P= 1 No. Resp.: A004
W=2 Tanggal : 28 12 2016
ALAMAT: Jl. Sukajadi No.39 RT,RW,Kelurahan: 05 01 Sukajadi
KANAN KIRI
Keadaan gigi B E
DIAGNOSA DG PN 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA EA DA 1 0 KMD-ART =
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
Keadaan gigi B 1 0 0 0 GOYANG

0 0 0 DI 0 0 0 CI M= 0 e= 1
0 1 0 1 0.33 0 1 0 1 0.33 F= 1 f= 0
OHI - S = 0.67 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Meta Gender: 2P= 1 No. Resp.: A005
W=2 Tanggal : 29 12 2016
ALAMAT: Jl. Mekarjaya No. 34 RT,RW,Kelurahan: 16 18 Mekarwangi
KANAN KIRI
Keadaan gigi E E
DIAGNOSA PN PN 0 0 0 0
Letak Caries MO MO 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA EG DG 0 1
Letak Caries O O 0 1 DIAGNOSA
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
DIAGNOSA DA EA 1 0 KMD-ART =
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV

0 0 0 DI 0 0 0 CI M= 0 e= 2
0 1 0 1 0.33 0 0 0 1 0.17 F= 2 f= 0
OHI - S = 0.5 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Santi Gender: 2P= 1 No. Resp.: A006
W=2 Tanggal : 29 12 2016
KANAN KIRI
Letak Caries MO O 0 2 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
DIAGNOSA DG DG 0 0 0 0 PERSISTEN
Keadaan gigi B A A B 0 2 0 0 GOYANG

0 0 0 DI 0 0 0 CI M= 0 e= 0
0 1 1 1 0.5 0 1 1 1 0.5 F= 0 f= 0
OHI - S = 1 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
7 81 71
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Meitha Gender: 2P= 1 No. Resp.: A007
W=2 Tanggal : 29 12 2016
KANAN KIRI
Keadaan gigi B B B
DIAGNOSA DG DG DG 0 0 0 0
Letak Caries O P O 0 3 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
Letak Caries MO O KMA = A
DIAGNOSA PN DG 0 0 0 0 PERSISTEN
Keadaan gigi E B 0 1 0 0 GOYANG

0 0 1 DI 0 0 0 CI M= 0 e= 1
0 2 0 2 0.83 0 1 0 1 0.33 F= 0 f= 0
OHI - S = 1.17 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Deni Gender: 1P= 1 No. Resp.: A008
W=2 Tanggal : 30 12 2016
ALAMAT: Jl. Mekarjaya No.56 RT,RW,Kelurahan: 34 30 Mekarwangi
KANAN KIRI
Keadaan gigi B B A A A B A A B B
DIAGNOSA DG EG DG DG DG 0 1 0 0
Letak Caries MO O L O O 0 4 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
DIAGNOSA DG EA 1 0 0 0 PERSISTEN
Keadaan gigi B A A A A A A A F A 0 1 0 0 GOYANG

1 0 1 DI 0 0 0 CI M= 0 e= 0
0 1 0 2 0.83 0 1 1 1 0.5 F= 0 f= 1
OHI - S = 1.33 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Gibran Gender: 1P= 1 No. Resp.: A009
W=2 Tanggal : 30 12 2016
ALAMAT: Jl. Sukasana No.14 RT,RW,Kelurahan: 12 10 Sukasini
KANAN KIRI
Keadaan gigi B A B B
DIAGNOSA DG DG DG 0 0 0 0
Letak Caries O P O 0 3 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV

0 0 1 DI 0 0 0 CI M= 0 e= 0
0 2 0 0 0.5 0 1 0 1 0.33 F= 0 f= 0
OHI - S = 0.83 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: Leo Gender: 1P= 1 No. Resp.: A010
W=2 Tanggal : 30 12 2016
ALAMAT: Jl. Sukasuka No.30 RT,RW,Kelurahan: 30 31 Sukasuka
KANAN KIRI
DIAGNOSA DA DA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
Periodontal 0 0 0 0
DIAGNOSA EG 0 1
Letak Caries O 0 0 DIAGNOSA
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART=
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Periodontal 0 0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NONV
Letak Caries O MO KMA = A
Keadaan gigi B A A B 0 2 0 0 GOYANG

1 0 0 DI 0 0 0 CI M= 0 e= 0
0 1 0 0 0.33 0 1 0 0 0.17 F= 1 f= 0
OHI - S = 0.5 ____ ____
3
di atas
0

- Tak ada =0
- Ada =1
Konservasi
- Baik =0 Perio
2
0 0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
0 0
STENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: DAYANG MUTIA Gender: 2P= 1 No. Resp.: 001
W=2 Tanggal : 01 12 2016
ALAMAT: jl. setiabudi no 7 Bandung RT,RW,Kelurahan: 02 01 wangunsari
KANAN KIRI
Keadaan gigi B - - - - - - - - E
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 DI 0 CI M= 0 e= 1
0 1 0.33 0 1 0.17 F= 0 f= 1
OHI - S = 0.5 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: IRFAN Gender: 1P= 1 No. Resp.: 002

W=2 Tanggal : 01 01 2017
ALAMAT: BUAH BATU NO. 7 RT,RW,Kelurahan: 02 01 SUKASARI
KANAN
Keadaan gigi E - - - - - - A A E
DIAGNOSA G3 PS 0 0
Letak Caries 0 0
55 54 53 52 51 61 62 63 64 65
Keadaan gi 9 9 1 0 0 0 0 0 7 0 0 0 0 5 9
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
Letak Caries
DIAGNOSA
Keadaan gi 9 9 9 0 0 0 0 0 0 0 0 0 0 6 9
85 84 83 82 81 71 72 73 74 75
Letak Caries O O
DIAGNOSA EA EA 2 0
Keadaan gigi B B - - - - - A - - 0 0

1 0 1 DI 0 1 1 CI
0 1 0 0 0.5 0 0 0 1 0.5
OHI - S = 1
Artinya : BAIK
CPITN
17 16 11 21 26 27 0 0 1 0 0 1 0
0 17 46 41 31 36 37 0 0 0 0 0 0 1 0

- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan mulu
- Memerlukan Perawatan Khusus da
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
MULUT
T
Swasta
SUKASARI
KIRI
1 0
1 0
0 0
0 0 0 0
9 0 0 0 KODE:
0 0
0 1 DIAGNOSA
28 KME-ART= EA
38 KME-GI= EG
0 0 0 KMD-GI = DG
0 0 KMD-ART = DA
9 0 0 KMP VITAL = PV
0 0 0 0
KMA = A
0 0 GOYANG °3/°4 = G3/G4
D= 1 d= 2
M= 0 e= 2
F= 1 f= 0
____ ____
DMF = 2 def = 4
Segmen JumlahKode
1 1 3 2
0 1 0 0
0
ukan scaling = 0
= 1 3
enyikat gigi = 2
n scaling dan = 3 1 3
1
erlukan perawatan = 0
truksi Kesehatan mulut = 1
n Scaling dan EIKM = 2 1
n Scaling dan EIKM = 3
n Perawatan Khusus dan EIKM = 4
GT GS
0 2 gigi
1 0 gigi
CE INF
1 1 gigi
0 0 gigi
Puskesmas
BANDUNG

NAMA: SUCI NURKIFTIA Gender: 2P= 1 No. Resp.: 003

W=2 Tanggal : 03 01
ALAMAT: JL. MAWAR NO 6 RT,RW,Kelurahan: 08
KANAN
Keadaan gigi A B A
DIAGNOSA PS EA EG
Letak Caries
55 54 53 52 51 61 62 63 64 65
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25
48 47 46 45 44 43 42 41 31 32 33 34 35
Letak Caries V
DIAGNOSA EG
Keadaan gigi 0 1 0 0 0 0 0 0 0 0 0 0
85 84 83 82 81 71 72 73 74 75
Letak Caries
DIAGNOSA
Keadaan gigi

1 0 0 DI 0 0 0 CI
0 1 0 1 0.50 0 1 0 0 0.17
OHI - S = 0.67
Artinya : BAIK
CPITN
Gigi Index Score
17 16 11 21 26 27 0 0 0 0
0 17 46 41 31 36 37 0 1 0 0 1

- Mahkota khusus =7 0 0= G - Tidak memerlukan perawa
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
DAN MULUT
AKAT
2017
POLRI
08 CIBINONG
KIRI
1 1 1 0
0 0 0 0
0 0
0 0 0 0
0 0 0 0 0 KODE:
0 0
0 1 KMD-ART = DA BUCCAL/VESTIBULAR = V
6 0 0 0 KMP VITAL = PV LABIAL = L
0 0 0 0
0 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 1 d= 1
M= 0 e= 0
F= 0 f= 0
____ ____
DMF = 1 def = 1
Segmen JumlaKode
0 0 0 2 2
1 0 1 0 0
0
ANA PERAWATAN
Kebersihan Mulut :
Tak memerlukan scaling = 0
Memerlukan scaling = 1 3
Instruksi menyikat gigi = 2
Memerlukan scaling dan = 3 1 3
Tidak memerlukan perawatan = 0

Edukasi Instruksi Kesehatan mulut = 1
Memerlukan Scaling dan EIKM = 2 1
Memerlukan Scaling dan EIKM = 3
Memerlukan Perawatan Khusus dan EIKM = 4
Konservasi : GT GS
Tumpatan ART 0 1 gigi
Tumpatan GI 1 1 gigi
Pencabutan : CE INF
Gigi sulung 0 1 gigi
0 0 gigi
Keterangan :
BANDUNG

NAMA: FADLI Gender: 1P= 1 No. Resp.: 004

W=2 Tanggal : 04
ALAMAT: JL.SUKAMULYA NO 8 RT,RW,Kelurahan:
KANAN
Keadaan gigi A B A A A E A A B
DIAGNOSA DA A PV
Letak Caries L MO
55 54 53 52 51 61 62 63 64
Keadaan gigi 9 9 9 9 9 9 9 9 9 9 9 9
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24
48 47 46 45 44 43 42 41 31 32 33 34
Letak Caries
DIAGNOSA
Keadaan gigi 9 9 9 9 9 9 9 9 9 9 9 9
85 84 83 82 81 71 72 73 74
Letak Caries L
DIAGNOSA DA G4
Keadaan gigi B A A A E A A A A
Segment Segment

0 0 0 DI 1 0 1 CI
0 1 2 2 0.8333 0 0 2 0 0.6667
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index Score
17 16 11 21 26 27 0 1 1 0 1
0 17 46 41 31 36 37 0 0 1 1 2 2

- Gigi sehat =0 0 16 = A - Tak memerlukan sc
- Gigi lubang/karies =1 0 3=B - Memerlukan scalin
- Tumpatan dgn karies =2 0 0=C - Instruksi menyikat
- Tumpatan tanpa karies =3 0=D - Memerlukan scalin
- Gigi dicabut karena karies =4 0 2=E intruksi menyikat g
- Mahkota khusus =7 0 0=G - Tidak memerlukan
- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi K
- Gigi tidak termasuk kriteria =9 32 - - Memerlukan Scalin
di atas - Memerlukan Scalin
- Memerlukan Peraw
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
GI DAN MULUT
YARAKAT
01 2017
Lain-lain
16 05 PONDOK BITUNG
KIRI
A
0 0 0 0
1 0 0 0
65 0 0
0 0 0 0
9 9 9 9 0 0 0 KODE:
0 0
25 26 27 28 KME-ART= EA MESIAL = M
35 36 37 38 KME-GI= EG DISTAL = D
9 9 9 9 0 0 KMP VITAL = PV LABIAL = L
0 0 0 0
75 0 >0 0 KMP NONVITAL = PN PALATAL = P
A 1 0 0 1 GOYANG °3/°4 = G3/G4
Segment
D= 0 d= 3
M= 0 e= 2
F= 0 f= 0
____ ____
DMF = 0 def = 5
Segmen JumlahKode
2 1 1 2 3 2
0 1 2 2 0 0
0
NCANA PERAWATAN
Kebersihan Mulut :

Konservasi : GT GS
Pencabutan : CE INF
Observasi :
*Keterangan :
Konservasi
Prosto
BANDUNG

NAMA: ADNAN Gender: 1P=1 No. Resp.:

W=2 Tanggal :
ALAMAT: JL. CIPICUNG NO 9 RT,RW,Kelurahan:
KANAN
Keadaan gigi B A A B B B A
DIAGNOSA DG DA DG PV
Letak Caries B O
55 54 53 52 51 61 62
Keadaan gigi 8 0 0 0 0 0 0 0 0 0
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22
48 47 46 45 44 43 42 41 31 32
Letak Caries O O
DIAGNOSA EG EG
Keadaan gigi 8 1 1 6 0 0 0 0 0 0
85 84 83 82 81 71 72
Letak Caries O
DIAGNOSA G4
Keadaan gigi A A A A A A A
Segment Segment

2 1 0 DI 2 1 2
0 0 0 0 0.5 0 1 0 1
OHI - S = 1.666667
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26 2 1
0 46 31 36 0 1
1. DIAGNOSA 2.
- Gigi sehat =0 22 14 = A
- Tumpatan tanpa karies =3 0= D
- Sealant =6 3 0= F
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0 2
N GIGI DAN MULUT
MASYARAKAT
005
05 01 2017
kerjaan (orang tua/wali) : TNI
RW,Kelurahan: 05 02 CIOMAS
KIRI
A B A
DA PV 0 0 0 0
OB 2 2 0 0
63 64 65 0 0
0 0 0 0
0 0 6 6 0 8 0 0 0 KODE:
0 0
23 24 25 26 27 28 KME-ART= EA MESIAL = M
33 34 35 36 37 38 KME-GI= EG DISTAL = D
O O 0 0 0 KMD-GI = DG OCLUSAL = O
EG EG 0 4 KMD-ART = DA BUCCAL = B
0 0 0 1 1 0 0 0 KMP VITAL = PV LABIAL = L
0 0 0 0
73 74 75 0 >0 0 KMP NONVITAL = PN PALATAL = P
O KMA = A RK = Rampan Karies
A A B 1 0 0 1 GOYANG °3/°4 = G3/G4
Segment
D= 4 d= 7
CI M= 0 e= 0
1.167 F= 0 f= 0
____ ____
DMF 4 def = 7
Segmen JumlaKode
2 2 1 2 2 2
0 0 1 0 0 0 0
0
RENCANA PERAWATAN
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
BANDUNG
KARTU SURVEY KESEHATAN GIGI DAN MULU

NAMA: IMAM NUZULUDIN Gender: 1P= 1 No. Resp.: 006

W=2 Tanggal : 06 01
ALAMAT: JL. KOTA BATU NO 9 RT,RW,Kelurahan: 10
KANAN
Keadaan gigi B A A - A A A
DIAGNOSA DA G4
Letak Caries D
55 54 53 52 51 61 62 63 64 65
DIAGNOSA A PS
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25
48 47 46 45 44 43 42 41 31 32 33 34 35
Letak Caries
DIAGNOSA A
85 84 83 82 81 71 72 73 74 75
Letak Caries B P
DIAGNOSA EA DA

1 0 1 DI 1 0 1 CI
0 1 2 2 1.167 0 1 0 0 0.5
OHI - S = 1.667
Artinya : SEDANG
CPITN
Gigi Index Score
17 16 11 21 26 27 1 1 1 0 0 1
0 17 46 41 31 36 37 0 1 0 1 0 0 1

- Mahkota khusus =7 0 0= G - Tidak memerlukan peraw
- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Keseha
- Gigi tidak termasuk kriteria =9 0 - - Memerlukan Scaling dan
di atas - Memerlukan Scaling dan
- Memerlukan Perawatan K
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
Prosto
AN GIGI DAN MULUT
I MASYARAKAT
2017
PNS
07 CIBEREUM
KIRI
0 0 0 0
1 0 0 1
0 0
0 0 0 0
0 0 0 0 KODE:
A 0 0
A 0 0 KMD-ART = DA BUCCAL = B
0 0 0 0
1 0 0 0 GOYANG °3/°4 = G3/G4
D= 0 d= 4
M= 0 e= 0
F= 0 f= 1
____ ____
DMF = 0 def = 5

1 1 1 6 2
1 1 1 0 0
0
PERAWATAN
ersihan Mulut :
ruksi menyikat gigi 1
dak memerlukan perawatan = 0

GT GS
mpatan ART 0 3 gigi
0 0 gigi
CE INF
1 0 gigi
0 0 gigi
mpan Karies
BANDUNG

NAMA: FAUZIA NURUL Gender: 2P= 1 No. Resp.: 007

W=2 Tanggal : 07 01 2017
ALAMAT: JL. RAMBUTAN NO. 10 RT,RW,Kelurahan: 08 01
KANAN
DIAGNOSA DA 0
Letak Caries O 1
55 54 53 52 51 61 62 63 64 65
DIAGNOSA DA A A A A DG
Letak Caries O O
18 17 16 15 14 13 12 11 21 22 23 24 25 26
48 47 46 45 44 43 42 41 31 32 33 34 35 36
Letak Caries
DIAGNOSA A A A A A A A A A A
Keadaan gigi 0 0 0 0 0 0 0 0 0 0
85 84 83 82 81 71 72 73 74 75
Letak Caries
DIAGNOSA 0
Keadaan gigi A A 0

2 0 0 DI 1 0 0 CI
0 2 1 2 1.1667 0 1 0 1 0.5
OHI - S = 1.67
Artinya : SEDANG
CPITN
Gigi Index Score
17 16 11 21 26 27 1 1 0 0 1 1
0 17 46 41 31 36 37 0 1 1 0 0 1 1

- Gigi lubang/karies =1 2 1=B - Memerlukan scaling
- Tumpatan dgn karies =2 0 0=C - Instruksi menyikat gigi
- Tumpatan tanpa karies =3 0=D - Memerlukan scaling dan
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
UT
2017
Wiraswasta
CICAHEUM
KIRI
0 0 0
0 0 0
0 ###
### 0 0 0
0 ###
0 KODE:
0 0
0 ###
### 0 0 0
0 >0
### KMP NONVITAL = PALATAL = P
0 0 0 GOYANG °3/°4 = G3/G4
D= 2 d 1
M= 0 e 0
F= 0 f 0
____ ____
DMF 2 de 1
Segmen J Kode
1 0 1 ### 2
1 0 1 ### 0
###
ERAWATAN
sihan Mulut :
memerlukan scaling = ###
merlukan scaling = ###3
uksi menyikat gigi = ###
merlukan scaling dan = ###1 3
ksi menyikat gigi 1
k memerlukan perawatan = 0
kasi Instruksi Kesehatan mulut = 1
merlukan Perawatan Khusus dan = 4
GT GS
1 1 gigi
1 0 gigi
CE INF
0 0 gigi
0 0 gigi
BANDUNG

NAMA: DINDA RAMADHANIA Gender: 2P= 1 No. Resp.: 008

W=2 Tanggal : 08 01 2017
ALAMAT: JL. TAMAN SARI NO 13 RT,RW,Kelurahan: 11 09
KANAN
Keadaan gigi A A
DIAGNOSA PS
Letak Caries
55 54 53 52 51 61 62 63 64 65
Keadaan gigi 0 6 0 0 0 1 1 0 0 0 0 6
DIAGNOSA EG EG
Letak Caries M M
18 17 16 15 14 13 12 11 21 22 23 24 25 26
48 47 46 45 44 43 42 41 31 32 33 34 35 36
Letak Caries
DIAGNOSA
Keadaan gigi 6 6 0 0 0 0 0 0 0 0 0 0 6
85 84 83 82 81 71 72 73 74 75
Letak Caries
DIAGNOSA 0
Keadaan gigi 0

2 1 1 DI 2 0 0 CI
0 1 0 2 1.17 0 1 0 1 0.67
OHI - S = 1.83
Artinya : SEDANG
CPITN
Gigi Index Score
17 16 11 21 26 27 1 0 0 0
0 17 46 41 31 36 37 0 1 0 0 1

- Gigi tidak tumbuh =8 0 - - Edukasi Instruksi Kesehatan mu
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
N MULUT
KAT
2017
PNS
CIAPUS
KIRI
0 0 0
0 0 0 0 KODE:
0 2
0 0 KMD-ART = DA BUCCAL/VESTIBULAR = V
0 0 0 0
0 >0 0 KMP NONVITAL = PALATAL = P
0 0 0 GOYANG °3/°4 = G3/G4
D= 2 d= 0
M= 0 e= 0
F= 0 f= 0
____ ____
DMF = 2 def = 0
Segmen Jumlah Kode

1 0 0 3 2
1 0 1 0 0
0
ERAWATAN
sihan Mulut :
memerlukan scaling = 0
erlukan scaling = 1 3
uksi menyikat gigi = 2
erlukan scaling dan = 3 1 3
ksi menyikat gigi 1
asi Instruksi Kesehatan mulut = 1
erlukan Scaling dan EIKM = 2 1
erlukan Scaling dan EIKM = 3
erlukan Perawatan Khusus dan EIKM = 4
GT GS
0 0 gigi
2 0 gigi
CE INF
0 0 gigi
0 0 gigi
Puskesmas
BANDUNG

USAHA KESEHATAN GIGI MASY
NAMA: MUHAMAD KAISYA Gender: 1P=1 No. Resp.:

W=2 Tanggal :
ALAMAT: SUKAWANA RT,RW,Kelurahan:
KANAN
Keadaan gigi - - - - - - -
DIAGNOSA
Letak Caries
55 54 53 52 51 61 62
Keadaan gigi 9 9 1 0 9 9 0 0 0 0
DIAGNOSA EG
Letak Caries L
18 17 16 15 14 13 12 11 21 22
48 47 46 45 44 43 42 41 31 32
Letak Caries OL
DIAGNOSA EG
Keadaan gigi 9 9 1 0 9 9 0 0 0 9
85 84 83 82 81 71 72
Letak Caries M
DIAGNOSA PV
Keadaan gigi - B - - -
Segment Segment

0 0 0 DI 1 0 2
0 0 0 0 0 0 0 2 0
OHI - S = 0.83
Artinya : BAIK
CPITN
Gigi Index Score
17 16 11 21 26 27 0 1 1
0 17 46 41 31 36 37 0 X 0 1
1. DIAGNOSA 2.
- Tumpatan tanpa karies =3 0= D
- Sealant =6 0 0= F
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0 0
VEY KESEHATAN GIGI DAN MULUT
KESEHATAN GIGI MASYARAKAT
009
09 01 2017
n (orang tua/wali) : PNS
01 12 KARYAWANGI
KIRI
B A B
DG DG 0 0 0 0
OL B 0 2 0 0
63 64 65 0 0
0 0
9 9 9 1 9 9 0 0 0 KODE:
DG 0 1
O 0 1 DIAGNOSA
23 24 25 26 27 28 KME-ART= EA
33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
0 1 KMD-ART = DA
9 9 0 9 9 9 0 0 KMP VITAL = PV
0 0
73 74 75 0 >0 0 KMP NONVITAL = PN
B KMA = A
DG 0 0 0 0 PERSISTENSI = PS
A A B 0 1 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 3 d= 6
CI M= 0 e= 0
0.833333 F= 0 f= 0
____ ____
DMF = 3 def = 6

0 0 0 1 1 0 3 2
1 2 X 0 1 2 0 0
0
RENCANA PERAWATAN
- Memerlukan scaling dan = 3 1
2.2. CPITN
- Tidak memerlukan perawatan =
- Edukasi Instruksi Kesehatan mulut =
- Memerlukan Scaling dan EIKM =
- Memerlukan Scaling dan EIKM =

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0 0

0 0
RK = Rampan Karies
PERSISTENSI = PS
1
0
1
2 2
3
4
BANDUNG

NAMA: MIRA HAERANI Gender: 2P= 1 No. Resp.: 010

W=2 Tanggal : 10 01 2017
ALAMAT: SERANG RT,RW,Kelurahan: 07 11 CIJAMBE
KANAN
Keadaan gigi A A A A A A B B
DIAGNOSA EG PN 0 1
55 54 53 52 51 61 62 63 64 65
Keadaan gi 9 9 0 9 9 9 9 0 0 9 9 9 9 0 9
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
Letak Caries
DIAGNOSA
Keadaan gi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9
85 84 83 82 81 71 72 73 74 75
Letak Caries O B
DIAGNOSA EG EG 0 2
Keadaan gigi C A A A A C 0 0

0 0 0 DI 0 0 0 CI
0 1 1 2 0.67 0 0 0 1 0.17
OHI - S = 0.833
Artinya : BAIK
CPITN
16 11 21 26 1 0 0 1 1
0 46 41 31 36 0 1 0 0 1 1

- Memerlukan Perawatan Khusus dan E
2.3. Pencabutan :
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LUT
CIJAMBE
KIRI
0 0
0 0
0 0
0 0 0 0
9 0 0 0 KODE:
0 0
0 0 0 0
0 >0 0 KMP NONVITAL =PALATAL = P
0 0 GOYANG °3/°4 = G3/G4
D= 0 d= 5
M= 0 e= 0
F= 0 f= 0
____ ____
DMF 0 def = 5
Segmen JumlaKode
0 1 4 2
0 1 0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
ukan perawatan = 0
uksi Kesehatan mulut = 1
Scaling dan EIKM = 2 1
Scaling dan EIKM = 3
Perawatan Khusus dan EIKM = 4
GT GS
0 0 gigi
0 3 gigi
CE INF
0 0 gigi
0 0 gigi
Puskesmas
BANDUNG

NAMA: adinda nur f 2P= 1
Gender: No. Resp.: a412
W=2 Tanggal : 02 01 2017
ALAMAT: jl. Kartini no 32 kabupaten sumedang RT,RW,Kelurahan: 04 02 cipamempek
KANAN KIRI
Keadaan gigi A A A - - - - - A A
DIAGNOSA A 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI=
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DA 0 0 0 0 PERSISTE
Keadaan gigi A B A - - - - A D A 1 0 0 0 GOYANG

1 0 0 DI 0 0 0 CI M= 0 e= 0
0 2 0 1 0.67 0 1 0 1 0.33 F= 0 f= 1
OHI - S = 1 ____ ____
CPITN
17 16 11 21 26 27 0 2 1 0 0 0 2 1 0 1 1
0 17 46 41 31 36 37 0 2 2 0 0 2 2 2 0 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSLETAK CARIES
ART= MESIAL = M
GI= DISTAL = D
GI = OCLUSAL = O
ARTBUCCAL = B
VITALLABIAL = L
0
NONV PALATAL = P
= A RK = Rampan Karies
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: riki andriana Gender: 1P= 1 No. Resp.: r211
W=2 Tanggal : 07 01 2017
ALAMAT: baginda no 24, sumedang RT,RW,Kelurahan: 05 01 baginda
KANAN KIRI
Keadaan gigi A A - - - - - A B A
DIAGNOSA EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI=
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA PN PV 0 0 0 0 PERSISTE
Keadaan gigi A B A - - - - A B A 0 0 0 0 GOYANG

2 0 1 DI 0 0 0 CI M= 0 e= 0
0 2 0 2 1.17 0 2 1 2 0.83 F= 0 f= 0
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 0 0
0 17 46 41 31 36 37 0 2 2 2 2 2 2 2 2 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSLETAK CARIES
ART= MESIAL = M
GI= DISTAL = D
GI = OCLUSAL = O
ARTBUCCAL = B
VITALLABIAL = L
0
NONV PALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Doni Ahmad Gender: 1P= 1 No. Resp.: d212
W=2 Tanggal : 02 01 2017
ALAMAT: dsn sabagi , sumedang RT,RW,Kelurahan: 02 05 ciherang
KANAN KIRI
Keadaan gigi A B A - - - - A A A
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI=
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA PV G3 0 0 0 0 PERSISTE
Keadaan gigi A B A A A - A A A A 0 0 1 0 GOYANG

1 0 1 DI 0 0 0 CI M= 0 e= 0
0 2 0 0 0.67 0 2 0 0 0.33 F= 0 f= 0
OHI - S = 1 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 0 0
0 17 46 41 31 36 37 0 2 2 0 0 0 0 2 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSLETAK CARIES
ART= MESIAL = M
GI= DISTAL = D
GI = OCLUSAL = O
ARTBUCCAL = B
VITALLABIAL = L
0
NONV PALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: tsani ariani 2P= 1
Gender: No. Resp.: t413
W=2 Tanggal : 03 01 2017
ALAMAT: pasanggrahan no 38 kabupaten sumedang RT,RW,Kelurahan: 08 02 pasanggrahan
KANAN KIRI
Keadaan gigi A D A - - - - A A -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI=
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA PN 0 0 0 0 PERSISTE
Keadaan gigi A B - - - - - - D - 0 0 0 0 GOYANG

2 0 1 DI 0 0 0 CI M= 0 e= 0
0 2 0 2 1.17 0 2 0 1 0.5 F= 0 f= 1
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 0 2 1 0 0 0 2 1 0 1 1
0 17 46 41 31 36 37 0 2 2 0 0 2 2 2 0 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSLETAK CARIES
ART= MESIAL = M
GI= DISTAL = D
GI = OCLUSAL = O
ARTBUCCAL = B
VITALLABIAL = L
0
NONV PALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: kurnia A Gender: 1P= 1 No. Resp.: k213
W=2 Tanggal : 03 01 2017
KANAN KIRI
Keadaan gigi A A A A - - - A A A
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI=
DIAGNOSA EA EG 1 1 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA A 0 0 0 0 PERSISTE
Keadaan gigi A A A - - - - - A A 0 0 0 0 GOYANG

1 0 0 DI 0 0 0 CI M= 0 e= 0
0 2 1 2 1 0 1 1 1 0.5 F= 0 f= 0
OHI - S = 1.5 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 0 0
0 17 46 41 31 36 37 0 1 2 0 0 2 0 2 0 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSLETAK CARIES
ART= MESIAL = M
GI= DISTAL = D
GI = OCLUSAL = O
ARTBUCCAL = B
VITALLABIAL = L
0
NONV PALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: afriansyah Gender:1P= 1 No. Resp.: a214
W=2 Tanggal : 03 01 2017
KANAN KIRI
Keadaan gigi A A A - - - - A A A
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-AR
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI=
Letak Caries 0 0 0 KMD-GI
DIAGNOSA 0 0 KMD-AR
Keadaan gigi 9 0 0 9 9 0 0 0 0 0 0 9 9 0 0 9 0 0 KMP VIT
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NO
DIAGNOSA PS PS PS PS 0 0 4 0 PERSIST
Keadaan gigi A A - - - - - - A A 0 0 0 0 GOYANG

0 0 0 DI 0 0 0 CI M= 0 e= 0
0 1 0 1 0.33 0 1 0 0 0.17 F= 0 f= 0
OHI - S = 0.5 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 1 1
0 17 46 41 31 36 37 0 0 1 0 0 0 0 1 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
- Tak bersih satu segment =1 2.5. Dirujuk ke : klinik gigi sukajadi
- Tak bersih lebih satu segment =2 2 *Keterangan : ortho
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSLETAK CARIES
ART= MESIAL = M
GI= DISTAL = D
GI = OCLUSAL = O
ARTBUCCAL = B
VITALLABIAL = L
0
NONV PALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: ahmad meinanda Gender: 1P= 1 No. Resp.: a215
W=2 Tanggal : 04 01 2017
KANAN KIRI
Keadaan gigi A A B - - - - - A A
DIAGNOSA EA A 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA PS PS 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI=
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA A 0 0 0 0 PERSIST
Keadaan gigi A A - - - - - - A A 0 0 0 0 GOYANG

0 0 0 DI 0 0 0 CI M= 0 e= 0
0 0 0 1 0.17 0 0 0 0 0 F= 0 f= 0
OHI - S = 0.17 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 0 0
0 17 46 41 31 36 37 0 0 0 0 0 0 0 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 1
- Tak bersih satu segment =1 2.5. Dirujuk ke : klinik gigi
- Tak bersih lebih satu segment =2 1 *Keterangan : ortho
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSLETAK CARIES
ART= MESIAL = M
GI= DISTAL = D
GI = OCLUSAL = O
ARTBUCCAL = B
VITALLABIAL = L
0
NONV PALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
0
BANDUNG

NAMA: nurmala S Gender: 2P= 1 No. Resp.: n414
W=2 Tanggal : 05 01 2017
KANAN KIRI
Keadaan gigi A A A A - - - A B A
DIAGNOSA PV 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0
DIAGNOSA 0 0
Letak Caries 0 0 DIAGN
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-A
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-G
Letak Caries 0 0 0 KMD-G
DIAGNOSA 0 0 KMD-A
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0 0 KMP V
0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP N
Letak Caries B KMA =
DIAGNOSA DA 0 0 0 0 PERSIS
Keadaan gigi A A A - - - - A B A 1 0 0 0 GOYAN

1 0 2 DI 1 0 1 CI M= 0 e= 0
0 2 1 2 1.33 0 1 1 2 1 F= 0 f= 0
OHI - S = 2.33 ____ ____
CPITN
17 16 11 21 26 27 0 1 0 0 1 0 1 0 1 4 2
0 17 46 41 31 36 37 0 1 1 0 0 1 1 1 0 1 0 0
0

- Ada =1
2.4. Observasi :
1.4. Kelainan Dentofacial : gigi 64
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
RI
0 0
DE:
AGNOSLETAK CARIES
E-ART= MESIAL = M
E-GI= DISTAL = D
D-GI = OCLUSAL = O
D-ARTBUCCAL = B
P VITALLABIAL = L
0 0
P NONV PALATAL = P
A = A RK = Rampan Karies
RSISTENSI = PS
YANG °3/°4 = G3/G4
de
0
1
2 1
3
4
BANDUNG

NAMA: koswara Gender: 1P= 1 No. Resp.: k216
W=2 Tanggal : 04 01 2017
ALAMAT: pasanggrahanno 42 RT,RW,Kelurahan: 07 04 pasanggrahan
KANAN KIRI
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-AR
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI
Letak Caries O 0 0 0 KMD-GI
DIAGNOSA EG 0 1 KMD-AR
Keadaan gigi 9 0 1 9 9 0 0 0 0 0 9 9 9 0 0 9 0 0 KMP VI
0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NO
DIAGNOSA DA A A DA 0 0 0 0 PERSIS
Keadaan gigi A B - - - - - - B A 2 0 0 0 GOYAN

1 0 1 DI 0 0 0 CI M= 0 e= 0
0 2 1 2 1.17 0 2 1 2 0.83 F= 0 f=
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 0 0 0 0 0 0 0 0 0 0 0
0 17 46 41 31 36 37 0 0 2 0 0 2 2 2 0 2 0 0
0

- Ada =1
2.4. Observasi :
gigi 73
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
RI
0 0
DE:
AGNOSLETAK CARIES
E-ART= MESIAL = M
E-GI= DISTAL = D
D-GI = OCLUSAL = O
D-ARTBUCCAL = B
P VITALLABIAL = L
0 0
P NONV PALATAL = P
A = A RK = Rampan Karies
RSISTENSI = PS
YANG °3/°4 = G3/G4
de
0
1
2 2
3
4
BANDUNG

NAMA: shelvia M Gender: 2P= 1 No. Resp.: s415
W=2 Tanggal : 05 01 2017
ALAMAT: pasanggrahan no 51 RT,RW,Kelurahan: 02 04 pasanggrahan
KANAN KIRI
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI=
Letak Caries B O 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA PN A 0 0 0 0 PERSISTE
Keadaan gigi A B - - - - - - - A 0 0 0 0 GOYANG

2 0 2 DI 1 0 1 CI M= 0 e= 0
0 2 0 2 1.33 0 2 1 2 1.17 F= 0 f= 0
OHI - S = 2.5 ____ ____
CPITN
17 16 11 21 26 27 1 2 0 0 0 1 2 0 1 1 1
0 17 46 41 31 36 37 0 2 2 0 0 2 2 2 0 2 0 0
0

- Ada =1
2.4. Observasi :
- Tak ada kelainan =0 0 gigi 74 dan 84
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSLETAK CARIES
ART= MESIAL = M
GI= DISTAL = D
GI = OCLUSAL = O
ARTBUCCAL = B
VITALLABIAL = L
0
NONV PALATAL = P
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: Nadhaafa Nur Walida Gender: 2P= 1 No. Resp.: 1
W=2 Tanggal : 06 02 2017
ALAMAT: Ciparay RT,RW,Kelurahan: 01 03 Ciparay
KANAN KIRI
Keadaan gigi B B A - A - A B B A
DIAGNOSA DA EA G3 - PS - PS DG A G3 1 0 2 0
Letak Caries M O - - - - - M O - 1 1 2 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA - - - - - - - - - - - - - - - - 0 0
Letak Caries - - - - - - - - - - - - - - - - 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O O D - - - - - - O KMA = A
DIAGNOSA EA EA EG - - - - - - DA 2 1 0 0 PERSISTE
Keadaan gigi B B B - - A A A A B 1 0 0 0 GOYANG

1 1 0 DI 1 0 1 CI M= 0 e= 0
0 0 1 1 0.67 0 1 0 1 0.67 F= 0 f= 1
OHI - S = 1.33 ____ ____
CPITN
17 16 11 21 26 27 X 1 0 0 1 X 1 0 1 2 2
0 17 46 41 31 36 37 0 X X 0 0 X X 0 0 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Atla Dhamar Sabat Gender: 1P= 1 No. Resp.: 2
W=2 Tanggal : 06 02 2017
KANAN KIRI
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 0 2 DI 0 0 1 CI M= 0 e= 1
0 1 0 1 0.83 0 0 0 1 0.33 F= 0 f= 0
OHI - S = 1.17 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Ghalya Setiadimas Put
Gender: 2P= 1 No. Resp.: 3
W=2 Tanggal : 06 02 2017
KANAN KIRI
DIAGNOSA DG A 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DA EG EG DA 0 3
Letak Caries O O M M O 2 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

2 1 1 DI 1 0 1 CI M= 0 e= 1
0 1 1 1 1.17 0 1 0 1 0.67 F= 0 f= 0
OHI - S = 1.83 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Adzkya fadla Naima Gender: 2P= 1 No. Resp.: 4
W=2 Tanggal : 06 02 2017
KANAN KIRI
Keadaan gigi B B A A A B A A A E
DIAGNOSA DA DA PS DG G3 0 0 1 0
Letak Caries M O M 2 1 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DA DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA EA DG G4 PS DA 1 0 1 0 PERSISTE

1 2 1 DI 0 0 0 CI M= 0 e= 1
0 1 1 1 1.17 0 0 0 1 0.17 F= 0 f= 0
OHI - S = 1.33 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Zasqia Fahira Gender: 2P= 1 No. Resp.: 5
W=2 Tanggal : 06 02 2017
KANAN KIRI
Keadaan gigi B A A B A B A A A E
DIAGNOSA DA DG DG G3 0 0 0 0
Letak Caries M D M 1 2 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O M O O KMA = A
DIAGNOSA EA DG G4 DA DA 1 0 0 0 PERSISTE
Keadaan gigi B A A B A A A A B B 2 1 0 1 GOYANG

1 1 1 DI 0 0 0 CI M= 0 e= 1
0 1 1 1 1 0 0 0 1 0.17 F= 0 f= 1
OHI - S = 1.17 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Wanda Alya Gender: 2P= 1 No. Resp.: 6
W=2 Tanggal : 06 02 2017
KANAN KIRI
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DA EG DG 0 2
Letak Caries O O D O 1 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 1 2 DI 1 1 1 CI M= 0 e= 1
0 1 1 1 1.17 0 1 1 1 1 F= 0 f= 1
OHI - S = 2.17 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Ghirah Jihad Gender: 1P= 1 No. Resp.: 7
W=2 Tanggal : 06 02 2017
KANAN KIRI
DIAGNOSA DA G3 DG G3 G3 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA A DG G4 DG 0 0 0 0 PERSISTE

1 2 1 DI 0 0 0 CI M= 0 e= 1
0 2 1 2 1.5 0 0 0 1 0.17 F= 0 f= 0
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Azhar Azali Gender: 1P= 1 No. Resp.: 8
W=2 Tanggal : 06 02 2017
KANAN KIRI
DIAGNOSA DA G3 DG G3 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DA DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

1 1 1 DI 0 0 0 CI M= 0 e= 1
0 1 1 1 1 0 0 0 1 0.17 F= 0 f= 0
OHI - S = 1.17 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Sayid Nasrulhaq Gender: 1P= 1 No. Resp.: 9
W=2 Tanggal : 06 02 2017
KANAN KIRI
Keadaan gigi B A A - - - - A A E
DIAGNOSA DA DG G3 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi B A A - - - A A B 1 0 0 0 GOYANG

1 1 1 DI 1 1 1 CI M= 0 e= 1
0 1 1 1 1 0 1 1 1 1 F= 0 f= 0
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Nidaa Aulia U Gender: 2P= 1 No. Resp.: 10
W=2 Tanggal : 06 02 2017
KANAN KIRI
Keadaan gigi B A A - - - - A A E
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA EA DG DA 1 0 0 0 PERSISTE
Keadaan gigi B A A B - - A A A B 1 1 0 0 GOYANG

1 1 1 DI 1 1 1 CI M= 0 e= 1
0 1 1 1 1 0 1 1 1 1 F= 0 f= 0
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 6 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: Umery Lathifa Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 11 12 2016
ALAMAT: Perum Tanjung Indah Blok K.01 RT,RW,Kelurahan: 01 02 Tanjung Kamuning
KANAN KIRI
Keadaan gigi A A A A - - A A A A
DIAGNOSA - - - - - - - - - - 0 0 0 0
Letak Caries - - - - - - - - - - 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA - - - - - - - EA EG - - - - - - - 1 1
Letak Caries - - - - - - - M D - - - - - - - 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries - - - - - - - - - - - - - - - - 0 0 0 KMD-GI =
DIAGNOSA - - - - - - - - - - - - - - - - 0 0 KMD-ART
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

Letak Caries O O B M M D M O O - KMA = A
DIAGNOSA EA EA EG EG EG EG EG DG EA - 3 5 0 0 PERSISTE
Keadaan gigi F B E B B B B B B A 0 1 0 0 GOYANG

2 1 2 DI 1 0 2 CI M= 0 e= 1
0 3 1 3 2 0 2 0 2 1.17 F= 0 f= 0
OHI - S = 3.17 ____ ____
CPITN
X 16 11 26 27 x X 2 0 2 2 X 2 2 2 1 1
0 x 47 46 31 36 X 0 X 2 1 1 2 X 2 1 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
- Tak bersih satu segment =1 2.5. Dirujuk ke : Puskesmas Merpati
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
2 9
0 0
BANDUNG

NAMA: Audhy Ramadhani Gender: 1P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: Perum Bumi Asri Blok K.02 RT,RW,Kelurahan:
KANAN
Keadaan gigi D E A - - -
DIAGNOSA DG - - - - -
Letak Caries O - - - - -
55 54 53 52 51 61
Keadaan gigi 9 9 9 9 9 9 1 1 1
DIAGNOSA - - - - - - EA EG EA
Letak Caries - - - - - - M D M
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Keadaan gigi 9 9 9 9 9 9 1 1 1
85 84 83 82 81 71
Letak Caries O O - - - -
DIAGNOSA EA DG - - - -
Keadaan gigi B B A - - -
Segment Segment

2 2 3 DI 2 1
0 3 2 3 2.5 0 3 1
OHI - S = 4.5
Artinya : BURUK
CPITN
Gigi Index Score
X 16 11 26 27 X X 2
0 x 47 46 31 36 X 0 X 1
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
12 12 2016
RT,RW,Kelurahan: 02 03 Tanjung Perak
KIRI
- A B A
- - EA - 1 0 0 0
- - O - 0 1 0 0
62 63 64 65 0
1 9 9 9 9 9 9 0 0 0 KODE:
EG - - - - - - 2 2
D - - - - - - 0 0 DIAGNOSA LETAK CARIES
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D
D - - - - - - 0 0 0 KMD-GI = DG OCLUSAL = O
EA - - - - - - 3 1 KMD-ART = DA BUCCAL = B

- - L O KMA = A RK = Rampan Kar
- - EG DG 1 1 0 0 PERSISTENSI = PS
- A B B 0 2 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 8 d= 0
2 CI M= 0 e= 1
3 2 F= 0 f= 0
____ ____
DMF = 8 def = 1
Segmen JumlaKode
2 2 2 X 2 2 2 1 1
1 2 2 X 1 2 2 0 0
0
2.2. CPITN

2.4. Observasi :
2.5. Dirujuk ke : Puskesmas Cempaka

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Firyal Fakhri Ramadhan Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: Perum Bumi Cempaka Asri Blok K.03
KANAN
Keadaan gigi A B A A -
DIAGNOSA - EA - - -
Letak Caries - O - - -
55 54 53 52 51
Keadaan gigi 9 9 9 9 9 9 9 0
DIAGNOSA - - - - - - - -
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries - - - - - - M -
DIAGNOSA - - - - - - EA -
Keadaan gigi 9 9 9 9 9 9 1 9
85 84 83 82 81
Letak Caries O O - - M
DIAGNOSA EA DG - - DG
Keadaan gigi B B A - B
Segment Segment

1 1 1 DI 1
0 2 1 2 1.33 0 1
OHI - S = 2.333333
Artinya : SEDANG
CPITN
Gigi Index Score
X 16 11 26 X X X
0 X X 46 31 36 X 0 X
1. DIAGNOSA
- Gigi sehat =0 2 9
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 13 12 2016
RT,RW,Kelurahan: 03 04 Sucinaraja
KIRI
- A A B A
- - - EA - 2 0 0 0
- - - O - 0 0 0 0
61 62 63 64 65 0
0 9 9 9 9 9 9 9 0 0 0 KODE:
- - - - - - - - 0 0
- - - - - - - - 0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
- - - - - - - - 0 0 0 KMD-GI = DG
- - - - - - - - 1 0 KMD-ART = DA
9 9 9 9 9 9 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

M D - - B KMA = A
DG DG - - EG 1 1 0 0 PERSISTENSI = PS
B B A A B 0 4 0 0 GOYANG
Segment
1 1 CI M= 0 e= 0
1 1 1 F= 0 f= 1
____ ____
DMF = 1 def = 10
Segmen JumlaKode
2 0 2 X X 2 2 0 0 0
X 2 2 2 X 0 2 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :
2.5. Dirujuk ke : Puskesmas Mawar

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: Nicken Shaquilla Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: Perumahan Al-Azhar Blok C.06
KANAN
Keadaan gigi A B A B -
DIAGNOSA - EA - EG -
Letak Caries - O - M -
55 54 53 52 51
Keadaan gigi 9 9 9 9 9 9 9 1
DIAGNOSA - - - - - - - EG
Letak Caries - - - - - - - D
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries - - - - - - D -
Keadaan gigi 9 9 9 9 9 9 1 9
85 84 83 82 81
Letak Caries - O - - M
DIAGNOSA - EG - - EG
Keadaan gigi A B A - B
Segment Segment

0 2 1 DI 0
0 1 1 1 1 0 2
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index Score
X 16 11 26 X X X
0 X X 46 31 36 X 0 X
1. DIAGNOSA
- Gigi sehat =0 2 9
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 04
Tanggal : 14 12 2016
RT,RW,Kelurahan: 04 05 Tanah Abang
KIRI
- B A B A
- EG - EA - 2 2 0 0
- D - O - 0 0 0 0
61 62 63 64 65 0
0 9 9 9 9 9 9 9 0 0 0 KODE:
- - - - - - - - 0 1
- - - - - - - - 0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
- - - - - - - - 0 0 0 KMD-GI = DG
- - - - - - - - 1 0 KMD-ART = DA
0 9 9 9 9 9 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

- - - O - KMA = A
- - - EA - 1 2 0 0 PERSISTENSI = PS
- A A B A 0 0 0 0 GOYANG
Segment
1 1 CI M= 0 e= 0
1 1 1 F= 0 f= 3
____ ____
DMF = 2 def = 10
Segmen JumlahKode
0 0 0 X X 0 0 0 0 0
X 2 2 2 X 0 2 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Dimas Kalimasyada Gender: 1P=1

W=2
Umur: 9 tahun
ALAMAT: Perumahan Cibiru Blok K.08
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries - O - M
DIAGNOSA - EA - EG
Segment
Plaque Score
0 1 0 DI
0 1 0 1 0.5 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 0
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 15 12 2016
RT,RW,Kelurahan: 05 06 Cibiru Utara
- B B A A A
- EG EG - - - 0 2 0 0
- D D - - - 0 0 0 0
51 61 62 63 64 65
1 9 9 9 9 9 9 9 9 0
EA - - - - - - - - 1
M - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
9 9 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
- M - - O -
- EG - - EA - 2 2 0 0
A B A A B A 0 0 0 0
Segment Segment
Calculus Score D= 1
0 1 0 CI M= 0
2 1 2 1 F= 0
____
DMF = 1
Score Segmen
X 0 0 0 0 X 0 0 0
X 2 2 2 2 X 2 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Salamun
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 6
e= 0
f= 2
____
def = 8
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
2 gigi
4 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Inez Al-Mughny Gender: 2P= 1

W=2
Umur: 9 tahun
ALAMAT: Intan Balarea Blok C.10 No.B4
KANAN
Keadaan gigi A A A -
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries - B - -
DIAGNOSA - EG - -
Keadaan gigi A B A A
Segment
Plaque Score
0 1 1 DI
0 1 1 1 0.833333 0
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 2
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 16 12 2016
RT,RW,Kelurahan: 06 07 Simpang Lima
B B G A A A
EG EG - - - - 0 2 0 0
M D - - - - 0 0 0 0
51 61 62 63 64 65
9 9 0 9 9 9 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
9 9 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
M M - - O -
EG EG - - EA - 1 3 0 0
B B A A B A 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
1 0 1 0.333333 F= 0
____
DMF = 0
Score Segmen
X 0 0 0 0 X 0 0 0
X 2 1 2 2 X 2 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Langonsari
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 7
e= 0
f= 2
____
def = 9
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
5 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Salma Hanifatul Kamila Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: Jl.Terusan Pembanguna No.08
KANAN
Keadaan gigi B E A B
DIAGNOSA EG - - EG
Letak Caries D - - D
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA EA - - -
Keadaan gigi B E A A
Segment
Plaque Score
1 0 1 DI
0 1 2 1 1 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 2
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 17 12 2016
RT,RW,Kelurahan: 07 08 Cimanuk
- - E A B A
- - - - EG - 0 3 0 0
- - - - O - 0 0 0 0
51 61 62 63 64 65
0 0 9 9 9 9 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
M - - - - - - - - 0
EA - - - - - - - - 1
1 9 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
- D D - O O
- EG EG - EG EA 2 3 0 0
- B B A B B 0 0 0 0
Segment Segment
Calculus Score D= 1
1 0 0 CI M= 0
1 0 1 0.5 F= 0
____
DMF = 1
Score Segmen
X 1 1 1 1 X 1 1 1
X 1 1 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 8
e= 3
f= 4
____
def = 15
Jumlah ScKode
6 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
2 gigi
6 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Fauzi Rabbani Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Jl.Patriot No.07
KANAN
Keadaan gigi - D A B
DIAGNOSA - - - EG
Letak Caries - - - M
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries - - - D
DIAGNOSA - - - EG
Segment
Plaque Score
0 1 0 DI
0 1 0 1 0.5 0
OHI - S = 1
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 2
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 18 12 2016
RT,RW,Kelurahan: 03 05 Pasanggiri
B B A A B -
EG EG - - EA - 1 3 0 0
D D - - O - 0 0 0 0
51 61 62 63 64 65
9 9 9 9 9 0 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
9 9 9 9 9 0 9 9 9 0
81 71 72 73 74 75 0
- - - - L -
- - - - EG - 0 2 0 0
A A A A B - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 2
Score Segmen
X 1 1 1 0 X 1 1 0
X 2 2 0 2 X 2 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Ledeng
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 6
e= 0
f= 5
____
def = 11
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
5 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: Aliza Kusuma Gender: 1P= 1

W=2
Umur: 9 tahun
ALAMAT: Perum Jati Indah Blok.K10 No.08
KANAN
DIAGNOSA EG EG - -
Letak Caries P O - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries - O - D
DIAGNOSA - EG - EG
Segment
Plaque Score
1 0 1 DI
0 2 0 2 1 0
OHI - S = 1.333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 3
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 19 12 2016
RT,RW,Kelurahan: 02 04 Tarogong Kaler
- - B A B B
- - EG - EG EA 1 4 0 0
- - O - O O 0 0 0 0
51 61 62 63 64 65
0 0 9 9 9 9 9 9 9 0 0
- - - - - - - - - 0 0
- - - - - - - - - 0 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- M - - - - - - - 0 0
- EA - - - - - - - 1 0
0 1 9 9 9 9 9 9 9 0 0
81 71 72 73 74 75 0 >0
- - - - O O
- - - - EG EA 1 3 0 0
- - A A B B 0 0 0 0
Segment Segment
Calculus Score D= 1
0 0 0 CI M= 0
1 0 1 0.333333 F= 0
____
DMF = 1
Score Segmen
X 0 1 0 0 X 0 1 0
X 0 1 0 0 X 0 1 0
-
0= F 2.2. CPITN
2 - Tumpatan GI 0 7

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Trisakti
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 9
e= 0
f= 1
____
def = 10
JumlaKode
2 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: Bakti Islam Santoso Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: Jl. Bank No.17
KANAN
DIAGNOSA - - - EG
55 54 53 52
Letak Caries - - - - O - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - EG - -
85 84 83 82
DIAGNOSA - - - -
Keadaan gigi - - A A
Segment
Plaque Score
0 2 0 DI
0 0 1 0 0.5 0
OHI - S = 0.833333
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 5
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 20 12 2016
RT,RW,Kelurahan: 01 02 Pataruman
ART GI
B B A A - -
EG EG - - - - 0 3 0 0
M D - - - - 0 0 0 0
51 61 62 63 64 65
9 9 9 9 0 0 9 9 9 0
- - - - - - - - - 1
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - O - - - - 0
- - - - EA - - - - 1
9 9 9 9 1 0 9 9 9 0
81 71 72 73 74 75 0
D D - - - -
EA EA - - - - 2 0 0 0
B B A A - - 0 0 0 0
Segment Segment
Calculus Score D= 3
0 1 0 CI M= 0
0 1 0 0.3333333 F= 0
____
DMF = 3
Score Segmen
X 1 1 1 1 X 1 1 1
X 1 1 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Cibatu
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 5
e= 0
f= 4
____
def = 9
Jumlah ScKode
6 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
2 gigi
3 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Annisa A Gender: 2P= 1 No. Resp.: 01
W=2 Tanggal : 11 12 2016
ALAMAT: kp.bobojong cidaun RT,RW,Kelurahan: 01 02 cimaragang
KANAN KIRI
Keadaan gigi A A A A - - A A A A
DIAGNOSA - - - - - - - - - - 0 0 0 0
Letak Caries - - - - - - - - - - 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0

DIAGNOSA - - - - - - - EA EG - - - - - - - 1 1
Letak Caries - - - - - - - M D - - - - - - - 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries - - - - - - - - - - - - - - - - 0 0 0 KMD-GI =
DIAGNOSA - - - - - - - - - - - - - - - - 0 0 KMD-ART
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

Letak Caries O O B M M D M O O - KMA = A
DIAGNOSA EA EA EG EG EG EG EG DG EA - 3 5 0 0 PERSISTE
Keadaan gigi F B E B B B B B B A 0 1 0 0 GOYANG

2 1 2 DI 1 0 2 CI M= 0 e= 1
0 3 1 3 2 0 2 0 2 1.17 F= 0 f= 0
OHI - S = 3.17 ____ ____
CPITN
X 16 11 26 27 x X 2 0 2 2 X 2 2 2 1 1
0 x 47 46 31 36 X 0 X 2 1 1 2 X 2 1 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
- Tak bersih satu segment =1 2.5. Dirujuk ke : Puskesmas Merpati
Exo
Endo
Konservasi
Ortho
Perio
Prosto
OSA LETAK CARIES
RT= EA MESIAL = M
I= EG DISTAL = D
I = DG OCLUSAL = O
RT = DA BUCCAL = B
TAL = PV LABIAL = L
STENSI = PS
NG °3/°4 = G3/G4
= 0
= 1
= 2 2
= 3
= 4
2 9
0 0
BANDUNG

NAMA: Anggara Putra Gender: 1P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: kp haur wangi RT,RW,Kelurahan:
KANAN
Keadaan gigi D E A - - -
DIAGNOSA DG - - - - -
Letak Caries O - - - - -
55 54 53 52 51 61
Keadaan gigi 9 9 9 9 9 9 1 1 1
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Keadaan gigi 9 9 9 9 9 9 1 1 1
85 84 83 82 81 71
Letak Caries O O - - - -
DIAGNOSA EA DG - - - -
Keadaan gigi B B A - - -
Segment Segment

2 2 3 DI 2 1
0 3 2 3 2.5 0 3 1
OHI - S = 4.5
Artinya : BURUK
CPITN
Gigi Index Score
X 16 11 26 27 X X 2
0 x 47 46 31 36 X 0 X 1
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
12 12 2016
RT,RW,Kelurahan: 02 03 agrabinta
KIRI
- A B A
- - EA - 1 0 0 0
- - O - 0 1 0 0
62 63 64 65 0
1 9 9 9 9 9 9 0 0 0 KODE:
EG - - - - - - 2 2
D - - - - - - 0 0 DIAGNOSA LETAK CARIES
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D
D - - - - - - 0 0 0 KMD-GI = DG OCLUSAL = O
EA - - - - - - 3 1 KMD-ART = DA BUCCAL = B

- - L O KMA = A RK = Rampan Kar
- - EG DG 1 1 0 0 PERSISTENSI = PS
- A B B 0 2 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 8 d= 0
2 CI M= 0 e= 1
3 2 F= 0 f= 0
____ ____
DMF = 8 def = 1
Segmen JumlaKode
2 2 2 X 2 2 2 1 1
1 2 2 X 1 2 2 0 0
0
2.2. CPITN

2.4. Observasi :
2.5. Dirujuk ke : Puskesmas Cempaka

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Nursoffa jovi Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: bojong terong
KANAN
Keadaan gigi A B A A -
DIAGNOSA - EA - - -
Letak Caries - O - - -
55 54 53 52 51
Keadaan gigi 9 9 9 9 9 9 9 0
DIAGNOSA - - - - - - - -
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries - - - - - - M -
Keadaan gigi 9 9 9 9 9 9 1 9
85 84 83 82 81
Letak Caries O O - - M
DIAGNOSA EA DG - - DG
Keadaan gigi B B A - B
Segment Segment

1 1 1 DI 1
0 2 1 2 1.33 0 1
OHI - S = 2.333333
Artinya : SEDANG
CPITN
Gigi Index Score
X 16 11 26 X X X
0 X X 46 31 36 X 0 X
1. DIAGNOSA
- Gigi sehat =0 2 9
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 13 12 2016
RT,RW,Kelurahan: 03 04 suryakencana
KIRI
- A A B A
- - - EA - 2 0 0 0
- - - O - 0 0 0 0
61 62 63 64 65 0
0 9 9 9 9 9 9 9 0 0 0 KODE:
- - - - - - - - 0 0
- - - - - - - - 0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
- - - - - - - - 0 0 0 KMD-GI = DG
- - - - - - - - 1 0 KMD-ART = DA
9 9 9 9 9 9 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

M D - - B KMA = A
DG DG - - EG 1 1 0 0 PERSISTENSI = PS
B B A A B 0 4 0 0 GOYANG
Segment
1 1 CI M= 0 e= 0
1 1 1 F= 0 f= 1
____ ____
DMF = 1 def = 10
Segmen JumlaKode
2 0 2 X X 2 2 0 0 0
X 2 2 2 X 0 2 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :
2.5. Dirujuk ke : Puskesmas Mawar

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: Bagas Ruari Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: perum gading asri
KANAN
Keadaan gigi A B A B -
DIAGNOSA - EA - EG -
Letak Caries - O - M -
55 54 53 52 51
Keadaan gigi 9 9 9 9 9 9 9 1
DIAGNOSA - - - - - - - EG
Letak Caries - - - - - - - D
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries - - - - - - D -
Keadaan gigi 9 9 9 9 9 9 1 9
85 84 83 82 81
Letak Caries - O - - M
DIAGNOSA - EG - - EG
Keadaan gigi A B A - B
Segment Segment

0 2 1 DI 0
0 1 1 1 1 0 2
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index Score
X 16 11 26 X X X
0 X X 46 31 36 X 0 X
1. DIAGNOSA
- Gigi sehat =0 2 9
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 04
Tanggal : 14 12 2016
RT,RW,Kelurahan: 04 05 kertajadi
KIRI
- B A B A
- EG - EA - 2 2 0 0
- D - O - 0 0 0 0
61 62 63 64 65 0
0 9 9 9 9 9 9 9 0 0 0 KODE:
- - - - - - - - 0 1
- - - - - - - - 0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
- - - - - - - - 0 0 0 KMD-GI = DG
- - - - - - - - 1 0 KMD-ART = DA
0 9 9 9 9 9 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

- - - O - KMA = A
- - - EA - 1 2 0 0 PERSISTENSI = PS
- A A B A 0 0 0 0 GOYANG
Segment
1 1 CI M= 0 e= 0
1 1 1 F= 0 f= 3
____ ____
DMF = 2 def = 10
Segmen JumlahKode
0 0 0 X X 0 0 0 0 0
X 2 2 2 X 0 2 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: elfrida swandi Gender: 1P=1

W=2
Umur: 9 tahun
ALAMAT: Perumahan Cibiru Blok K.08
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries - O - M
DIAGNOSA - EA - EG
Segment
Plaque Score
0 1 0 DI
0 1 0 1 0.5 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 0
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 15 12 2016
RT,RW,Kelurahan: 05 06 pelabuhan ratu
- B B A A A
- EG EG - - - 0 2 0 0
- D D - - - 0 0 0 0
51 61 62 63 64 65
1 9 9 9 9 9 9 9 9 0
EA - - - - - - - - 1
M - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
9 9 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
- M - - O -
- EG - - EA - 2 2 0 0
A B A A B A 0 0 0 0
Segment Segment
Calculus Score D= 1
0 1 0 CI M= 0
2 1 2 1 F= 0
____
DMF = 1
Score Segmen
X 0 0 0 0 X 0 0 0
X 2 2 2 2 X 2 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Salamun
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 6
e= 0
f= 2
____
def = 8
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
2 gigi
4 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Aldi bagas Gender: 2P= 1

W=2
Umur: 9 tahun
ALAMAT: cimahi bandung
KANAN
Keadaan gigi A A A -
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries - B - -
DIAGNOSA - EG - -
Keadaan gigi A B A A
Segment
Plaque Score
0 1 1 DI
0 1 1 1 0.833333 0
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 2
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 16 12 2016
RT,RW,Kelurahan: 06 07 simpang
B B G A A A
EG EG - - - - 0 2 0 0
M D - - - - 0 0 0 0
51 61 62 63 64 65
9 9 0 9 9 9 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
9 9 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
M M - - O -
EG EG - - EA - 1 3 0 0
B B A A B A 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
1 0 1 0.333333 F= 0
____
DMF = 0
Score Segmen
X 0 0 0 0 X 0 0 0
X 2 1 2 2 X 2 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Langonsari
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 7
e= 0
f= 2
____
def = 9
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
5 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: reki aditya Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: Jl.Terusan Pembanguna No.08
KANAN
DIAGNOSA EG - - EG
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA EA - - -
Segment
Plaque Score
1 0 1 DI
0 1 2 1 1 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 2
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 17 12 2016
RT,RW,Kelurahan: 07 08 sindangbarang
- - E A B A
- - - - EG - 0 3 0 0
- - - - O - 0 0 0 0
51 61 62 63 64 65
0 0 9 9 9 9 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
M - - - - - - - - 0
EA - - - - - - - - 1
1 9 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
- D D - O O
- EG EG - EG EA 2 3 0 0
- B B A B B 0 0 0 0
Segment Segment
Calculus Score D= 1
1 0 0 CI M= 0
1 0 1 0.5 F= 0
____
DMF = 1
Score Segmen
X 1 1 1 1 X 1 1 1
X 1 1 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 8
e= 3
f= 4
____
def = 15
Jumlah ScKode
6 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
2 gigi
6 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: Ayu dwi audisa Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: jl sukaraja
KANAN
DIAGNOSA - - - EG
Letak Caries - - - M
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA - - - EG
Segment
Plaque Score
0 1 0 DI
0 1 0 1 0.5 0
OHI - S = 1
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 2
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 18 12 2016
RT,RW,Kelurahan: 03 05 cidaun
B B A A B -
EG EG - - EA - 1 3 0 0
D D - - O - 0 0 0 0
51 61 62 63 64 65
9 9 9 9 9 0 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
9 9 9 9 9 0 9 9 9 0
81 71 72 73 74 75 0
- - - - L -
- - - - EG - 0 2 0 0
A A A A B - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 2
Score Segmen
X 1 1 1 0 X 1 1 0
X 2 2 0 2 X 2 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Ledeng
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 6
e= 0
f= 5
____
def = 11
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
5 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: astri miastari Gender: 1P= 1

W=2
Umur: 9 tahun
ALAMAT: jl salabintana
KANAN
DIAGNOSA EG EG - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA - EG - EG
Segment
Plaque Score
1 0 1 DI
0 2 0 2 1 0
OHI - S = 1.333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 3
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 19 12 2016
RT,RW,Kelurahan: 02 04 naringgul
- - B A B B
- - EG - EG EA 1 4 0 0
- - O - O O 0 0 0 0
51 61 62 63 64 65
0 0 9 9 9 9 9 9 9 0 0
- - - - - - - - - 0 0
- - - - - - - - - 0 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- M - - - - - - - 0 0
- EA - - - - - - - 1 0
0 1 9 9 9 9 9 9 9 0 0
81 71 72 73 74 75 0 >0
- - - - O O
- - - - EG EA 1 3 0 0
- - A A B B 0 0 0 0
Segment Segment
Calculus Score D= 1
0 0 0 CI M= 0
1 0 1 0.333333 F= 0
____
DMF = 1
Score Segmen
X 0 1 0 0 X 0 1 0
X 0 1 0 0 X 0 1 0
-
0= F 2.2. CPITN
2 - Tumpatan GI 0 7

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 9
e= 0
f= 1
____
def = 10
JumlaKode
2 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: neki aji nur Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: Jl. Bank No.17
KANAN
DIAGNOSA - - - EG
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
0 2 0 DI
0 0 1 0 0.5 0
OHI - S = 0.833333
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 5
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 20 12 2016
RT,RW,Kelurahan: 01 02 kebonkopi
ART GI
B B A A - -
EG EG - - - - 0 3 0 0
M D - - - - 0 0 0 0
51 61 62 63 64 65
9 9 9 9 0 0 9 9 9 0
- - - - - - - - - 1
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - O - - - - 0
- - - - EA - - - - 1
9 9 9 9 1 0 9 9 9 0
81 71 72 73 74 75 0
D D - - - -
EA EA - - - - 2 0 0 0
B B A A - - 0 0 0 0
Segment Segment
Calculus Score D= 3
0 1 0 CI M= 0
0 1 0 0.3333333 F= 0
____
DMF = 3
Score Segmen
X 1 1 1 1 X 1 1 1
X 1 1 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 5
e= 0
f= 4
____
def = 9
Jumlah ScKode
6 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
2 gigi
3 gigi
INF
0 gigi
0 gigi
BAN D U N G
NAMA: Astri Yulianda Gender: 2P= 1 No. Resp.: A001
W=2 Tanggal : 11 02 2006
ALAMAT: Kp. Sekecengek RT,RW,Kelurahan: 02 02 Galanggang
KANAN
Keadaan gigi B B
DIAGNOSA DA PV 0 0 0 0
Letak Caries O MOD 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0
DIAGNOSA A A A PS A A A A A A PS A DG A 0 0
Letak Caries M 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A EA PS A A A A A A A A PS A A 1 0
Keadaan gigi 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries M DO

1 1 0 DI 1 0 0 CI M= 0 e=
0 1 1 1 0.83 0 1 1 0 0.5 F= 0 f=
OHI - S = 1.333 ____ ____
CPITN
17 16 11 21 26 27 0 0 1 0 0 1 0 1 1 5
0 17 46 41 31 36 37 0 1 0 1 0 1 0 1 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
- Tak bersih lebih satu segment =2 5 *Keterangan : Endo
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
4
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Ayu Gita Rahayu Gender: 2P= 1 No. Resp.: A002
W=2 Tanggal : 18 09 2001
ALAMAT: Kp. Sinarmukti RT,RW,Kelurahan: 03 03 Selacau
KANAN
Keadaan gigi B B A - - A A A
DIAGNOSA DA EG G3 G3 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 0 0 0 0 0 0 0 0 0
DIAGNOSA A PS PS A 0 0
Letak Caries 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A A 0 0
Keadaan gigi 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries D O

1 2 1 DI 0 1 0 CI M= 0 e=
0 1 0 1 1 0 1 0 1 0.5 F= 0 f=
OHI - S = 1.5 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 0 0 1 1 1 1 6
0 17 46 41 31 36 37 0 1 0 1 0 0 1 1 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
4
0
1
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Asep Hadiansyah Gender: 1P= 1 No. Resp.: A003
W=2 Tanggal : 19 01 2010
ALAMAT: Selacau RT,RW,Kelurahan: 02 04 Selacau
KANAN
Keadaan gigi B B A A A A B B
DIAGNOSA EG DG DG DG 0 1 0 0
Letak Caries M O B O 0 3 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
DIAGNOSA A A 0 0
Letak Caries 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A A 0 0
0
85 84 8382 81 71 72 73 74 75 0 >0 0
Letak Caries O M O
Keadaan gigi B A A B A A A B 1 1 0 0

1 1 1 DI 0 0 0 CI M= 0 e=
0 2 1 2 1.33 0 1 0 1 0.33 F= 0 f=
OHI - S = 1.67 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 0 0 1 1 1 1 6
0 17 46 41 31 36 37 0 1 1 1 0 1 1 1 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
8
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Dini Nurazizah E.P Gender: 2P= 1 No. Resp.: D001
W=2 Tanggal : 12 12 2002
ALAMAT: Cihampelas RT,RW,Kelurahan: 01 05 Cihampelas
KANAN
Keadaan gigi A A A A A A A B
DIAGNOSA EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
DIAGNOSA A A 0 0
Letak Caries 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA DG A 0 0
Keadaan gigi 1 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries M D O
DIAGNOSA EA EG EG 1 2 0 0
Keadaan gigi B B A A A B 0 0 0 0

1 0 1 DI 0 0 0 CI M= 0 e=
0 0 0 0 0.33 0 0 0 0 0 F= 0 f=
OHI - S = 0.33 ____ ____
CPITN
17 16 11 21 26 27 1 0 1 0 0 1 1 1 1 6
0 17 46 41 31 36 37 0 1 0 1 0 0 1 1 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
4
0
1
Kode
2
0
2 2
0
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Evan Erydian Deni Gender: 1P= 1 No. Resp.: E001
W=2 Tanggal : 01 01 2007
ALAMAT: Kopassus RT,RW,Kelurahan: 05 03 Batujajar
KANAN
Keadaan gigi A
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 0 0 0 0 0 0 0 0 1 0 0 0
DIAGNOSA DA A A A A A A A A DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0 0 0
DIAGNOSA A A A A A A A A A EG 0 1
Keadaan gigi 0 0 0 0 0 0 0 0 0 1 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries MO
DIAGNOSA EG 0 1 0 0

1 0 1 DI 0 0 0 CI M= 0 e=
0 1 0 0 0.5 0 0 0 1 0.17 F= 0 f=
OHI - S = 0.67 ____ ____
CPITN
17 16 11 21 26 27 1 0 0 0 0 0 1 0 0 3
0 17 46 41 31 36 37 0 1 0 0 0 0 1 1 0 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
1
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Fathia Nurul A Gender: 2P= 1 No. Resp.: F001
W=2 Tanggal : 07 12 2006
ALAMAT: Perum Kota Mas RT,RW,Kelurahan: 11 06 Cimahi
KANAN
Keadaan gigi - -
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0
DIAGNOSA DA EG A PS A A A A PS PN DG 0 1
Letak Caries O O O 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A EG A A A A A A A A A A A A 0 1
Keadaan gigi 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries
DIAGNOSA 0 0 0 0

1 2 1 DI 1 0 1 CI M= 0 e=
0 1 2 1 1.33 0 1 1 1 0.83 F= 0 f=
OHI - S = 2.17 ____ ____
CPITN
17 16 11 21 26 27 1 1 1 1 1 1 1 1 1 6
0 17 46 41 31 36 37 0 1 1 1 1 1 1 1 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
0
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Luthfi Fahan Gender: 1P= 1 No. Resp.: L001
W=2 Tanggal : 05 09 2008
ALAMAT: Jl. Terusan SMP RT,RW,Kelurahan: 04 04 Batujajar
KANAN
Keadaan gigi A A A A A B
DIAGNOSA EG 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 0 0 0 0 1 0 0 0
DIAGNOSA EG A A A A DG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA A A A A A A A A PS A 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O
DIAGNOSA G3 DA 0 0 0 0
Keadaan gigi A - B 1 0 1 0

0 0 0 DI 0 0 CI M= 0 e=
0 0 0 2 0.33 0 0 0 1 0.17 F= 0 f=
OHI - S = 0.5 ____ ____
CPITN
17 16 11 21 26 27 1 0 0 0 0 0 1 0 0 2
0 17 46 41 31 36 37 0 1 0 0 0 0 0 1 0 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 1
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
2
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Mutiara Maghfira P Gender: 2P= 1 No. Resp.: M002
W=2 Tanggal : 05 01 2010
ALAMAT: Jl. Terusan SMP RT,RW,Kelurahan: 02 05 Batujajar
KANAN
Keadaan gigi B A A A A A A A
DIAGNOSA DA 0 0 0 0
Letak Caries DO 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
DIAGNOSA DA A A DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O O

2 1 2 DI 1 0 1 CI M= 0 e=
0 1 1 2 1.5 0 0 0 1 0.5 F= 0 f=
OHI - S = 2 ____ ____
CPITN
17 16 11 21 26 27 1 0 1 0 0 1 1 1 1 5
0 17 46 41 31 36 37 0 1 1 0 0 0 1 1 0 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
3
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Nisa Diwani Gender: 2P=1 No. Resp.: N001
W=2 Tanggal : 20 12 2008
ALAMAT: Gg. Lurah No.36 RT,RW,Kelurahan: 02 03 Selacau
KANAN
DIAGNOSA DG 0 0 0 0
Letak Caries MOD 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 0 0 0 0 1 0 0 0
DIAGNOSA DA A A A A DG 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
Keadaan gigi 0 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries
DIAGNOSA 0 0 0 0

2 0 0 DI 1 0 0 CI M= 0 e=
0 2 1 2 1.167 0 1 0 1 0.5 F= 0 f=
OHI - S = 1.7 ____ ____
CPITN
17 16 11 21 26 27 1 1 0 0 1 1 1 0 1 4
0 17 46 41 31 36 37 0 1 1 0 0 1 1 1 0 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
1
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BAN D U N G
NAMA: Rizki Fauzi M H Gender: 1P= 1 No. Resp.: R001
W=2 Tanggal : 12 09 2008
ALAMAT: Gg. H Amir RT,RW,Kelurahan: 07 03 Galanggang
KANAN
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 0 0 0 0 0 1 0 0 0
DIAGNOSA A A A A EG 0 1
Letak Caries O 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0 0 0
DIAGNOSA DG A A A A A A A A A 0 0
Keadaan gigi 1 0 0 0 0 0 0 0 0 0 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries
DIAGNOSA 0 0 0 0

1 0 0 DI 0 0 0 CI M= 0 e=
0 2 1 1 0.83 0 1 0 0 0.17 F= 0 f=
OHI - S = 1 ____ ____
CPITN
17 16 11 21 26 27 1 1 0 0 1 1 1 0 1 4
0 17 46 41 31 36 37 0 1 1 0 0 1 1 1 0 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
2
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 1
= 3
= 4
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: wayan semprina Gender: 1P= 1

W=2
Umur: 6 tahun
ALAMAT: kampung serang kongsi
KANAN
Keadaan gigi D A B B
DIAGNOSA - - DA A
Letak Caries - - O D
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries DO O - -
DIAGNOSA EG EA - -
Segment
Plaque Score
3 2 3 DI
0 2 2 1 2.1666667 0
OHI - S = 4.3333333
Artinya : BURUK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 6
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 01
Tanggal : 23 12 2016
RT,RW,Kelurahan: 10 02 sukasari
B B B A A F
A A A - - - 0 0 0 0
M MD MP - - - 1 0 0 0
51 61 62 63 64 65
9 9 9 9 9 9 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 9 9 9 0 9 9 0
81 71 72 73 74 75 0
- - - - - O
- - - - - PV 1 1 0 0
- - - A A B 0 0 0 0
Segment Segment
Calculus Score D= 0
2 2 3 CI M= 0
3 2 1 2.1666667 F= 0
____
DMF = 0
Score Segmen
X 2 0 2 1 X 2 2 1
X 1 3 1 2 X 1 3 2
-
1= F 2.2. CPITN
0 - Tumpatan ART 0
3 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 8
e= 0
f= 0
____
def = 8
Jumlah ScKode
2 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
2 gigi 0 3
1 gigi
INF
0 gigi 0 0
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: arya wiguna santoso Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: serang baru
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
2 3 2 DI
0 3 2 3 2.5 0
OHI - S = 5
Artinya : BURUK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 02
Tanggal : 23 12 2016
RT,RW,Kelurahan: 08 02 sukamahi
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - B - OB - - 0
- - - - DG - DG - - 0
0 0 0 0 1 0 2 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
3 2 3 CI M= 0
3 1 3 2.5 F= 2
____
DMF = 4
Score Segmen
X 1 0 2 3 X 1 2 3
X 3 0 2 1 X 3 2 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
4 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
2 4
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: lina bayau putri Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: cikarang selatan
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
1 1 1 DI
0 2 0 2 1.1666667 0
OHI - S = 2.1666667
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 17
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 03
Tanggal : 24 12 2016
RT,RW,Kelurahan: 08 03 sukadami
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - DG - - 0
0 0 0 9 0 0 1 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
1 1 1 CI M= 0
1 1 1 1 F= 0
____
DMF = 2
Score Segmen
X 4 0 0 3 X 4 0 3
X 3 2 0 2 X 3 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
4 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
0 0
2 4
1
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 4
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: deva mahendra koenela Gender: 1P= 1

W=2
Umur: 8 tahun
ALAMAT: jalan cibarusah
KANAN
DIAGNOSA EA - G3 -
55 54 53 52
Letak Caries - - L - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA DA EA - -
Segment
Plaque Score
0 0 0 DI
0 1 0 1 0.3333333 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 04
Tanggal : 24 12 2016
RT,RW,Kelurahan: 03 03 sukadami
- - - - C F
- - - - DA - 1 0 0 0
- - - - O O 1 0 1 0
51 61 62 63 64 65
0 0 0 9 9 9 6 9 9 0
- - - - - - - - - 1
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - M - - 0
- - - - - - DA - - 0
0 0 0 9 9 9 1 9 9 2
81 71 72 73 74 75 0
- - - - O O
- - - G4 DA PN 1 0 0 0
- - - - B B 2 0 0 1
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
2 1 2 0.8333333 F= 0
____
DMF = 3
Score Segmen
X 2 0 0 1 X 2 0 1
X 2 3 0 2 X 2 3 2
-
1= F 2.2. CPITN
0 - Tumpatan ART 3
3 - Tumpatan GI 0
- Gigi sulung 2
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 5
e= 0
f= 2
____
def = 7
Jumlah ScKode
1 1
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
5 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: rina multazam Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: jalan cibarusah
KANAN
DIAGNOSA - - PS -
Letak Caries - - MO -
55 54 53 52
DIAGNOSA - - PV - - - EG
Letak Caries - - O - - - M
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
0 0 0 DI
0 1 0 1 0.3333333 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 24 12 2016
RT,RW,Kelurahan: 02 04 sukatani
- - - - - -
- - - - - - 0 0 1 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 1 0 0 3 9 9 0
- - - DA - - - - - 0
- - - P - - - - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- D - - - - - - - 0
- EG - - - - - - - 0
0 1 0 0 0 0 0 0 9 1
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 5
0 0 0 CI M= 0
2 1 2 0.8333333 F= 1
____
DMF = 6
Score Segmen
X 1 0 0 2 X 1 0 2
X 1 2 0 2 X 1 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 1
e= 0
f= 1
____
def = 2
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: erau mahendra Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: cibarusah
KANAN
DIAGNOSA - - - -
55 54 53 52
Letak Caries - - - - M - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries - - OB - - - -
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
1 0 1 DI
0 2 1 2 1.1666667 0
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 24 12 2016
RT,RW,Kelurahan: 08 02 sukatani
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 9 9 0
- - - - - - EG - - 1
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - DG - - 0
0 0 0 0 0 0 1 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 4
0 0 0 CI M= 0
2 1 2 0.8333333 F= 1
____
DMF = 5
Score Segmen
X 2 0 2 3 X 2 2 3
X 1 0 1 2 X 1 1 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: rustandi Gender: 1P= 1

W=2
Umur: 8 tahun
ALAMAT: cijambe
KANAN
DIAGNOSA EA DA G3 -
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA EG DA - -
Segment
Plaque Score
2 0 1 DI
0 1 1 1 1 0
OHI - S = 1.3333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 24 12 2016
RT,RW,Kelurahan: 04 07 ciasem
- - - A B A
- - - - PN - 1 0 0 0
- - - - D - 1 0 1 0
51 61 62 63 64 65
0 0 0 9 9 9 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - EG - - 0
0 0 0 9 9 9 2 9 9 0
81 71 72 73 74 75 0
- - - - O -
- - - - EA - 1 1 0 0
- - - A C A 1 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
1 0 1 0.3333333 F= 1
____
DMF = 3
Score Segmen
X 3 1 0 2 X 3 1 2
X 1 2 1 1 X 1 2 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 2
- Gigi sulung 1
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 4
e= 0
f= 2
____
def = 6
Jumlah ScKode
3 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
4 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: desi dwi astuti Gender: 2P= 1

W=2
Umur: 7 tahun
ALAMAT: jalan turunan
KANAN
Keadaan gigi C D A B
DIAGNOSA DA - - EG
Letak Caries O - - D
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
Letak Caries - O - MOD
DIAGNOSA - DA - PN
Keadaan gigi D C A B
Segment
Plaque Score
0 0 0 DI
0 2 0 2 0.6666667 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 4
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 25 12 2016
RT,RW,Kelurahan: 02 05 cijampang
- - A A C C
- - - - EG EG 0 3 0 0
- - - - D O 1 0 0 0
51 61 62 63 64 65
0 0 9 9 9 9 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - MOD - - 0
- - - - - - PN - - 0
0 0 9 9 9 9 1 9 9 0
81 71 72 73 74 75 0
- - M - - -
- - EA - - - 1 0 0 0
- - B A D D 1 0 0 0
Segment Segment
Calculus Score D= 4
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 4
Score Segmen
X 2 1 0 1 X 2 1 1
X 1 0 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 3
e= 0
f= 4
____
def = 7
Jumlah ScKode
5 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
3 gigi
3 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: lulu linggar puteri Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: jalan tanjakan
KANAN
DIAGNOSA - - - PS
55 54 53 52
Letak Caries - - MO - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
2 0 1 DI
0 1 0 1 0.8333333 0
OHI - S = 1.3333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 16
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 30 12 2016
RT,RW,Kelurahan: 01 04 cibarembol
- - - A - -
- - - - - - 0 0 1 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 9 3 0 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 0 0 9 0 9 9 1
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
1 1 1 0.5 F= 1
____
DMF = 3
Score Segmen
X 2 0 0 1 X 2 0 1
X 2 0 0 1 X 2 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: yanna purwanto Gender: 1P= 1

W=2
Umur: 8 tahun
ALAMAT: jalan mantan
KANAN
Keadaan gigi D C A -
DIAGNOSA - DA - -
Letak Caries - O - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA EG - - -
Keadaan gigi C D A -
Segment
Plaque Score
0 0 0 DI
0 2 1 0 0.5 0
OHI - S = 0.8333333
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 10
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 30 12 2016
RT,RW,Kelurahan: 07 01 terkasih
ART GI
- - - A C C
- - - - DA DA 0 0 0 0
- - - - M O 3 0 0 0
51 61 62 63 64 65
0 0 0 9 9 9 3 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 9 9 9 0 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 1 0 0
- - - A D A 0 0 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
1 0 1 0.3333333 F= 0
____
DMF = 0
Score Segmen
X 3 0 1 1 X 3 1 1
X 2 1 0 3 X 2 1 3
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
4 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 4
____
def = 4
Jumlah ScKode
3 2
2 4
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
3 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: CICI Gender: 2P= 1 No. Resp.: 001
W=2 Tanggal : 09 01 2017
ALAMAT: jl.pasir kaliki no.26 Bandung RT,RW,Kelurahan: 01 04 Sukajadi
KANAN
Keadaan gigi A B F A - - B A B A
DIAGNOSA - EA - - - EA - EA - 3 0 0 0
Letak Caries - O O - - - M - O - 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 9 9 1 9 9 9 9 0 1 9 9 9 9 0 9 9 0 0 0
DIAGNOSA - - DG - - - - - EA - - - - - - - 1 0
Letak Caries - - O - - - - - P - - - - - - - 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - M - - - - - - L - - - - - - 0 0 0
DIAGNOSA - - EA - - - - - - DA - - - - - - 1 0
Keadaan gigi 0 0 1 9 9 0 0 0 0 1 9 9 9 0 9 9 1 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries - - - - - - - - - B
DIAGNOSA - - - - - - - - - EA 1 0 0 0
Keadaan gigi A A A - - - - A A B 0 0 0 0

1 2 1 DI 2 1 0 CI M= 0 e=
0 1 1 2 1.3333 0 1 1 0 0.83 F= 0 f=
OHI - S = 2.17 ____ ____
CPITN
X 16 11 X 26 X X 3 3 X 0 X 3 3 0 0
0 X 46 X 31 36 X 0 X 3 X 3 0 X 3 3 0 4
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
5
0
0
Kode
0
4
1 3
1
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: zaky Gender: 1P= 1 No. Resp.: 002
W=2 Tanggal : 06 01 2017
ALAMAT: jl.citra padalarang indah bandung barat RT,RW,Kelurahan: 04 01 padalarang
KANAN
Keadaan gigi B - B - - - - A A B
DIAGNOSA DA - EG - - - - - - EA 1 1 0 0
Letak Caries B - M - - - - - - O 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 9 9 1 9 9 9 0 0 0 0 9 9 9 1 9 9 0 0 0
DIAGNOSA - - EG - - - - - - - - - - DG - - 0 1
Letak Caries - - M - - - - - - - - - - OB - - 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - - - - - - - - - - - - O - - 0 0 0
DIAGNOSA - - - - - - - - - - - - - DA - - 0 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 1 9 9 1 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries B - - - - - - - - O
DIAGNOSA EG - - - - - - - - DG 0 1 0 0
Keadaan gigi B A A - - - - A A B 0 1 0 0

1 1 2 DI 1 0 2 CI M= 0 e=
0 2 1 1 1.33 0 2 0 1 1 F= 0 f=
OHI - S = 2.33 ____ ____
CPITN
X 16 11 X 26 X X 3 1 X 3 X 3 1 3 1
0 X 46 X 31 36 X 0 X 3 X 3 3 X 3 3 3 5
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
7
0
0
Kode
1
4
1 3
1
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: ratna Gender: 2P= 1 No. Resp.: 003
W=2 Tanggal : 05 01 2017
ALAMAT: jl.sukasirna no 5 RT,RW,Kelurahan: 03 03 sukasirna
KANAN
Keadaan gigi B A A - - - - A B B
DIAGNOSA DA - - - - - - - DG DG 0 0 0 0
Letak Caries M - - - - - - - M O 1 2 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 9 9 1 9 9 9 0 0 0 0 9 9 9 1 9 9 0 0 0
DIAGNOSA - - DA - - - - - - - - - - DG - - 0 0
Letak Caries - - O - - - - - - - - - - O - - 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - MOD - - - - - - - - - - - - - 0 0 0
DIAGNOSA - - DG - - - - - - - - - - - - - 0 0
Keadaan gigi 9 9 1 9 9 9 0 0 0 0 9 9 9 0 9 9 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O - - - - - - - O O
DIAGNOSA EA - - - - - - - DG DG 1 0 0 0
Keadaan gigi B A A - - - - A B B 0 2 0 0

1 1 1 DI 1 1 1 CI M= 0 e=
0 1 1 1 1 0 1 1 1 1 F= 0 f=
OHI - S = 2 ____ ____
CPITN
X 16 11 X 26 X X 1 1 X 1 X 1 1 1 3
0 X 46 X 31 36 X 0 X 2 X 2 3 X 2 2 3 1
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
6
0
0
Kode
2
3
1 3
1
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: agus Gender: 1P= 1 No. Resp.: 004
W=2 Tanggal : 08 04 2017
ALAMAT: jl.indah no 10 RT,RW,Kelurahan: 01 01 Sukajadi
KANAN
Keadaan gigi B A A A B B A A A E
DIAGNOSA DG - - - EA DG - - - G3 1 0 0 0
Letak Caries M - - - L M - - - - 0 2 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 9 9 1 9 9 9 9 0 0 9 9 9 9 1 9 9 0 0 0
DIAGNOSA - - DA - - - - - - - - - DG - - 0 0
Letak Caries - - O - - - - - - - - - O - - 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - O - - - - - EA - - - - - - 0 0 0
DIAGNOSA - - DA - - - - - DG - - - - - - 0 0
Keadaan gigi 0 0 1 0 0 0 0 0 0 1 9 9 9 0 9 9 1 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O - - - - - - - - O
DIAGNOSA EA - - - - - - - - DA 1 0 0 0
Keadaan gigi B A A A A A A A A B 1 0 0 0

2 1 2 DI 1 0 1 CI M= 0 e=
0 2 1 1 1.5 0 1 0 1 0.67 F= 0 f=
OHI - S = 2.17 ____ ____
CPITN
X 16 11 X 26 X X 1 1 X 3 X 1 1 3 2
0 X 46 X 31 36 X 0 X 2 X 2 3 X 2 2 3 2
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
5
1
0
Kode
2
4
1 3
1
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: indah Gender: 2P= 1 No. Resp.: 005
W=2 Tanggal : 09 01 2017
jl.mawar no
ALAMAT: jl.mawar no 4
4 RT,RW,Kelurahan: 03 04 sukawana
KANAN
Keadaan gigi B A A - - - - A B B
DIAGNOSA DA - - - - - - - EA EG 1 1 0 0
Letak Caries M - - - - - - - M D 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 9 9 1 0 0 0 0 0 0 0 0 0 0 1 9 9 0 0 0
DIAGNOSA - - DA - - - - - - - - - - DG - - 0 0
Letak Caries - - O - - - - - - - - - - O - - 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - B - - - - - - - - - - O - - 0 0 0
DIAGNOSA - - DA - - - - - - - - - - DA - - 0 0
Keadaan gigi 9 9 1 0 0 0 0 0 0 0 0 0 0 1 9 9 2 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
DIAGNOSA EA - - - - - - - - DA 1 0 0 0

1 1 1 DI 1 1 1 CI M= 0 e=
0 1 1 1 1 0 1 1 1 1 F= 0 f=
OHI - S = 2 ____ ____
CPITN
X 16 11 X 26 X X 2 1 X 2 X 2 1 2 2
0 X 46 X 31 36 X 0 X 2 X 1 2 X 2 1 2 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
5
0
1
Kode
2
0
1 3
1
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: juned Gender: 1P= 1 No. Resp.: 006
W=2 Tanggal : 06 01 2017
ALAMAT: jl.asri 3 RT,RW,Kelurahan: 04 03 warnasari
KANAN
Keadaan gigi B A B - - - - A A A
DIAGNOSA DA - EA - - - - - - - 1 0 0 0
Letak Caries M - M - - - - - - - 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 1 1 9 9 9 0 0 0 0 9 9 9 1 9 9 0 0 0
DIAGNOSA - DA DA - - - - - - - - - - DG - - 0 0
Letak Caries - O O - - - - - - - - - - B - - 2 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - - - - - - - - - - - - B - - 0 0 0
DIAGNOSA - - - - - - - - - - - - - DG - - 0 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 1 9 9 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
DIAGNOSA EA - - - - - - - - DA 1 0 0 0
Keadaan gigi B A - - - - - - A B 1 0 0 0

2 2 2 DI 1 1 1 CI M= 0 e=
0 1 2 2 1.83 0 1 1 1 1 F= 0 f=
OHI - S = 2.83 ____ ____
CPITN
X 16 11 X 26 X X 3 1 X 3 X 3 1 3 2
0 X 46 X 31 36 X 0 X 3 X 1 3 X 3 1 3 4
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
4
0
0
Kode
2
4
1 3
1
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: SARI Gender: 2P= 1 No. Resp.: 007
W=2 Tanggal : 06 01 2017
ALAMAT: jn.merdeka RT,RW,Kelurahan: 03 02 merdeka
KANAN
Keadaan gigi B A A - - - - A A A
DIAGNOSA DA - - - - - - - - - 0 0 0 0
Letak Caries M - - - - - - - - - 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 9 9 1 0 0 - 0 0 0 0 9 0 0 1 9 9 0 0 0
DIAGNOSA - - DA - - - - - - - - - - DG - - 0 0
Letak Caries - - O - - - - - - - - - - O - - 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - O - - - - - - - - - - - - - 0 0 0
DIAGNOSA - - DG - - - - - - - - - - - - - 0 0
Keadaan gigi 9 9 1 0 0 - 0 0 0 0 9 0 0 0 9 9 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
DIAGNOSA EA - - - - - - - - DA 1 0 0 0

2 1 1 DI 2 1 1 CI M= 0 e=
0 3 1 1 1.5 0 1 1 1 1.17 F= 0 f=
OHI - S = 2.67 ____ ____
CPITN
X 16 11 X 26 X X 3 1 X 1 X 3 1 1 5
0 X 46 X 31 36 X 0 X 1 X 1 1 X 1 1 1 1
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
3
0
0
Kode
2
3
1 3
1
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: lucky Gender: 1P= 1 No. Resp.: 008
W=2 Tanggal : 05 01 2017
ALAMAT: jl.melati no 12 RT,RW,Kelurahan: 02 02 pagarsih
KANAN
Keadaan gigi B A A - - - - A A B
DIAGNOSA DA - - - - - - - - DA 0 0 0 0
Letak Caries M - - - - - - - - O 2 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 9 9 1 9 9 9 0 0 0 0 9 9 9 1 9 9 0 0 0
DIAGNOSA - - DA - - - - - - - - - - DG - - 0 0
Letak Caries - - O - - - - - - - - - - O - - 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - O - - - - - - - - - - M - - 0 0 0
DIAGNOSA - - EG - - - - - - - - - - EG - - 0 2
Keadaan gigi 9 9 1 0 0 0 0 0 0 0 0 0 0 1 9 9 0 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
DIAGNOSA EA - - - - - - - - DA 1 0 0 0
Keadaan gigi B A - - - - - - A B 1 0 0 0

1 2 1 DI 2 1 1 CI M= 0 e=
0 1 1 3 1.5 0 1 1 2 1.33 F= 0 f=
OHI - S = 2.83 ____ ____
CPITN
X 16 11 X 26 X X 2 1 X 2 X 2 1 2 3
0 X 46 X 31 36 X 0 X 2 X 1 1 X 2 1 1 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
4
0
0
Kode
2
0
1 3
1
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: mirna Gender: 2P= 1 No. Resp.: 009
W=2 Tanggal : 03 01 2017
ALAMAT: ln.gunungbatu no 15 RT,RW,Kelurahan: 04 04 wanayasa
KANAN
Keadaan gigi B B A - - - - B A A
DIAGNOSA DA DA - - - - - EG - - 0 1 0 0
Letak Caries M M - - - - - B - - 2 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 9 9 1 0 0 0 0 0 0 0 0 0 0 1 9 9 0 0 0
DIAGNOSA - - DA - - - - - - - - - - DG - - 0 0
Letak Caries - - O - - - - - - - - - - O - - 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - D - - - - - - - - - - O - - 0 0 0
DIAGNOSA - - EG - - - - - - - - - - DA - - 0 1
Keadaan gigi 9 9 1 0 0 0 0 0 0 0 0 0 0 1 9 9 1 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O M - - - - - - - O
DIAGNOSA EA EG - - - - - - - DA 1 1 0 0
Keadaan gigi B B - - - - - - A B 1 0 0 0

2 1 2 DI 2 1 0 CI M= 0 e=
0 3 1 2 1.83 0 1 1 1 1 F= 0 f=
OHI - S = 2.83 ____ ____
CPITN
X 16 11 X 26 X X 3 1 X 0 X 3 1 0 1
0 X 46 X 31 36 X 0 X 3 X 2 3 X 3 2 3 3
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
7
0
0
Kode
1
4
1 3
1
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: bagus Gender: 1P= 1 No. Resp.: 010
W=2 Tanggal : 06 01 2017
ALAMAT: jl. Badak putih RT,RW,Kelurahan: 06 03 badak putih
KANAN
Keadaan gigi A A A A - - A A B B
DIAGNOSA - - - - - - - - EG DA 0 1 0 0
Letak Caries - - - - - - - - B D 1 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0
Keadaan gigi 1 0 1 9 9 9 9 0 0 9 9 9 9 1 9 9 0 0 0
DIAGNOSA - - DA - - - - - - - - - - DG - - 0 0
Letak Caries - - O - - - - - - - - - - O - - 1 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries - - O - - - - - - - - - - D - - 0 0 0
DIAGNOSA - - DA - - - - - - - - - - EG - - 0 1
Keadaan gigi 9 9 1 9 9 9 0 0 0 0 9 9 9 1 9 9 1 0
0
85 84 83 82 81 71 72 73 74 75 0 >0 0
Letak Caries O - - - - - - D - O
DIAGNOSA EA - - - - - - EG - DA 1 1 0 0
Keadaan gigi B A A - - - - B A B 1 0 0 0

2 0 1 DI 1 0 1 CI M= 0 e=
0 1 1 2 1.17 0 2 1 1 1 F= 0 f=
OHI - S = 2.17 ____ ____
CPITN
X 16 11 X 26 X X 3 1 X 2 X 3 1 2 1
0 X 46 X 31 36 X 0 X 3 X 2 2 X 3 2 2 2
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 0
KODE:

0 0 0
PERSISTENSI = PS
6
0
2
Kode
1
4
1 3
1
= 0
= 1
= 2 3
= 3
= 4
OLITEKNIK KESEHATAN BANDUNG
PRO. EYCKMAN NO. 40 TLP. 2033630
BANDUNG

NAMA: rido Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: jl. Anugrah
KANAN
Keadaan gigi B A A -
DIAGNOSA DA
Letak Caries M
55 54 53 52
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries O
DIAGNOSA EA
Keadaan gigi B A -
Segment
Plaque Score
1 2 1 DI
0 1 1 3 1.5 0
OHI - S = 2.8333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 X 26 X
0 X 46 X 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 07 12 2016
RT,RW,Kelurahan: 03 02 simah
- - - A A B
DA 0 0 0 0
O 2 0 0 0
51 61 62 63 64 65
0 0 0 9 9 9 1 9 9 0
DG 0
O 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
M 0
EG 0
0 0 0 9 9 9 1 9 9 0
81 71 72 73 74 75 0
O
DA 1 0 0 0
- - - - A B 1 0 0 0
Segment Segment
Calculus Score D= 4
2 1 1 CI M= 0
1 1 2 1.3333333 F= 0
____
DMF = 4
Score Segmen
X 2 1 X 2 X 2 1 2
X 2 X 1 1 X 2 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 3
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Prahia
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: divana Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: riwangan
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O M
DIAGNOSA PV DG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 2 0 DI
0 0 3 2 1.3333333 0
OHI - S = 2.1666667
Artinya : SEDANG
CPITN
Gigi Index
16 11 26 27
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 24
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 12 02 2016
RT,RW,Kelurahan: 05 04 galingan
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0
EG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 3
0 0 2 CI M= 0
0 2 1 0.8333333 F= 0
____
DMF = 3
Score Segmen
2 2 3 2 3 0
3 3 2 3 3 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
4 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
2.5. Dirujuk ke : Puskesmas Prahia
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
3 4
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: ADISTY Gender: 2P= 1

W=2
Umur: 11 tahun
ALAMAT: Jl,karie
KANAN
Keadaan gigi B A A
DIAGNOSA DA
Letak Caries O
55 54 53 52
Keadaan gigi 1 0
DIAGNOSA DA
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
Keadaan gigi 0 0
85 84 83 82
Letak Caries O
DIAGNOSA EA
Keadaan gigi B A A
Segment
Plaque Score
1 0 DI
0 1 0 0 0.3333333 0
OHI - S = 0.6666667
Artinya : BAIK
CPITN
Gigi Index
- 16 11 21 26 -
2 - 46 41 31 36 - 2
1. DIAGNOSA
- Gigi sehat =0 10
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 08 01 2017
RT,RW,Kelurahan: 05 04 galangan
A A A A
PS 0 0 1 0
1 0 0 0
51 61 62 63 64 65 0
0 0 0 1 0
DG 0
O 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0
81 71 72 73 74 75 0
O
DA 1 0 0 0
A A B 1 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
1 0 1 0.3333333 F= 0
____
DMF = 2
Score Segmen
- 1 1 0 0 - 1 1 0
- 0 0 0 1 - 0 0 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
3 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: Dillan adea Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: Jln. Milka
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 1 1 DI
0 1 1 1 1 0
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 10 12 2016
RT,RW,Kelurahan: 06 03 Cigambi
- - - B - -
A 0 0 0 0
MOD 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 1
1 1 1 CI M= 0
1 1 1 1 F= 0
____
DMF = 1
Score Segmen
2 2 2 2 2 0
2 2 2 2 2 0
19 -
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: ilham Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: Jl. Radjiman
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
3 1 2 DI
0 3 2 1 2 0
OHI - S = 4.3333333
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 24
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 18 12 2016
RT,RW,Kelurahan: 10 02 sagiarsi
- - - B - -
DA 0 0 0 0
O 1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EA 1
0 0 0 0 0 0 6 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
3 0 3 CI M= 0
3 2 3 2.3333333 F= 0
____
DMF = 2
Score Segmen
2 0 2 2 2 0
3 2 2 0 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1
0 DIAGNOSA
KME-ART= EA
KME-GI= EG
0 0 KMD-GI = DG
1 KMD-ART = DA
0 KMP VITAL = PV

KMA = A
PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
=
=
=
=
=
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: indar Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jl. Sarijadi
KANAN
Keadaan gigi - B -
DIAGNOSA EA
Letak Caries O
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
0 1 0 DI
0 2 0 3 1 0
OHI - S = 1.8333333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 22
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 12
Tanggal : 10 01 2017
Pekerjaan (orang tua/wali) : guru
- - - A - -
1 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EG 0
0 0 0 9 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 2. CI M= 0
2 1 0 0.8333333 F= 0
____
DMF = 2
Score Segmen
0 0 0 0 0 0
2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: lliana Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: jln. subroto
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries MOD
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 1 2 1 1.3333333 0
OHI - S = 3.1666667
Artinya : BURUK
CPITN
Gigi Index
16 11 26
0 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 11 01 2017
RT,RW,Kelurahan: 01 03 banyu biru
ART GI
- - - B - -
KMA 0 0 0 1
MOD 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 0 0 0
EG 0
- - - - - - O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 9 0 1 0 0 0
81 71 72 73 74 75 0
O
DA 0 0 0 0
- - - - B - 1 0 0 0
Segment Segment
Calculus Score D= 4
3 1 1 CI M= 0
2 1 3 1.8333333 F= 0
____
DMF = 4
Score Segmen
2 1 1 2 1 0
3 2 2 0 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
3 - Tumpatan GI 3
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 2
e= 0
f= 0
____
def = 2
Jumlah ScKode
1 1
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
1 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: bryan Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: jln. asri
KANAN
DIAGNOSA - - - EG
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
0 0 0 DI
0 0 1 2 0.5 0
OHI - S = 0.8333333
Artinya : BAIK
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 5
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 19 12 2016
RT,RW,Kelurahan: 01 02 radjiman
ART GI
B B A A - -
EG EG - - - - 0 3 0 0
M D - - - - 0 0 0 0
51 61 62 63 64 65
9 9 9 9 0 0 9 9 9 0
- - - - - - - - - 1
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - O - - - - 0
- - - - EA - - - - 1
9 9 9 9 1 0 9 9 9 0
81 71 72 73 74 75 0
D D - - - -
EA EA - - - - 2 0 0 0
B B A A - - 0 0 0 0
Segment Segment
Calculus Score D= 3
0 1 0 CI M= 0
0 0 1 0.3333333 F= 0
____
DMF = 3
Score Segmen
X 1 1 1 1 X 1 1 1
X 1 1 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 5
e= 0
f= 4
____
def = 9
Jumlah ScKode
6 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
2 gigi
3 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: khusunu qurbaa Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: Jl.pandean
KANAN
DIAGNOSA EG - - EG
55 54 53 52
DIAGNOSA - - DA - - -
Letak Caries - - O - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA EA - - -
Segment
Plaque Score
1 0 1 DI
0 1 1 2 1 0
OHI - S = 1.5
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 2
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 19 12 2016
RT,RW,Kelurahan: 06 05 trenggalek
- - E A B A
- - - - EG - 0 3 0 0
- - - - O - 0 0 0 0
51 61 62 63 64 65
0 0 9 9 9 9 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
M - - - - - - - - 0
EA - - - - - - - - 1
1 9 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
- D D - O O
- EG EG - EG EA 2 3 0 0
- B B A B B 0 0 0 0
Segment Segment
Calculus Score D= 1
1 0 0 CI M= 0
0 1 1 0.5 F= 0
____
DMF = 1
Score Segmen
X 1 1 1 1 X 1 1 1
X 1 1 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 8
e= 3
f= 4
____
def = 15
Jumlah ScKode
6 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
2 gigi
6 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Aleaa Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: asrian
KANAN
DIAGNOSA EG EG - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA - EG - EG
Segment
Plaque Score
1 2 1 DI
0 0 2 0 1 0
OHI - S = 1.3333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 X
0 X 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 3
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 12 12 2016
RT,RW,Kelurahan: 02 08 pandean
- - B A B B
- - EG - EG EA 1 4 0 0
- - O - O O 0 0 0 0
51 61 62 63 64 65
0 0 9 9 9 9 9 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- M - - - - - - - 0
- EA - - - - - - - 1
0 1 9 9 9 9 9 9 9 0
81 71 72 73 74 75 0
- - - - O O
- - - - EG EA 1 3 0 0
- - A A B B 0 0 0 0
Segment Segment
Calculus Score D= 1
0 1 0 CI M= 0
1 0 0 0.3333333 F= 0
____
DMF = 1
Score Segmen
X 0 1 0 0 X 0 1 0
X 0 1 0 0 X 0 1 0
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 9
e= 0
f= 1
____
def = 10
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
2 gigi
7 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Irfan Gender: 2P= 1 No. Resp.: N.201
W=2 Tanggal : 08 01 2017
ALAMAT: Sukajadi RT,RW,Kelurahan: 05 02 Pasteur
KANAN KIRI
Keadaan gigi D A A A B E
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG 0 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries D O KMA = A
DIAGNOSA DG DG 0 0 0 0 PERSISTE
Keadaan gigi E B A A B E 0 2 0 0 GOYANG

2 0 2 DI 1 0 0 CI M= 0 e= 3
0 2 1 2 1.5 0 2 0 1 0.67 F= 0 f= 2
OHI - S = 2.17 ____ ____
CPITN
16 11 21 26 1 0 0 0 1 0 0 2 2
0 46 41 31 36 0 2 0 0 1 2 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: gunawan Gender: 2P= 1 No. Resp.: A.355
W=2 Tanggal : 08 01 2017
ALAMAT: Sukagalih RT,RW,Kelurahan: 08 02 Pasteur
KANAN
Keadaan gigi B D A A B A B C
DIAGNOSA DA EA DA DA 1 0 0 0
Letak Caries O D O M 3 0 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 9 0 0 9 9 9 9 2 9 9 0
DIAGNOSA EG 0
Letak Caries M 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0
DIAGNOSA DG 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 1 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O B

0 0 0 DI 0 0 0 CI M= 0
0 1 0 2 0.5 0 2 1 1 0.67 F= 0
OHI - S = 1.17 ____
CPITN
16 11 21 26 0 0 0 2 0 0 2
0 46 41 31 36 0 0 1 0 2 0 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 7
e= 0
f= 2
____
def = 9
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
6 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: ucul Gender: 1P= 1 No. Resp.: H.555
W=2 Tanggal : 08 01 2017
ALAMAT: Jl.Bojong Kenyot RT,RW,Kelurahan: 06 01 Bojong Koneng
KANAN
Keadaan gigi A A B A A A A
DIAGNOSA PS PS EG PS PS PS G4 0 1 5 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 0 0 9 0 0 0 0 9 0 0 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O M 0
DIAGNOSA DG EG 0
Keadaan gigi 9 9 1 0 0 9 0 1 0 0 9 0 0 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries D
DIAGNOSA PS DG PS G4 G3 0 0 2 0
Keadaan gigi A B A A D A 0 1 1 1

0 0 1 DI 0 0 0 CI M= 0
0 3 1 1 1 0 3 1 0 0.67 F= 0
OHI - S = 1.67 ____
CPITN
16 11 21 26 0 0 0 1 0 0 1
0 46 41 31 36 0 3 1 0 1 3 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 2
e= 0
f= 2
____
def = 4
JumlahKode
3 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
2 gigi
INF
7 gigi
0 gigi
BANDUNG

NAMA: abbel Gender: 1P= 1 No. Resp.: A.300
W=2 Tanggal : 08 01 2017
ALAMAT: Jl. Terusan Perintis RT,RW,Kelurahan: 03 01 Sarijadi
KANAN
Keadaan gigi D A B A A A C
DIAGNOSA PS DG PS PS DG 0 0 3 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 0 9 0 0 0 0 9 0 9 1 9 9 0
DIAGNOSA EG 0
Letak Caries O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS PS PS PN 0 0 3 0
Keadaan gigi A A A A A A B 0 0 0 0

0 0 2 DI 0 0 0 CI M= 0
0 1 1 3 1.17 0 1 2 3 1 F= 0
OHI - S = 2.17 ____
CPITN
16 11 21 26 0 1 0 0 1 0 1 1
0 46 41 31 36 0 1 1 2 3 1 1 2 3

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 2
____
def = 5
JumlahKode
3 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
2 gigi
INF
6 gigi
0 gigi
BANDUNG

NAMA: sandi Gender: 1P= 1 No. Resp.: F.165
W=2 Tanggal : 08 01 2017
ALAMAT: Cibogo RT,RW,Kelurahan: 05 02 Margamulya
KANAN
DIAGNOSA DG PS PS G3 0 0 2 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 3 9 0 0 0 0 0 0 0 0 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 0 0 0 9 0 0 0 0 0 0 9 9 2 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS G4 EG 0 1 1 0
Keadaan gigi C A A C A 0 0 0 1

1 0 1 DI 0 0 0 CI M= 0
0 2 1 3 1.33 0 1 0 1 0.33 F= 0
OHI - S = 1.67 ____
CPITN
16 11 21 26 0 0 0 0 0 0 0
0 46 41 31 36 0 2 1 0 2 2 1 2

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 1
____
def = 4
JumlahKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
2 gigi
INF
3 gigi
0 gigi
BANDUNG

NAMA: osol Gender: 2P= 1 No. Resp.: H.228
W=2 Tanggal : 08 01 2017
ALAMAT: Jl.Jendral Sudirman RT,RW,Kelurahan: 13 08 Palawati
KANAN
Keadaan gigi A D A A C C
Letak Caries O D 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 9 0 0 0 0 9 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O M
Keadaan gigi B A A B A D 0 1 0 0

0 0 1 DI 0 0 0 CI M= 0
0 0 1 1 0.5 0 0 1 2 0.5 F= 0
OHI - S = 1 ____
CPITN
16 11 21 26 1 0 0 2 1 0 2
0 46 41 31 36 0 1 1 0 0 1 1 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 4
e= 0
f= 3
____
def = 7
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
4 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: bian Gender: 2P= 1 No. Resp.: M.124
W=2 Tanggal : 08 01 2017
ALAMAT: Jl.Cikeris RT,RW,Kelurahan: 07 04 Bojong Sawit
KANAN
Keadaan gigi A A C A A A A B
DIAGNOSA PS EG PS G4 G3 DG 0 1 2 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 2 9 0 0 0 0 9 0 9 0 9 9 0
DIAGNOSA EG 0
Letak Caries O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries M 0
DIAGNOSA DG 0
Keadaan gigi 9 0 0 9 0 0 0 0 0 0 0 0 9 2 3 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA EG PS PS 0 1 2 0
Keadaan gigi B A A A 0 0 0 0

1 1 1 DI 1 0 0 CI M= 0
0 0 0 2 0.83 0 1 1 3 1 F= 1
OHI - S = 1.83 ____
CPITN
16 11 21 26 0 1 1 1 0 1 1
0 46 41 31 36 0 1 0 1 3 1 1 3

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
JumlahKode
4 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
3 gigi
INF
4 gigi
0 gigi
BANDUNG

NAMA: ciput Gender: 2P= 1 No. Resp.: T.200
W=2 Tanggal : 08 01 2017
ALAMAT: Jl. Sawit RT,RW,Kelurahan: 10 03 Darangdan
KANAN
Keadaan gigi A D B A A A A C
DIAGNOSA EG PS PS EG 0 2 2 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 2 9 9 9 0 0 0 0 9 9 9 0 9 9 0
DIAGNOSA DG 0
Letak Caries OB 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries 0
DIAGNOSA 0
Keadaan gigi 9 9 0 9 9 0 0 0 0 0 0 9 9 0 9 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS G4 DA 0 0 1 0
Keadaan gigi D A A A A B 1 0 0 1

1 0 0 DI 1 0 0 CI M= 0
0 1 1 0 0.5 0 2 2 1 1 F= 0
OHI - S = 1.5 ____
CPITN
16 11 21 26 1 0 0 0 1 0 0
0 46 41 31 36 0 2 1 1 0 2 1 0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 3
____
def = 6
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi
2 gigi
INF
3 gigi
0 gigi
BANDUNG

NAMA: tresar Gender: 1P= 1 No. Resp.: D.176
W=2 Tanggal : 08 01 2017
ALAMAT: Jl.Tunggakjati RT,RW,Kelurahan: 06 03 Tanjung Pura
KANAN
Keadaan gigi B A A A A A C
DIAGNOSA EG PS PS G4 EG 0 2 2 0
Letak Caries B O 0 0 0 1
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 9 0 9 0 9 0 0 0 0 9 0 9 0 9 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O 0
DIAGNOSA DG 0
Keadaan gigi 9 0 2 9 0 0 0 0 0 0 0 0 9 0 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries
Keadaan gigi D A A A 0 0 0 0

0 0 0 DI 0 0 0 CI M= 0
0 1 1 0 0.33 0 1 1 0 0.33 F= 0
OHI - S = 0.67 ____
CPITN
16 11 21 26 0 0 0 0 0 0 0
0 46 41 31 36 0 2 1 0 1 2 1 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
0
0 0 0 0
PERSISTENSI = PS
d= 3
e= 0
f= 1
____
def = 4
JumlahKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
2 gigi
INF
4 gigi
0 gigi
RESP
BANDUNG

NAMA: jungkuk Gender: 1P= 1 No. Resp.: M.205
W=2 Tanggal : 08 01 2017
ALAMAT: Gang Sawo RT,RW,Kelurahan: 17 05 Klari
KANAN
DIAGNOSA EG PS PS G4 PS 0 1 3 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 9 1 3 9 0 0 0 0 0 0 0 0 9 0 0 9 0
DIAGNOSA EG 0
Letak Caries M 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries MOD 0
DIAGNOSA PV 0
Keadaan gigi 9 0 1 9 0 0 0 0 0 0 0 0 9 1 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O
DIAGNOSA PS PS DG 0 0 2 0
Keadaan gigi A A A B 0 1 0 0

1 1 1 DI 1 0 1 CI M= 0
0 1 1 3 1.33 0 1 1 3 1.17 F= 1
OHI - S = 2.5 ____
CPITN
16 11 21 26 1 0 0 1 1 0 1
0 46 41 31 36 0 1 2 2 3 1 2 3

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 2
e= 0
f= 0
____
def = 2
JumlahKode
3 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 3
= 3
GS
0 gigi
2 gigi
INF
5 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Derryawan Hamidi Gender: 1P= 1

W=2
Umur: 9 tahun
ALAMAT: Jl. Raya Gading Tutuka 1 no.8
KANAN
DIAGNOSA EG - - -
Letak Caries D - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA EA EA - -
Segment
Plaque Score
2 1 2 DI
0 1 0 2 1.3333333 0
OHI - S = 1.8333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 01
Tanggal : 29 12 2016
RT,RW,Kelurahan: 08 04 Cingcin
B B A A A B
EG DG - - - DG 0 2 0 0
M M - - - O 0 2 0 0
51 61 62 63 64 65
9 9 9 9 9 9 0 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 9 9 9 0 9 9 0
81 71 72 73 74 75 0
- - - - - O
- - - - - EG 2 1 0 0
- - - A A B 0 0 0 0
Segment Segment
Calculus Score D= 0
1 0 1 CI M= 0
0 0 1 0.5 F= 0
____
DMF = 0
Score Segmen
X 2 0 1 1 X 2 1 1
X 1 2 1 2 X 1 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 7
e= 0
f= 0
____
def = 7
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
2 gigi 0 7
5 gigi
INF
0 gigi 0 0
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Thomson Aji Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: jl. Cessna 2 no.10, Lanud Sulaiman
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries - - B - - - -
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
2 2 2 DI
0 2 0 2 1.6666667 0
OHI - S = 2.8333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 02
Tanggal : 29 12 2016
RT,RW,Kelurahan: 02 02 Angkasa
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 9 9 0
- - - - - - DG - - 0
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - O - OB - - 0
- - - - EG - DG - - 0
0 0 0 0 1 0 2 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 1 2 CI M= 0
1 0 1 1.1666667 F= 2
____
DMF = 4
Score Segmen
X 2 1 2 2 X 2 2 2
X 1 0 2 1 X 1 2 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Welly Gita Pratiwi Gender: 2P= 1

W=2
Umur: 10 tahun
ALAMAT: Jl. Otter no.2, Lanud Sulaiman
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
1 0 1 DI
0 2 0 2 1 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 17
- Sealant =6 3
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 03
Tanggal : 28 12 2016
RT,RW,Kelurahan: 07 03 Angkasa
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 6 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - EG - - 0
0 0 0 0 0 0 1 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 1
0 0 0 CI M= 0
0 0 1 0.1666667 F= 0
____
DMF = 1
Score Segmen
X 1 0 0 1 X 1 0 1
X 1 1 0 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
5 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Ana Dina Sakinah Gender: 2P= 1

W=2
Umur: 8 tahun
ALAMAT: Jl. Permai 21 blok 33/34, Margahayu
KANAN
DIAGNOSA EA - G3 -
Letak Caries M - - -
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
Letak Caries O M - -
DIAGNOSA DA EA - -
Segment
Plaque Score
0 0 0 DI
0 1 0 1 0.3333333 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 04
Tanggal : 28 12 2016
RT,RW,Kelurahan: 01 01 Margahayu
- - - - B F
- - - - DA - 1 0 0 0
- - - - O O 1 0 1 0
51 61 62 63 64 65
0 0 0 9 9 9 6 9 9 0
- - - - - - - - - 1
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - DA - - 0
0 0 0 9 9 9 1 9 9 2
81 71 72 73 74 75 0
- - - - O O
- - - G3 DA PN 1 0 0 0
- - - - B B 2 0 1 0
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
2 1 2 0.8333333 F= 0
____
DMF = 3
Score Segmen
X 2 0 0 1 X 2 0 1
X 2 2 0 2 X 2 2 2
-
1= F 2.2. CPITN
0 - Tumpatan ART 3
1 - Tumpatan GI 0
- Gigi sulung 2
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 6
e= 0
f= 1
____
def = 7
Jumlah ScKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
5 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Reza Ardhiansyah Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Jl. Raya Katapang No. 53, Katapang
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - EG
Letak Caries - - - - - - M
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
0 0 0 DI
0 1 0 1 0.3333333 0
OHI - S = 0.8333333
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 19
- Sealant =6 5
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 28 12 2016
RT,RW,Kelurahan: 04 01 Katapang
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
1 0 0 1 0 0 6 0 9 0
EG - - DG - - - - - 0
D - - D - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- M - - - - - - - 0
- EG - - - - - - - 0
0 1 0 0 0 0 6 0 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 4
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 4
Score Segmen
X 1 0 0 1 X 1 0 1
X 1 1 0 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 4
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
2

PERSISTENSI = PS
d= 0
e= 0
f= 2
____
def = 2
Jumlah ScKode
5 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Adhi Putra Pangestu Gender: 1P= 1

W=2
Umur: 11 tahun
ALAMAT: Jl. Taman Kopo Indah no.121, Margaasih
KANAN
DIAGNOSA - - - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
1 1 1 DI
0 2 1 2 1.3333333 0
OHI - S = 1.8333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 18
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 28 12 2016
RT,RW,Kelurahan: 07 03 Margaasih
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 5 1 9 9 0
- - - - - - EG - - 0
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - DG - - 0
0 0 0 0 0 0 1 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 3
Score Segmen
X 1 0 1 1 X 1 1 1
X 1 0 0 2 X 1 0 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Dea Amalia Putri Prattiwi Gender: 2P= 1

W=2
Umur: 8 tahun
ALAMAT: Jl. Cilampeni no.36
KANAN
DIAGNOSA EA DA G4 -
Letak Caries MB O - -
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
Letak Caries D O - -
DIAGNOSA EG DA - -
Segment
Plaque Score
2 0 2 DI
0 1 1 1 1.1666667 0
OHI - S = 1.6666667
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 28 12 2016
RT,RW,Kelurahan: 04 02 Cilampeni
- - - A B A
- - - - PV - 1 0 0 0
- - - - MOD - 1 0 0 1
51 61 62 63 64 65
0 0 0 9 9 9 1 9 9 0
- - - - - - DA - - 0
- - - - - - O - - 2
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - EA - - 2
0 0 0 9 9 9 1 9 9 0
81 71 72 73 74 75 0
- - - - O -
- - - - EA - 1 1 0 0
user:
- - - A B A 1 0 GS 0
KMD ART 0
Segment Segment
Calculus Score D= 4
0 0 1 CI M= 0
1 0 1 0.5 F= 0
____
DMF = 4
Score Segmen
X 1 1 0 2 X 1 1 2
X 1 1 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 4
2 - Tumpatan GI 0
- Gigi sulung 1
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 6
e= 0
f= 0
____
def = 6
Jumlah ScKode
5 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
4 gigi
1 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Dewi Puji Astuti Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: Jl. Bojong no.33, Soreang
KANAN
DIAGNOSA - - - -
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
0 0 0 DI
0 2 0 2 0.6666667 0
OHI - S = 1.1666667
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 18
- Sealant =6 2
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 29 12 2016
RT,RW,Kelurahan: 02 01 Soreang
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
51 61 62 63 64 65
0 0 0 0 6 6 1 9 9 0
- - - - - - DG - - 0
- - - - - - P - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - OB - - 0
- - - - - - DG - - 0
0 0 0 0 0 0 1 9 9 0
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 4
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 4
Score Segmen
X 0 0 0 0 X 0 0 0
X 1 0 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Deni Surya Gender: 1P= 1

W=2
Umur: 10 tahun
ALAMAT: JL. Cingcin Permata Indah no.3
KANAN
DIAGNOSA - - - G3
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
DIAGNOSA - - - -
Segment
Plaque Score
2 0 1 DI
0 1 0 1 0.8333333 0
OHI - S = 1.3333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 16
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 29 12 2016
RT,RW,Kelurahan: 01 01 Cingcin
- - - A - -
- - - - - - 0 0 0 0
- - - - - - 0 0 1 0
51 61 62 63 64 65
0 0 0 9 2 0 1 9 9 0
- - - - EG - DG - - 0
- - - - O - O - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 0 0 0 0 9 9 1
81 71 72 73 74 75 0
- - - - - -
- - - - - - 0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
0 0 0 CI M= 0
1 1 1 0.5 F= 2
____
DMF = 4
Score Segmen
X 1 0 0 1 X 1 0 1
X 2 2 2 1 X 2 2 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 2
2 - Tumpatan GI 2
- Gigi sulung 1
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY
USAHA KES
NAMA: Rezkyansah Gender: 1P= 1

W=2
Umur: 8 tahun
ALAMAT: Jl. Kenangan no.90
KANAN
Keadaan gigi E B A -
DIAGNOSA - DA - -
Letak Caries - O - -
55 54 53 52
DIAGNOSA - - - - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
DIAGNOSA EG - - -
Keadaan gigi B E A -
Segment
Plaque Score
0 0 0 DI
0 2 1 0 0.5 0
OHI - S = 0.8333333
Artinya : BAIK
CPITN
Gigi Index
X 16 11 16 26 X
0 X 46 41 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 8
- Sealant =6 4
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 30 12 2016
RT,RW,Kelurahan: 07 01 Padasuka
ART GI
- - - A E E
- - - - - - 0 0 0 0
- - - - - - 1 0 0 0
51 61 62 63 64 65
0 0 0 9 9 9 6 9 9 0
- - - - - - - - - 0
- - - - - - - - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - - - - 0
- - - - - - - - - 0
0 0 0 9 9 9 6 9 9 0
81 71 72 73 74 75 0
- - - - - D
- - - - - DG 0 1 0 0
- - - A E B 0 1 0 0
Segment Segment
Calculus Score D= 0
0 0 0 CI M= 0
1 0 1 0.3333333 F= 0
____
DMF = 0
Score Segmen
X 0 0 0 0 X 0 0 0
X 2 0 0 2 X 2 0 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
0 - Tumpatan GI 0
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 3
e= 5
f= 0
____
def = 8
Jumlah ScKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Asep Gender: 1P= 1 No. Resp.: 01
W=2 Tanggal : 03 03 2016
ALAMAT: kp.sirnabakti RT,RW,Kelurahan: 02 03 kp.sirnabakti
KANAN KIRI
DIAGNOSA - EA - - EA - 2 0 0 0
Letak Caries - M B O - 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG - - - 0 0
Letak Caries O O B - O 0 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

2 0 2 DI 1 1 2 CI M= 0 e= 1
0 3 1 3 1.83 0 1 1 1 1.17 F= 0 f= 0
OHI - S = 3 ____ ____
CPITN
17 16 11 21 26 27 2 2 2 2 2 2 3 2
0 17 46 41 31 36 37 0 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: dadan Gender: 1P= 1 No. Resp.: 02
W=2 Tanggal : 02 07 2016
ALAMAT: kp.sirnabakti RT,RW,Kelurahan: 02 03 kp.sirnabakti
KANAN KIRI
Keadaan gigi B A B B B B B B A B
DIAGNOSA - A - - - - - EA 1 0 0 0
Letak Caries O RK - - - MO MOD B 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EA EA 2 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries B M D O KMA = A
DIAGNOSA EG - DG - DA 0 1 0 0 PERSISTE
Keadaan gigi B A A B B A B A A B 1 1 0 0 GOYANG

3 1 3 DI 1 0 1 CI M= 0 e= 0
0 3 1 1 2 0 1 0 1 0.67 F= 0 f= 1
2.67 ____ ____
CPITN
17 16 11 21 26 27 2 1 1 1 1 1 2 1 1 3 2
0 46 41 31 36 37 0 1 2 1 1 1 2 2 1 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: agustia Gender: 1P= 1 No. Resp.: 04
W=2 Tanggal : 06 10 2016
ALAMAT: jl sirnabakti RT,RW,Kelurahan: 02 03 sirnabakti
KANAN KIRI
Keadaan gigi A B A A A A A A A B
DIAGNOSA EG - - - G4 - 0 1 0 0
Letak Caries MOD B DO 0 0 0 1
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O M D M O KMA = A
DIAGNOSA EA DG PS G4 - - 1 0 1 0 PERSISTE

3 1 1 DI 1 1 1 CI M= 0 e= 0
0 1 1 1 1.33 0 2 0 2 1.17 F= 0 f= 1
OHI - S = 2.5 ____ ____
CPITN
X 16 11 X 26 27 X 1 1 X 1 1 1 1 1 5 2
0 X 46 41 31 36 X 0 X 1 1 1 2 X 1 1 2 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: agung Gender: 1P= 1 No. Resp.: 03
W=2 Tanggal : 04 12 2016
KANAN KIRI
Keadaan gigi B B B A B B A A A A
DIAGNOSA - - A EA EG - G4 1 1 0 0
Letak Caries O B - D M O 0 0 0 1
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries M O D O KMA = A
DIAGNOSA - - - DA PS EG A 0 1 1 0 PERSISTE
Keadaan gigi A B A B A B A A A B 1 0 0 0 GOYANG

3 1 0 DI 1 1 2 CI M= 0 e= 0
0 2 1 0 1.17 0 1 0 1 1 F= 0 f= 2
OHI - S = 2.17 ____ ____
CPITN
17 16 11 X 26 27 2 1 0 X 3 2 2 0 3 2 2
0 47 46 X 31 36 37 0 0 1 X 0 0 1 1 0 1 1 3
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
3
BANDUNG

NAMA: maman Gender: 1P= 1 No. Resp.: 02
W=2 Tanggal : 03 02 2016
KANAN KIRI
DIAGNOSA EA - - - DG PN 1 0 0 0
Letak Caries O O - M D O 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DA DG 0 1
Letak Caries B O O 1 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B M 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O O B KMA = A
DIAGNOSA DG EG PS G4 G4 DA 0 1 1 0 PERSISTE
Keadaan gigi B B A B A A A A A B 1 1 0 2 GOYANG

2 1 2 DI 1 1 0 CI M= 0 e= 2
0 2 1 1 1.5 0 0 1 0 0.5 F= 0 f= 1
OHI - S = 2 ____ ____
CPITN
X 16 11 21 26 X X 1 0 2 0 X 1 2 0 4 2
0 X 46 41 31 36 X 0 X 1 0 1 1 X 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
OSA LETAK CARIES

RT= EA MESIAL = M
I= EG DISTAL = D
GI = DG OCLUSAL = O
RT = DA BUCCAL = B
ITAL = PV LABIAL = L
0
STENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: ucup Gender: 1P= 1 No. Resp.: 06
W=2 Tanggal : 08 07 2016
KANAN KIRI
Keadaan gigi B B B B A A A A A B
DIAGNOSA A A DA G3 PS PS DA 0 0 2 0
Letak Caries O O P O 2 0 1 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG EG 0 2
Letak Caries P M 0 0 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries L 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA DA DG G4 PS DA 0 0 1 0 PERSISTE

2 1 1 DI 2 0 1 CI M= 0 e= 0
0 3 1 2 1.67 0 3 1 3 1.67 F= 0 f= 0
OHI - S = 3.33 ____ ____
CPITN
X 16 11 21 26 X X 2 0 2 1 X 2 2 1 4 2
0 47 46 41 31 36 37 0 1 1 1 1 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: mu'min Gender: 1P= 1 No. Resp.: 03
W=2 Tanggal : 04 09 2016
KANAN KIRI
Keadaan gigi B A A B B B A A B A
DIAGNOSA EG DA G4 G4 DA G3 0 1 0 0
Letak Caries O D O 2 0 1 2
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA 0 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O O O O 0 0 0 KMD-GI =
DIAGNOSA EG EG EG EG 0 4 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O D M O KMA = A
DIAGNOSA EA DA DA G4 DA 1 0 0 0 PERSISTE

3 2 1 DI 2 1 2 CI M= 0 e= 0
0 3 1 1 1.83 0 1 0 1 1.17 F= 0 f= 2
OHI - S = 3 ____ ____
CPITN
17 16 11 21 26 27 1 2 1 2 2 2 2 2 2 3 2
0 X 46 41 31 36 37 0 X 1 1 0 1 1 1 1 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG

NAMA: aris Gender: 1P= 1 No. Resp.: 03
W=2 Tanggal : 10 07 2016
KANAN KIRI
DIAGNOSA DA PS PS G3 0 0 2 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DG EG 0 2
Letak Caries O MB M 0 1 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries B B 0 0 0 KMD-GI =
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Letak Caries O O O O KMA = A
DIAGNOSA A A PS G4 PV DA 0 0 1 0 PERSISTE
Keadaan gigi B B A A A A A A B B 1 0 0 1 GOYANG

1 1 1 DI 2 0 1 CI M= 0 e= 1
0 1 1 1 1 0 1 0 1 0.83 F= 0 f= 0
OHI - S = 1.83 ____ ____
CPITN
16 11 26 0 0 0 0 0 0 1 1
0 46 31 36 0 0 0 1 0 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

NAMA: daud Gender: 1P= 1 No. Resp.: 02
W=2 Tanggal : 13 07 2016
ALAMAT: sirnabakti RT,RW,Kelurahan: 02 03 sirnabakti
KANAN KIRI
Keadaan gigi B B A A A A A A A B
DIAGNOSA A PV PV 0 0 0 0
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA DG DG EG EG 0 2
Letak Caries O P M O 0 2 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries M O O M D O O 0 0 0 KMD-GI =
DIAGNOSA EG DG EG EG EG EG EG 0 6 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
Keadaan gigi B A A A A A A A A B 0 0 0 0 GOYANG

2 1 2 DI 1 1 1 CI M= 0 e= 0
0 1 1 1 1.33 0 1 1 1 1 F= 0 f= 1
OHI - S = 2.33 ____ ____
CPITN
16 11 26 0 0 1 0 0 1 3 2
0 46 31 36 0 1 0 1 1 0 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
1
BANDUNG

W=2 Tanggal : 10 12 2016
jl cimangkok rt/rw 02/02
ALAMAT: sirnabakti RT,RW,Kelurahan: 02 03 sirnabakti
KANAN KIRI
55 54 53 52 51 61 62 63 64 65 0 0
0 0 0
DIAGNOSA EG DG EG DG EG DG 0 3
Letak Caries B O O P M O 0 3 DIAGNOS
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 KME-ART
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 KME-GI= E
Letak Caries O O M M O B 0 0 0 KMD-GI =
DIAGNOSA DG EG EG EG EG EG 0 5 KMD-ART
0 0 0
85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON
DIAGNOSA A PN PS 0 0 1 0 PERSISTE
Keadaan gigi B B A A A A A A A A 0 0 0 0 GOYANG

3 1 3 DI 0 0 0 CI M= 0 e= 1
0 3 2 3 2.5 0 1 2 1 0.67 F= 0 f= 0
OHI - S = 3.17 ____ ____
CPITN
16 11 26 1 1 1 1 1 1 5 2
0 46 31 36 0 1 2 1 1 2 1 0 0
0

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
0
:
NOSA LETAK CARIES

ART= EA MESIAL = M
GI= EG DISTAL = D
GI = DG OCLUSAL = O
ART = DA BUCCAL = B
0
ISTENSI = PS
NG °3/°4 = G3/G4
2
BANDUNG


W=2 Tanggal : 10 12 2016
KANAN
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 8 1 1 0 1 0 1 0 1 0 0 0 0 1 0 8 0
DIAGNOSA EG DG EG DG EG DG 0
Letak Caries B O O P M O 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O O M M O B 0
DIAGNOSA DG EG EG EG EG EG 0
Keadaan gigi 8 1 1 0 0 0 0 1 1 0 0 0 6 1 1 8 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O
DIAGNOSA A PN PS 0 0 1 0
Keadaan gigi B B A A A A A A A A 0 0 0 0

3 1 3 DI 0 0 0 CI M= 0
0 3 2 3 2.5 0 1 2 1 0.67 F= 0
OHI - S = 3.17 ____
CPITN
16 11 26 1 1 1 1 1 1
0 46 31 36 0 1 2 1 1 2 1

- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
3
0 0 0 0
PERSISTENSI = PS
d= 3
e= 1
f= 0
____
def = 4
JumlahKode
5 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
0 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG

NAMA: maman Gender: 1P= 1 No. Resp.: 02

W=2 Tanggal : 03 02 2016
ALAMAT: sirnbakti RT,RW,Kelurahan: 02 03 sirnabakti
KANAN
DIAGNOSA EA - - - DG PN 1 0 0 0
Letak Caries O O - M D O 0 1 0 0
55 54 53 52 51 61 62 63 64 65 0
Keadaan gigi 8 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0
DIAGNOSA EG DA DG 0
Letak Caries B O O 1
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries B M 0
DIAGNOSA EG EG 0
Keadaan gigi 8 0 1 0 0 0 0 0 0 0 1 0 0 6 6 0 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries O O B
DIAGNOSA DG EG PS G4 G4 DA 0 1 1 0
Keadaan gigi B B A B A A A A A B 1 1 0 2

2 1 2 DI 1 1 0 CI M= 0
0 2 1 1 1.5 0 0 1 0 0.5 F= 0
OHI - S = 2 ____
CPITN
X 16 11 21 26 X X 1 0 2 0 X 1 2 0
0 X 46 41 31 36 X 0 X 1 0 1 1 X 1 1 1

- Gigi lubang/karies =1 4 10 = B - Memerlukan scaling
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0
0 0 0 0
0 0 KODE:
1
0 0 0 0
PERSISTENSI = PS
d= 10
e= 2
f= 1
____
def = 13
JumlahKode
4 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
2 gigi
3 gigi
INF
1 gigi
0 gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: edrik Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: sirnabakti
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries MOD
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 2 1 1 1.33 0
OHI - S = 3.166667
Artinya : BURUK
CPITN
Gigi Index
17 16 11 26 27 -
0 47 46 31 36 37 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 03 06 2016
RT,RW,Kelurahan: 02 03 sirnabakti
ART GI
- - - B - -
KMA 0 0 0 1
MOD 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 0 0 0
EG 0
- - - - - - O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
DG 0
0 0 0 0 9 0 1 0 0 0
81 71 72 73 74 75 0
O
DA 0 0 0 0
- - - - B - 1 0 0 0
Segment Segment
Calculus Score D= 5
2 1 1 CI M= 1
3 1 3 1.8333333 F= 2
____
DMF = 8
Score Segmen
1 2 1 1 1 - 2 1 1
0 3 2 2 1 0 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
3 - Tumpatan GI 3
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 3
e= 0
f= 0
____
def = 3
Jumlah ScKode
2 2
1 3
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 3
= 3
= 4
GS
1 gigi
0 gigi
INF
1 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: yosep Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: jl sirnabakti
KANAN
DIAGNOSA EG EG
Letak Caries O M
55 54 53 52
DIAGNOSA EG DA
Letak Caries O M
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 1 1 1 1.166667 0
OHI - S = 2.5
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27
0 47 46 31 36 X 0
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 04
Tanggal : 06 05 2016
- - - - - -
EG 0 3 0 0
M 0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0 0
0 1
1 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0 0
0 0
0 0 0 9 0 0 0 0 9 0 0
81 71 72 73 74 75 0 >0
B
EA 1 0 0 0
- - - B - - 0 0 0 0
Segment Segment
Calculus Score D= 1
1 0 1 CI M= 0
2 2 2 1.333333 F= 1
____
DMF = 2
Score Segmen
X 1 0 1 1 1 1 1
1 2 2 2 X 1 2 2
-
0= F 2.2. CPITN
2 - Tumpatan GI 1 3

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 4
e= 0
f= 0
____
def = 4
JumlaKode
4 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: maman Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: jl.sirnabakti
KANAN
DIAGNOSA EG
Letak Caries M
55 54 53 52
DIAGNOSA DG EG
Letak Caries D D
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O D
DIAGNOSA EG DA
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
2 1 1 DI
0 2 2 1 1.5 0
OHI - S = 2.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26 27
0 47 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 16
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 04 06 2016
- - - A - -
EG 0 2 0 0
D 0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 1 9 9 0
DG 0
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
M 0
EG 0
1 0 0 9 0 0 0 9 9 1
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 4
1 2 0 CI M= 0
2 1 2 1.333333 F= 0
____
DMF = 4
Score Segmen
1 0 1 1 1 1 1
4 2 2 2 4 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
3 - Tumpatan GI 2
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 0
e= 0
f= 3
____
def = 3
Jumlah ScKode
3 2
0 3
1
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 4
= 3
= 4
GS
0 gigi
2 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: gusnaldi Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries
DIAGNOSA
85 84 83 82
Letak Caries O
DIAGNOSA EA
Segment
Plaque Score
2 1 2 DI
0 1 1 1 1.333333 0
OHI - S = 2.833333
Artinya : SEDANG
CPITN
Gigi Index
16 11 26 27
0 47 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 25
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 05 06 2016
- - - - - -
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 9 0
EA 1
O 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
0
0
0 0 0 0 0 0 0 0 9 0
81 71 72 73 74 75 0
1 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 1 2 CI M= 0
2 1 1 1.5 F= 0
____
DMF = 2
Score Segmen
2 0 2 1 2 2 1
1 2 2 2 1 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 1
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: cahya Gender: 1P= 1 No. Resp.: 08
W=2 Tanggal : 02 02 2016
KANAN
Keadaan gigi - - - - - - - - - -
DIAGNOSA 0 0 0 0
55 54 53 52 51 61 62 63 64 65
Keadaan gigi 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0
DIAGNOSA 0
Letak Caries 0
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Letak Caries O B 0
DIAGNOSA DG EG 0
Keadaan gigi 9 0 1 0 0 9 0 0 0 0 0 0 0 1 0 9 0
85 84 83 82 81 71 72 73 74 75 0
Letak Caries - - B - - - - - - -
DIAGNOSA EA 1 0 0 0
Keadaan gigi O 0 0 0 0

1 1 1 DI 1 0 1 CI M= 0
0 2 0 1 1 0 2 1 2 1.17 F= 0
OHI - S = 2.17 ____
CPITN
16 11 26 27 0 0 0 2 0 0 2
0 47 46 31 36 0 2 2 2 2 2 2 2

- Tak ada =0 0 - Gigi tetap 0
- Ada =1
2.4. Observasi :
- Ada kelainan =1

- Baik =0 2
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
JumlahKode
0 0
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
esehatan mulut = 1
= 2 2
= 3
GS
1 gigi 1 1
0 gigi
INF
0 gigi 0 0
0 gigi
esmas Sukajadi
BANDUNG

NAMA: ucup Gender: 1P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: jl sirnabakti RT,RW,Kelurahan:
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries - - A - C -
55 54 53 52 51 61
Keadaan gigi 9 0 0 0 0 9 0 0 0
DIAGNOSA EG EG
Letak Caries O O
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries O M
DIAGNOSA EG EG
Keadaan gigi 9 1 1 0 0 0 0 0 0
85 84 83 82 81 71
DIAGNOSA
Keadaan gigi
Segment Segment

1 0 0 DI 0 0
0 1 1 1 0.6667 0 1 1
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index Score
16 11 26 27 0
0 47 46 31 36 0 1
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
04 06 2016
KIRI
0 0 0 0
- - - - 0 0 0 0
62 63 64 65 0
0 0 0 0 0 0 9 0 0 0 KODE:
0 2
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D

O 1 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 2 d= 2
0 CI M= 0 e= 0
1 0.5 F= 0 f= 0
____ ____
DMF = 2 def = 2
Segmen JumlaKode
0 0 0 0 0 0 1 1
3 2 2 1 3 2 1 3
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
BANDUNG

NAMA: Cepi Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
Keadaan gigi - - O - A
DIAGNOSA EA EG
Letak Caries B D
55 54 53 52 51
Keadaan gigi 9 0 1 0 0 9 0 0
DIAGNOSA EG DA
Letak Caries O EA
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries O
DIAGNOSA EA
Keadaan gigi 9 0 6 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

1 1 1 DI 1
0 1 1 1 1 0 2
OHI - S = 2.166667
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26 X
0 47 46 31 36 0
1. DIAGNOSA
- Sealant =6 1 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 01 07 2016
KIRI
- - - - -
1 1 0 0
0 0 0 0
61 62 63 64 65 0
0 0 0 0 0 0 0 9 0 0 0 KODE:
0 1
1 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
0 0 0 KMD-GI = DG
1 0 KMD-ART = DA
0 0 9 0 0 0 0 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

MOD KMA =KMA
- - B - - 0 0 0 0 GOYANG
Segment
1 1 CI M= 0 e= 0
1 1 1.166667 F= 0 f= 1
____ ____
DMF = 1 def = 3
Segmen JumlaKode
2 0 2 X 2 2 0 1 1
1 2 2 3 1 2 3 1 3
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 3
= 3
= 4
BANDUNG

NAMA: riza Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: jl sirna bakti
KANAN
Keadaan gigi
DIAGNOSA
55 54 53 52 51
Keadaan gigi 9 1 1 0 0 9 0 0
DIAGNOSA EG EG
Letak Caries O O
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries
DIAGNOSA
Keadaan gigi 9 0 0 0 0 0 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Segment Segment

0 1 0 DI 1
0 1 0 1 0.5 0 1
OHI - S = 1.333333
Artinya : SEDANG
CPITN
Gigi Index Score
16 11 26 27
0 47 46 31 36 0
1. DIAGNOSA
- Sealant =6 1 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
9
No. Resp.: 04
Tanggal : 03 03 2017
KIRI
O
DA 0 0 0 0
- - B - - 1 0 0 0
61 62 63 64 65 0
0 0 9 0 0 0 0 9 0 0 0 KODE:
0 2
- 0 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
O 0 0 0 KMD-GI = DG
EA 1 0 KMD-ART = DA
0 0 0 0 0 6 0 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL = P

KMA = A
- - - - - 0 0 0 0 GOYANG
Segment
0 0 CI M= 0 e= 0
2 1 0.833333 F= 0 f= 0
____ ____
DMF = 4 def = 3
Segmen JumlahKode
2 0 0 1 2 0 1 1 1
3 2 2 2 3 2 2 1 3
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 3
= 3
= 4
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: erik Gender: 1P=1

W=2
Umur: 12 tahun
ALAMAT: JL SIRNABAKTI
KANAN
DIAGNOSA EA
Letak Caries O
55 54 53 52
DIAGNOSA
Letak Caries
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
1 0 2 DI
0 2 1 3 1.5 0
OHI - S = 3.166667
Artinya : BURUK
CPITN
Gigi Index
16 11 26 27
0 47 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 22
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 05
Tanggal : 05 07 2016
- - - A - -
1 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 9 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EG 0
0 0 0 9 0 0 1 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - A - - 0 0 0 0
Segment Segment
Calculus Score D= 2
3 0 2 CI M= 0
2 1 2 1.666667 F= 0
____
DMF = 2
Score Segmen
0 0 0 1 0 0 1
0 2 2 2 0 2 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
1 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
1 1
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: agus Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA EG
Letak Caries O
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O
DIAGNOSA EG
85 84 83 82
Letak Caries
DIAGNOSA
Segment
Plaque Score
3 1 2 DI
0 2 1 3 2 0
OHI - S = 4.166667
Artinya : BURUK
CPITN
Gigi Index
16 11 26 27
0 47 46 31 36 0
1. DIAGNOSA
- Gigi sehat =0 24
- Sealant =6 1
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 05 07 2016
- - - B - -
DA 0 0 0 0
O 1 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 0 0 9 0
0
0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
O 0
EA 1
0 0 0 0 0 0 6 0 9 0
81 71 72 73 74 75 0
0 0 0 0
- - - - - - 0 0 0 0
Segment Segment
Calculus Score D= 2
2 0 3 CI M= 0
3 2 3 2.166667 F= 0
____
DMF = 2
Score Segmen
2 0 2 4 2 2 4
2 3 2 2 2 3 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
4 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
1

PERSISTENSI = PS
d= 1
e= 0
f= 0
____
def = 1
Jumlah ScKode
0 0
1 4
1
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 4
= 3
= 4
GS
1 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KE
USAHA KESEH
NAMA: gustavo Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
1 1 2 DI
0 2 1 0 1.17 0
OHI - S = 1.666667
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 26 27 -
1 - 47 46 31 36 X 1
1. DIAGNOSA
- Gigi sehat =0 29
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 10
Tanggal : 28 12 2016
ART GI
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 0 0
- - - - - - DG - - 0
- - - - - - O - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - O - - - 0
- - - - - EG - - - 0
0 0 0 0 0 1 0 0 0 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 3
1 0 0 CI M= 0
1 0 1 0.5 F= 0
____
DMF = 3
Score Segmen
1 1 1 1 1 - 1 1 1
- 1 1 1 1 X 1 1 1
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
6 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: kaka Gender: 2P= 1

W=2
Umur: 12 tahun
ALAMAT: sirnabakti
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
1 0 1 DI
0 1 0 1 0.666667 0
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index
17 16 11 26 27 -
1 - 47 46 31 36 37 1
1. DIAGNOSA
- Gigi sehat =0 29
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 28 12 2016
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 0 0 0
- - - - - - DG - - 0 0
- - - - - - O - - 1 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - O - - - - 0 0
- - - - EG - - - - 0 1
0 0 0 0 1 0 0 0 0 0 0
81 71 72 73 74 75 0 >0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 3
Score Segmen
1 0 1 0 0 - 1 1 0
- 0 1 0 0 1 0 1 1
-
0= F 2.2. CPITN
2 - Tumpatan GI 2 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
JumlaKode
4 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG

USAHA KESEHATAN GIG
NAMA: ICANG Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: sirnabakti
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
DIAGNOSA - - - - - - -
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
1 0 1 DI
0 1 0 1 0.666667 0
OHI - S = 1.166667
Artinya : BAIK
CPITN
Gigi Index
17 16 11 26 27 -
1 - 47 46 31 36 37 1
1. DIAGNOSA
- Gigi sehat =0 29
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 09
Tanggal : 28 12 2016
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 0 0 0
- - - - - - DG - - 0 0
- - - - - - O - - 1 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - O - - - - 0 0
- - - - EG - - - - 0 1
0 0 0 0 1 0 0 0 0 0 0
81 71 72 73 74 75 0 >0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 3
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 3
Score Segmen
1 0 1 0 0 - 1 1 0
- 0 1 0 0 1 0 1 1
-
0= F 2.2. CPITN
2 - Tumpatan GI 2 0

- Gigi sulung 0 0
0 - Gigi tetap 0 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 KODE:


PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
JumlaKode
4 2
0 0
0
0
1 3
2
3 1 3
1
= 0
= 1
= 2 1
= 3
= 4
gigi
gigi
gigi
gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: mnama Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries - O O - - - -
DIAGNOSA - PV DG - - - -
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
0 1 1 DI
0 3 1 2 1.333333 0
OHI - S = 2
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 26 27 -
1 - 47 46 31 36 37 1
1. DIAGNOSA
- Gigi sehat =0 23
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 08
Tanggal : 25 07 2016
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 1 0 0 0 0 1 0 0 0
- EA - - - - DG - - 1
- M - - - - B - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O OB - 0
- - - - - - PN DG - 0
0 0 0 0 0 0 1 1 9 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 7
0 1 0 CI M= 0
2 1 0 0.666667 F= 0
____
DMF = 7
Score Segmen
2 2 1 1 1 - 2 1 1
- 2 1 1 2 1 2 1 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 0
- Gigi sulung 0
- Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: reki aditya Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: sirnabakti
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA DG - DA - - - -
Letak Caries O - O - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
2 0 1 DI
0 2 1 1 1.166667 0
OHI - S = 1.666667
Artinya : SEDANG
CPITN
Gigi Index
17 16 11 26 27 -
1 - 47 46 31 36 37 1
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 07
Tanggal : 25 12 2016
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 0 0
- - - - - - DG - - 0
- - - - - - O - - 1
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - OB - - 0
- - - - - - DG - - 0
0 0 0 0 0 0 1 0 1 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 6
0 0 0 CI M= 0
1 1 1 0.5 F= 0
____
DMF = 6
Score Segmen
2 1 1 1 2 - 2 1 2
- 1 1 0 1 2 1 1 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 1
2 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
3 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG
KARTU SURVEY KESEH

USAHA KESEHATAN
NAMA: aldi Gender: 1P= 1

W=2
Umur: 12 tahun
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52
DIAGNOSA - PV DG - - - -
Letak Caries - O OB - - - -
18 17 16 15 14 13 12
48 47 46 45 44 43 42
Letak Caries O - OP - - - -
DIAGNOSA PN - DG - - - -
85 84 83 82
Letak Caries
DIAGNOSA
Keadaan gigi
Segment
Plaque Score
1 1 1 DI
0 2 1 3 1.5 0
OHI - S = 2.333333
Artinya : SEDANG
CPITN
Gigi Index
X 16 11 26 27 -
1 - 47 46 31 36 X 1
1. DIAGNOSA
- Gigi sehat =0 26
- Sealant =6 0
di atas

- Sehat =0

- Tak ada =0
- Ada =1

- Ada kelainan =1

- Baik =0
No. Resp.: 06
Tanggal : 26 07 2016
0 0 0 0
0 0 0 0
51 61 62 63 64 65
0 0 0 0 0 0 1 0 0 0
- - - - - - DG - - 0
- - - - - - O - - 0
11 21 22 23 24 25 26 27 28
41 31 32 33 34 35 36 37 38
- - - - - - O - - 0
- - - - - - DG - - 0
0 0 0 0 0 0 1 0 0 0
81 71 72 73 74 75 0
0 0 0 0
0 0 0 0
Segment Segment
Calculus Score D= 6
1 0 0 CI M= 0
2 0 2 0.833333 F= 0
____
DMF = 6
Score Segmen
X 2 1 2 1 - 2 2 1
- 2 1 1 2 X 2 1 2
-
0= F 2.2. CPITN
0 - Tumpatan ART 0
2 - Tumpatan GI 2
- Gigi sulung 0
0 - Gigi tetap 0
2.4. Observasi :
2
*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KIRI
0 0 KODE:
0

PERSISTENSI = PS
d= 0
e= 0
f= 0
____
def = 0
Jumlah ScKode
2 2
0 0
0
= 0
= 1 3
= 2
= 3 1 3
1
= 0
= 1
= 2 2
= 3
= 4
GS
0 gigi
0 gigi
INF
0 gigi
0 gigi
BANDUNG

NAMA: Nursoffa jovi Gender: 1P= 1

W=2
Umur: 12 tahun
ALAMAT: sirnabakti
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52 51
Keadaan gigi 9 9 0 1 0 9 0 0
DIAGNOSA - - - DA - - - -
18 17 16 15 14 13 12 11
48 47 46 45 44 43 42 41
Letak Caries - - O - - - - -
DIAGNOSA - - EA - - - - -
Keadaan gigi 9 9 1 0 0 9 0 0
85 84 83 82 81
Letak Caries
DIAGNOSA
Keadaan gigi
Segment Segment

1 0 2 DI 1
0 2 0 2 1.17 0 1
OHI - S = 1.833333
Artinya : SEDANG
CPITN
Gigi Index Score
X 16 11 26 X - X
1 - X 46 31 36 X 1 -
1. DIAGNOSA
- Sealant =6 0 0
di atas

- Sehat =0

- Tak ada =0 0
- Ada =1

- Ada kelainan =1

- Baik =0 2
No. Resp.: 03
Tanggal : 24 10 2016
KIRI
0 0 0 0
0 0 0 0
61 62 63 64 65 0
0 0 9 0 0 1 9 9 0 0 0 KODE:
- - - - - EG - - 0 1
- - - - - B - - 1 0 DIAGNOSA
21 22 23 24 25 26 27 28 KME-ART= EA
31 32 33 34 35 36 37 38 KME-GI= EG
- - - - - B - - 0 0 0 KMD-GI = DG
- - - - - EA - - 2 0 KMD-ART = DA
0 0 9 0 0 1 9 9 0 0 KMP VITAL = PV
71 72 73 74 75 0 >0 0 KMP NONVITAL =

KMA = A
0 0 0 0 GOYANG
Segment
0 1 CI M= 0 e= 0
0 1 0.666667 F= 0 f= 0
____ ____
DMF = 4 def = 0
Segmen JumlaKode
1 0 2 X - 1 2 0 2 2
X 1 0 2 X 0 1 2 0 0
0
-
=F 2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
KODE:


PERSISTENSI = PS
3
= 0
= 1
= 2 2
= 3
= 4
BANDUNG

NAMA: putra Gender: 1P= 1 No. Resp.:

W=2 Tanggal :
ALAMAT: jl sirnabakti RT,RW,Kelurahan:
KANAN
Keadaan gigi
DIAGNOSA
Letak Caries
55 54 53 52 51 61
Keadaan gigi 8 0 1 0 1 0 0 0 0
DIAGNOSA - - PV - EG - - - -
Letak Caries - - O - O - - - -
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
Letak Caries - B O - - - - - -
DIAGNOSA - DG PN - - - - - -
Keadaan gigi 0 1 1 0 0 0 0 0 0
85 84 83 82 81 71
Letak Caries L
DIAGNOSA EG
Keadaan gigi 1
Segment Segment

0 2 1 DI 1 1
0 1 2 2 1.3333 0 3 1
OHI - S = 3
Artinya : SEDANG
CPITN
Gigi Index Score
- 16 11 26 27 - 2
1 47 46 31 36 37 2 - 3
1. DIAGNOSA
1.1.
- Sealant =6 0 0= F
di atas
1.2.
- Sehat =0
1.3.
- Tak ada =0 0
- Ada =1
1.4.
- Ada kelainan =1
1.5.
Kebersihan Mulut :
- Baik =0 2
No. Resp.: 02
27 06 2016
KIRI
0 0 0 0
0 0 0 0
62 63 64 65 0
0 0 0 0 1 0 0 0 0 0 KODE:
- - - - EG - - 0 2
- - - - O - - 0 0 DIAGNOSA LETAK CARIES
32 33 34 35 36 37 38 KME-GI= EG DISTAL = D
- - P - O - - 0 0 0 KMD-GI = DG OCLUSAL = O
- - EG - DG - - 0 1 KMD-ART = DA BUCCAL = B

0 0 0 0 GOYANG °3/°4 = G3/G4
Segment
D= 7 d= 0
1 CI M= 0 e= 0
3 1.666667 F= 0 f= 0
____ ____
DMF = 7 def = 0
Segmen JumlaKode
1 2 3 - 2 2 3 0 0
3 2 2 - 3 3 2 3 4
0
2.2. CPITN

2.4. Observasi :

*Keterangan :
Exo
Endo
Konservasi
Ortho
Perio
Prosto
LETAK CARIES
MESIAL = M
DISTAL = D
OCLUSAL = O
BUCCAL = B
LABIAL = L
PALATAL = P
RK = Rampan Karies
REKAP RESPONDEN BERDASARKAN GENDER
Count - Nama Siswa Gender

Umur (tahun) 1 2 Total Result 200
5 1 2 3 180
6 8 12 20 160
7 14 29 43 140
8 19 24 43 120
9 22 24 46 100
80 12;
10 32 28 60
60 1
11 35 30 65 7; 29 8; 24 9; 2410;10; 11;11;
32 28 35 30
12 68 48 116 40 8; 19 9; 22
6; 6;
8 127; 14
13 1 3 4 20 5; 15; 2
Total Result 200 200 400 0
REKAP RESPONDEN BERDASARKA
1. def-t rata-rata berdasarkan umur

Total
Total
Result;
Result;
200200
12; 68
12; 48
11;11;
35 30 Gender 1
7; 29 8; 24 9; 2410;10;
32 28
9; 22
14 8; 19 2
13;13;
1 3
REKAP RESPONDEN BERDASARKAN GENDER

Nama Sekolah - all -
Average - def-t Gender

Umur (tahun) 1 2 Total Result 8
5 7 8 7.666666667
6 6.25 4.666666667 5.3
7
7 6.2857142857 4.724137931 5.23255814
8 4.7894736842 5.75 5.325581395
9 4.8181818182 4.833333333 4.826086957 6
10 4.5 5.285714286 4.866666667
11 2.7142857143 2.1 2.430769231 5
12 3.1176470588 1.208333333 2.327586207
13 0 0.666666667 0.5
4
Total Result 3.965 3.67 3.8175
Keterangan Column Labels: 3

1 = Laki-laki
2 = Perempuan 2
0
5 6 7 8 9 1
Gender 1
2
1
d er
G en
7 8 9 10 11 12 13 Total Res ul t
def-t rata-rata berdasarkan umur
Average - DMF-T Gender

Umur (tahun) 1 2 Total Result
5 4 1 2
6 0.5 0.75 0.65
7 1.1428571429 0.689655172 0.837209302
8 0.8421052632 1.25 1.069767442
9 1.5454545455 1.666666667 1.608695652
10 2.0625 1.607142857 1.85
11 2.9714285714 2.533333333 2.769230769
12 3.3235294118 2.291666667 2.896551724
13 2 3 2.75
Total Result 2.36 1.705 2.0325
Keterangan Column Labels:

1 = Laki-laki
2 = Perempuan
5 6 7 8 9 10
DMF-T Rata-Rata Berdasarkan Umur
Gender 1
2
7 8 9 10 11 12 13 Tota l Resul t
Count - Kriteria OHI-S Kriteria OHI-S
Nama Sekolah BAIK BURUK SEDANG Total Result
SDN Sukamanah I 43 7 50 100
SDN Sukamanah II 34 10 56 100
SDN Sukamanah III 55 5 40 100
SDN Sukamanah IV 24 13 63 100 25000%
Total Result 156 35 209 400
20000%
15000%
10000%
5000%
0%
h
I II
a h
an na ah
m m
a an
ka ka ka
m
Su Su Su
DN N N
S SD SD
Kri teri a OHI-S BAIK
BURUK
SEDANG
SEDANG
BURUK
Kri teri a OHI-S BAIK
II III IV u lt
a h h h s
a a Re
an an an l
m m m ta
ka ka ka To
Su Su S u
N N N
SD SD SD Persentase Kriteria OHI-S Keseluruhan
Data
Nama Sekolah Count - Nama Siswa Sum - GT Sum - GS
SDN Sukamanah I 100 34 64
SDN Sukamanah II 100 33 137 137
SDN Sukamanah III 100 39 89
SDN Sukamanah IV 100 60 134
Total Result 400 166 424 100 100 100
Keterangan
count of nama siswa = jumlah anak
sum of GT = gigi tetap yang harus ditambal
64
sum of GS = gigi susu yang harus ditambal
39
34 33
Jumlah anak yang har

137 134
100 100 100 100

89
64 Data
60
Column C
39 Column D
34 33
Jumlah anak yang harus ditambal gigi susu dan gigi tetapnya
Data
Nama Sekolah Count - Nama Siswa Sum - GT2 Sum - GS2
SDN Sukamanah I 100 51 50
SDN Sukamanah II 100 79 102 Jumlah anak yang
SDN Sukamanah III 100 31 69
SDN Sukamanah IV 100 133 95
Total Result 400 294 316
100
Keterangan
count of nama siswa = jumlah anak
sum of GT2 = gigi tetap yang harus dicabut
sum of GS2 = gigi susu yang harus dicabut
51 50
I
ah h
ol a
S ek an
m
m
a ka
Na Su
N N
SD SD
Jumlah anak yang harus dicabut gigi susu dan
133
gigi tetapnya
100 100 102 100 100

95
79
69
Data
Col umn C
51 50 Col umn D
31
I II III
ah h IV
ol a a h h h
ek an an a na a na
m m
ka ka am ka
m
Su Su S uk Su
N N N
SD SD SD
N
SD
Umur (tahun) Sum - Keadaan Periodontal

5 6 Keadaan Periodontal Berd
6 34
7 70
8 79
9 82
10 99
11 105
12 181
13 6
Total Result 662
181
99 105
70 79 82
34
6 6
5 6 7 8 9 10 11 12 13
aan Periodontal Berdasarkan Umur
662
Sum - Keadaa n Peri odonta l
181
99 105
82
9 10 11 12 13 Total Res ul t
Umur (tahun) Sum - Patologi Mulut

5 0 Keadaan Patologi mulut Berdasa
6 0
7 0 1
8 0
0.9
9 0
10 0 0.8
11 0
12 0 0.7
13 0
Total Result 0 0.6
0.5
0.4
0.3
0.2
0.1
0
50 60 70 80 90 10
0 11
0 12
0 13
0 To
logi mulut Berdasarkan Umur
Sum - Patol ogi Mul ut
10
0 11
0 12
0 13
0 Total 0Res ul t
Umur (tahun) Count - Kel. Dentofacial

5 3
6 20 Kelainan Dentofacial Berdasarkan Umur
7 43 400
8 43
9 46 350
10 60
300
11 65
12 115 250
13 4
Total Result 399 200 Count - Kel . Dentofa
150
100
50
0
5 6 7 8 9 10 11 12 13 u lt
es
lR
ta
To
asarkan Umur
Count - Kel . Dentofaci al
u lt
es
Data
Nama Sekolah Average - GS3 Average - GT3 Average - GS4 Average - GT4
SDN Sukamanah I 0.0006113537 0.0285714286 1.68 1.58
SDN Sukamanah II 0.0011876485 0.0276243094 3.42 3.17
SDN Sukamanah III 0.0014728682 0.0529801325 2.99 1.43
SDN Sukamanah IV 0.002122449 0.0555555556 3.81 2.83
Total Result 0.0013485798 0.0411828565 2.975 2.2525
Keterangan
GS3 = PTI GS Persentase PTI da
GT3 = PTI GT
GS4 = RTI GS 400.00%
GT3 = RTI GT
350.00%
300.00%
250.00%
200.00%
150.00%
100.00%
50.00%
0.00%
l ah I
ko h
Se a II
a an h
m m na
Na ka a
Su am a
DN S uk am
S N uk
SD N
S
SD
Persentase PTI dan RTI
Data
Col umn C
Col umn D
Col umn E
I
h
a II
an h
III
na
a ah IV
am an a h
S uk m an
N ka m
SD Su ka
DN Su
S N
SD
Nama Sekolah Average - Prevalensi Karies
SDN Sukamanah I #VALUE! Prevalensi Karie
SDN Sukamanah II #VALUE!
SDN Sukamanah III #VALUE!
SDN Sukamanah IV #VALUE!
Total Result #VALUE!
Prevalensi Karies
SDN Suka manah I

SDN Suka manah II
SDN Suka manah III
SDN Suka manah IV
Tota l Res ul t
IDENTITAS PASIEN
Umur Pekerjaan
No Nama Sekolah Nama Siswa No.Resp Gender
(tahun) (Ortu/Wali)
1 SDN Sukamanah I Adang 1 1 12 Wiraswasta
2 SDN Sukamanah I Anisa Pratiwi 2 2 6 IRT
3 SDN Sukamanah I Asep Ramdan 3 1 7 POLRI
4 SDN Sukamanah I Ashri Azizah N 4 2 8 TNI
5 SDN Sukamanah I Asri Anggraeni 5 2 9 PNS
6 SDN Sukamanah I Chindy Maulidia 6 2 10 Buruh
7 SDN Sukamanah I Cintya Elsa Nurjanah 7 2 11 Wiraswasta
8 SDN Sukamanah I Danis Husni Mahesa 8 1 6 PNS
9 SDN Sukamanah I Desi Ratnasari 9 2 6 IRT
10 SDN Sukamanah I Dina Nurdiana Dewi 10 2 7 PNS
11 SDN Sukamanah I Romlah Asiah 01 2 10 Lain-lain
12 SDN Sukamanah I Deva Budi Permata 02 2 6 Lain-lain
13 SDN Sukamanah I Eristia Pradina 03 2 11 Lain-lain
14 SDN Sukamanah I Ega Mawarni 04 2 12 Lain-lain
15 SDN Sukamanah I Supri 05 1 7 Lain-lain
16 SDN Sukamanah I Janita Putri 06 2 11 Lain-lain
17 SDN Sukamanah I Rachmi Nurhidayanti 07 2 12 Lain-lain
18 SDN Sukamanah I Rifky Pratama 08 1 6 Lain-lain
19 SDN Sukamanah I Bima Agung Putra 09 2 12 Lain-lain
20 SDN Sukamanah I Della Imaisa 10 2 12 Lain-lain
21 SDN Sukamanah I Anggisa Aldefiona 01 2 7 TNI
22 SDN Sukamanah I Elmira Maulida 02 2 12 POLRI
23 SDN Sukamanah I Qiana Umaiza 03 2 11 Buruh
24 SDN Sukamanah I Rizky Farel 04 1 12 Swasta
25 SDN Sukamanah I Alvin Fadillah 05 1 10 Wiraswasta
26 SDN Sukamanah I Nevi Nuraeni 06 2 9 Buruh
27 SDN Sukamanah I Vera Virganita 07 2 11 Swasta
28 SDN Sukamanah I Khanza Azahra 08 2 8 Swasta
29 SDN Sukamanah I Reyhana Puspitasari 09 2 7 POLRI
30 SDN Sukamanah I Akbar Ferdiasyah 10 2 12 POLRI
31 SDN Sukamanah I PUTRI AFIFAH 0 2 9 PNS
32 SDN Sukamanah I RICKY TITO 02 1 12 TNI
33 SDN Sukamanah I SHANTY NOVIANTY 03 2 12 Wiraswasta
34 SDN Sukamanah I ANYA GERALDINE 04 2 12 Buruh
35 SDN Sukamanah I AINA SHERINA 05 2 7 Wiraswasta
36 SDN Sukamanah I ALEXANDER 06 1 12 Wiraswasta
37 SDN Sukamanah I MERRY RIANA 07 2 12 Swasta
38 SDN Sukamanah I JESSICA 08 2 9 Swasta
39 SDN Sukamanah I YENITA AGUSTINA 09 2 10 Swasta
40 SDN Sukamanah I YUSMAN MUHAMMAD10 1 10 Swasta
41 SDN Sukamanah I Asri 01 2 12 PNS
42 SDN Sukamanah I Balla 02 2 12 Lain-lain
43 SDN Sukamanah I Celsea 03 2 12 Swasta
44 SDN Sukamanah I Devy 04 2 12 Lain-lain
45 SDN Sukamanah I Endah 05 2 11 POLRI
46 SDN Sukamanah I Fitri 06 2 12 POLRI
47 SDN Sukamanah I Giselle 07 2 12 TNI
48 SDN Sukamanah I Hani 08 2 12 POLRI
49 SDN Sukamanah I Indah 09 2 11 Lain-lain
50 SDN Sukamanah I Jasmine 10 2 11 POLRI
51 SDN Sukamanah I Amelia Putri A 02 2 8 POLRI
52 SDN Sukamanah I Agung Nugraha A 10 1 7 PNS
53 SDN Sukamanah I Nagita Slavia N 12 2 10 POLRI
54 SDN Sukamanah I Nana N 11 1 11 Wiraswasta
55 SDN Sukamanah I Risa Cantika R 88 2 9 Swasta
56 SDN Sukamanah I Sri Anina S 12 2 12 TNI
57 SDN Sukamanah I Putra Wijaya P 01 1 8 Wiraswasta
58 SDN Sukamanah I M. Rizky Permana M 10 1 12 POLRI
59 SDN Sukamanah I Zaky Maulana Z 01 1 10 PNS
60 SDN Sukamanah I Joza Triyani J 12 2 7 TNI
61 SDN Sukamanah I Gina Oktarina 01 2 12 PNS
62 SDN Sukamanah I Doni 02 1 12 TNI
63 SDN Sukamanah I Nur alfreda 03 2 10 POLRI
64 SDN Sukamanah I Yogi saunan 04 1 11 Swasta
65 SDN Sukamanah I Elycia effensi 05 2 11 Wiraswasta
66 SDN Sukamanah I Aris nuari 06 1 11 IRT
67 SDN Sukamanah I Rizki meidina 07 2 11 IRT
68 SDN Sukamanah I Audisca gumilar 08 1 11 Buruh
69 SDN Sukamanah I Aprilianti 09 2 11 Lain-lain
70 SDN Sukamanah I Reno 10 1 11 POLRI
71 SDN Sukamanah I Jihan H A001 2 8 Lain-lain
72 SDN Sukamanah I Ilham R A002 2 10 Lain-lain
73 SDN Sukamanah I Meidiyani A003 1 7 Lain-lain
74 SDN Sukamanah I Dandi A004 1 12 Lain-lain
75 SDN Sukamanah I Reysita A005 2 13 Lain-lain
76 SDN Sukamanah I Ari M A008 1 8 Wiraswasta
77 SDN Sukamanah I Riza G A007 1 12 TNI
78 SDN Sukamanah I Ida N A008 2 6 PNS
79 SDN Sukamanah I Caca A009 2 10 PNS
80 SDN Sukamanah I Ferdiansyah A010 1 9 POLRI
81 SDN Sukamanah I Pongky P001 1 9 PNS
82 SDN Sukamanah I Ujang U002 1 10 TNI
83 SDN Sukamanah I Santi S003 2 9 Swasta
84 SDN Sukamanah I Cinta C004 2 7 Buruh
85 SDN Sukamanah I Gangan G005 1 10 PNS
86 SDN Sukamanah I Reza R006 1 8 PNS
87 SDN Sukamanah I Pujiastuti P007 2 12 PNS
88 SDN Sukamanah I Aday A008 1 11 Swasta
89 SDN Sukamanah I Zizan Z009 1 9 Buruh
90 SDN Sukamanah I Sisxa S010 2 12 Wiraswasta
91 SDN Sukamanah I Nabila Haura Autada 01 2 12 PNS
92 SDN Sukamanah I Sandi Iskandar 32 1 12 Swasta
93 SDN Sukamanah I Amelia Hendra 33 2 12 TNI
94 SDN Sukamanah I Yuliani Dwi 34 2 12 PNS
95 SDN Sukamanah I Dhea Ananda 35 2 12 PNS
96 SDN Sukamanah I Sari Astuti Dewi 36 2 12 TNI
97 SDN Sukamanah I Yuli Yulian 37 2 12 TNI
98 SDN Sukamanah I Farel Alif 38 1 12 Lain-lain
99 SDN Sukamanah I Risa Rismayani 39 2 12 Lain-lain
100 SDN Sukamanah I Wulan Permatasari 40 2 12 Lain-lain
101 SDN Sukamanah II Wawan Supriatna 01 1 6 Swasta
102 SDN Sukamanah II Ade Sukarsih 02 2 13 IRT
103 SDN Sukamanah II Lia Agustina 03 2 10 Swasta
104 SDN Sukamanah II Lisa Rosalina 04 2 8 Lain-lain
105 SDN Sukamanah II Ricco Maholtra 05 1 11 PNS
106 SDN Sukamanah II Eman Sulaeman 06 1 11 Lain-lain
107 SDN Sukamanah II Rukinah 07 2 8 IRT
108 SDN Sukamanah II Dwi Arianto 08 1 7 Lain-lain
109 SDN Sukamanah II LIZA NURTIKA 09 2 10 Lain-lain
110 SDN Sukamanah II FITRI 10 2 8 PNS
111 SDN Sukamanah II Diandra Putri D15 2 9 TNI
112 SDN Sukamanah II Nathasya Aljazira N12 2 7 PNS
113 SDN Sukamanah II Yonash Immanuel Y23 1 7 Swasta
114 SDN Sukamanah II Cikal Aji Sakti C15 1 7 POLRI
115 SDN Sukamanah II Vaiza Fairus V24 2 8 Wiraswasta
116 SDN Sukamanah II Reyhan Valdema R27 1 10 Wiraswasta
117 SDN Sukamanah II Devina Nur C D16 2 9 TNI
118 SDN Sukamanah II Alveo Ramadhan A13 1 10 Swasta
119 SDN Sukamanah II Viorel Lawiana V25 1 11 TNI
120 SDN Sukamanah II Andika Melody A14 1 12 PNS
121 SDN Sukamanah II Deva Nedia Sari 01 2 11 Lain-lain
122 SDN Sukamanah II Della Imaisa 02 2 11 Lain-lain
123 SDN Sukamanah II Andica Utama 03 1 11 Lain-lain
124 SDN Sukamanah II Fajar Ramadhan 04 1 11 Lain-lain
125 SDN Sukamanah II Intan Febriani 05 1 11 PNS
126 SDN Sukamanah II Desta Meliana 06 2 11 Lain-lain
127 SDN Sukamanah II Ani Rahmayani 06 2 11 Lain-lain
128 SDN Sukamanah II Agus Setia Boma 08 1 11 Lain-lain
129 SDN Sukamanah II Elsa Rahmatika 09 2 11 Lain-lain
130 SDN Sukamanah II Ega Mawarni 10 2 11 PNS
131 SDN Sukamanah II Devy Budi Pertiwi 01 2 12 Lain-lain
132 SDN Sukamanah II Putri Budi Winarti 02 2 12 Lain-lain
133 SDN Sukamanah II Atit Tajmiati 03 2 12 Swasta
134 SDN Sukamanah II Eristia Pradina 04 2 12 Lain-lain
135 SDN Sukamanah II Bambang 05 1 11 PNS
136 SDN Sukamanah II Iwan 06 1 12 Lain-lain
137 SDN Sukamanah II Amanda 07 2 12 IRT
138 SDN Sukamanah II Ridho 08 1 12 Lain-lain
139 SDN Sukamanah II Rifky 09 2 11 Lain-lain
140 SDN Sukamanah II Ariel 10 2 11 Lain-lain
141 SDN Sukamanah II Jessica J001 2 9 PNS
142 SDN Sukamanah II Abraham A005 1 10 PNS
143 SDN Sukamanah II Srikandi S011 2 9 TNI
144 SDN Sukamanah II Asep A008 1 12 Lain-lain
145 SDN Sukamanah II Ismail I005 1 8 Wiraswasta
146 SDN Sukamanah II Nurdian N006 2 6 POLRI
147 SDN Sukamanah II Rajby R007 1 12 PNS
148 SDN Sukamanah II Keisa K008 2 9 TNI
149 SDN Sukamanah II Raisa R009 1 9 IRT
150 SDN Sukamanah II Kholila K010 2 11 PNS
151 SDN Sukamanah II Reysita A F R005 2 12 Swasta
152 SDN Sukamanah II Neisya K N N001 2 8 PNS
153 SDN Sukamanah II Reynaldi A F R007 1 6 POLRI
154 SDN Sukamanah II Reysita A F A002 2 7 PNS
155 SDN Sukamanah II Yoga Ardiansyah Y009 1 10 POLRI
156 SDN Sukamanah II Ruhi Aurora R003 2 11 Swasta
157 SDN Sukamanah II Abhisek Sigh A005 1 9 Swasta
158 SDN Sukamanah II Ishita Iyer I002 2 7 PNS
159 SDN Sukamanah II Mihika M002 2 9 IRT
160 SDN Sukamanah II Aditya Bhala A007 1 9 TNI
161 SDN Sukamanah II Andhika Rachmadi A 01 1 8 POLRI
162 SDN Sukamanah II Mozes Rein M 02 1 9 Wiraswasta
163 SDN Sukamanah II Sherin Aprilia S 12 2 10 TNI
164 SDN Sukamanah II Ariesta Arfani A 02 2 12 Wiraswasta
165 SDN Sukamanah II Dinda Ayu D 19 2 6 Swasta
166 SDN Sukamanah II Fatimah Azzahra F 31 2 12 POLRI
167 SDN Sukamanah II Sofyan Kevin K 01 1 8 PNS
168 SDN Sukamanah II Rifqi Akaresyawa K 01 1 12 Swasta
169 SDN Sukamanah II Bogi Satrio B 01 1 10 PNS
170 SDN Sukamanah II Firman Ramadhan F 12 1 7 Wiraswasta
171 SDN Sukamanah II AKILA A001 2 10 PNS
172 SDN Sukamanah II ADI RAHMAT A002 2 7 PNS
173 SDN Sukamanah II ISYANA KUSUMAH A003 2 12 TNI
174 SDN Sukamanah II BILLY FUAD A004 1 9 Swasta
175 SDN Sukamanah II AYU NASYID A005 2 9 Wiraswasta
176 SDN Sukamanah II EDWIN SUPONO A006 1 12 PNS
177 SDN Sukamanah II LUTHFI AULIA A007 1 13 PNS
178 SDN Sukamanah II IKHSAN MUHAMMAD A008 1 11 Wiraswasta
179 SDN Sukamanah II ILYAS HASYIM A009 1 8 POLRI
180 SDN Sukamanah II ANGEL ELIZABETH A010 2 7 Swasta
181 SDN Sukamanah II Natasya Salsa. N N01 2 8 TNI
182 SDN Sukamanah II Anita Fujiawati A02 2 10 PNS
183 SDN Sukamanah II Yandi Purnama Y03 1 11 Wiraswasta
184 SDN Sukamanah II Cahya Gumilar C04 1 7 POLRI
185 SDN Sukamanah II Anti Purwanti A05 2 10 Buruh
186 SDN Sukamanah II Nia Komalasari N06 2 9 TNI
187 SDN Sukamanah II Andi Rustandi A07 1 8 PNS
188 SDN Sukamanah II Ilfa Nurrahmah. P I08 2 11 TNI
189 SDN Sukamanah II Asep Jaelani A09 1 9 Wiraswasta
190 SDN Sukamanah II Rizky Setiadi R10 1 10 PNS
191 SDN Sukamanah II Neng Susi N001 2 8 Wiraswasta
192 SDN Sukamanah II Iran Sutiawan I002 1 10 Wiraswasta
193 SDN Sukamanah II Cep Muhidin C003 1 11 Wiraswasta
194 SDN Sukamanah II Ratna Octaviana R004 2 7 PNS
195 SDN Sukamanah II Henny H005 2 6 PNS
196 SDN Sukamanah II Riki Muladi R006 1 8 PNS
197 SDN Sukamanah II Mardiana Keysha V.P M007 2 9 PNS
198 SDN Sukamanah II Tya Halimatul Sadiah T008 2 6 IRT
199 SDN Sukamanah II Yusuf Bahtiar Yoo9 1 10 PNS
200 SDN Sukamanah II Herni Damayanti H010 2 7 PNS
201 SDN Sukamanah III Nia Komalasari N.201 2 10 Swasta
202 SDN Sukamanah III Arini Putri A.355 2 7 PNS
203 SDN Sukamanah III Hanif Wijaya H.555 1 10 TNI
204 SDN Sukamanah III Anang Somantri A.300 1 11 POLRI
205 SDN Sukamanah III Fahrizal Zulfiqar F.165 1 12 PNS
206 SDN Sukamanah III Helmina Dwiyani H.228 2 8 Wiraswasta
207 SDN Sukamanah III Maelan Sri M.124 2 11 PNS
208 SDN Sukamanah III Tasya Febriana T.200 2 9 POLRI
209 SDN Sukamanah III Dino Andalisto D.176 1 11 Swasta
210 SDN Sukamanah III Muhammad Toyib M.205 1 12 POLRI
211 SDN Sukamanah III Dini Widiya 01 2 12 PNS
212 SDN Sukamanah III Sandi Ruswanda 02 1 12 TNI
213 SDN Sukamanah III Lastri Andini 03 2 11 Wiraswasta
214 SDN Sukamanah III Rani Febyani 04 2 12 Swasta
215 SDN Sukamanah III Rio Muhsyal 05 1 12 PNS
216 SDN Sukamanah III Ai Nuraini 06 2 12 TNI
217 SDN Sukamanah III Lisna Hidayat 07 2 12 TNI
218 SDN Sukamanah III Nida Hapiani 08 2 12 Lain-lain
219 SDN Sukamanah III Ayu Fitri 09 2 12 Lain-lain
220 SDN Sukamanah III Mila Rosa 10 2 12 POLRI
221 SDN Sukamanah III Erlangga 01 1 10 Wiraswasta
222 SDN Sukamanah III Novia Oktaviani 02 2 6 Swasta
223 SDN Sukamanah III Risal Salman 03 1 8 Swasta
224 SDN Sukamanah III Ulfah Fauziah 04 2 8 TNI
225 SDN Sukamanah III Tiya Utari 05 2 8 Swasta
226 SDN Sukamanah III Yudhistira 06 1 10 PNS
227 SDN Sukamanah III Rona Gusmawarni 07 2 6 Swasta
228 SDN Sukamanah III M. Hardiansyah 08 1 8 Swasta
229 SDN Sukamanah III Adi Muhammad 09 1 8 Swasta
230 SDN Sukamanah III Anastya Hana 10 2 9 Swasta
231 SDN Sukamanah III Ahmad 01 1 12 PNS
232 SDN Sukamanah III Bambang 02 1 12 Lain-lain
233 SDN Sukamanah III Cepi 03 1 12 Swasta
234 SDN Sukamanah III Deden 04 1 12 Lain-lain
235 SDN Sukamanah III Encep 05 1 11 POLRI
236 SDN Sukamanah III Farel 06 1 12 POLRI
237 SDN Sukamanah III Gunawan 07 1 12 TNI
238 SDN Sukamanah III Hadi 08 1 12 POLRI
239 SDN Sukamanah III Ibnu 09 1 11 Lain-lain
240 SDN Sukamanah III Jajang 10 1 11 POLRI
241 SDN Sukamanah III Fahmi Fachrezy F01 1 12 Swasta
242 SDN Sukamanah III Nafis Rizqullah N01 1 8 PNS
243 SDN Sukamanah III Kief Luthfi Abdul Rach K01 1 12 TNI
244 SDN Sukamanah III Rama Karisma Putra R01 1 10 POLRI
245 SDN Sukamanah III Iqbal Dicky Setiawan I01 1 10 PNS
246 SDN Sukamanah III Cahyadin C01 1 9 PNS
247 SDN Sukamanah III Nazibullah N01 1 11 PNS
248 SDN Sukamanah III Nazibulloh Bachir N01 1 11 PNS
249 SDN Sukamanah III Wisnu Al Kautsar W01 1 12 PNS
250 SDN Sukamanah III Timmy Daifa T01 1 11 Wiraswasta
251 SDN Sukamanah III Silvia A01 2 8 Lain-lain
252 SDN Sukamanah III Anggita A02 2 10 Lain-lain
253 SDN Sukamanah III Andrea A003 1 7 Lain-lain
254 SDN Sukamanah III Dika A004 1 12 Lain-lain
255 SDN Sukamanah III Meta A005 2 13 Lain-lain
256 SDN Sukamanah III Santi A006 2 7 Lain-lain
257 SDN Sukamanah III Meitha A007 2 11 Lain-lain
258 SDN Sukamanah III Deni A008 1 6 Lain-lain
259 SDN Sukamanah III Gibran A009 1 10 Lain-lain
260 SDN Sukamanah III Leo A010 1 9 Lain-lain
261 SDN Sukamanah III DAYANG MUTIA 001 2 6 PNS
262 SDN Sukamanah III IRFAN 002 1 10 Swasta
263 SDN Sukamanah III SUCI NURKIFTIA 003 2 10 POLRI
264 SDN Sukamanah III FADLI 004 1 7 Lain-lain
265 SDN Sukamanah III ADNAN 005 1 5 TNI
266 SDN Sukamanah III IMAM NUZULUDIN 006 1 8 PNS
267 SDN Sukamanah III FAUZIA NURUL 007 2 9 Wiraswasta
268 SDN Sukamanah III DINDA RAMADHANIA 008 2 10 PNS
269 SDN Sukamanah III MUHAMAD KAISYA 009 1 9 PNS
270 SDN Sukamanah III MIRA HAERANI 010 2 7 PNS
271 SDN Sukamanah III adinda nur f a412 2 8 PNS
272 SDN Sukamanah III riki andriana r211 1 7 PNS
273 SDN Sukamanah III Doni Ahmad d212 1 10 PNS
274 SDN Sukamanah III tsani ariani a412 2 7 PNS
275 SDN Sukamanah III kurnia A a412 2 7 PNS
276 SDN Sukamanah III afriansyah a412 2 7 PNS
277 SDN Sukamanah III ahmad meinanda a412 2 7 PNS
278 SDN Sukamanah III nurmala S a412 2 7 PNS
279 SDN Sukamanah III koswara a412 2 7 PNS
280 SDN Sukamanah III shelvia M a412 2 7 PNS
281 SDN Sukamanah III Nadhaafa Nur Walida 1 2 8 PNS
282 SDN Sukamanah III Atla Dhamar Sabat 2 1 9 PNS
283 SDN Sukamanah III Ghalya Setiadimas Putr3 2 9 PNS
284 SDN Sukamanah III Adzkya fadla Naima 4 2 5 PNS
285 SDN Sukamanah III Zasqia Fahira 5 2 5 PNS
286 SDN Sukamanah III Wanda Alya 6 2 6 PNS
287 SDN Sukamanah III Ghirah Jihad 7 1 7 PNS
288 SDN Sukamanah III Azhar Azali 8 1 10 PNS
289 SDN Sukamanah III Sayid Nasrulhaq 9 1 11 PNS
290 SDN Sukamanah III Nidaa Aulia U 10 2 7 PNS
291 SDN Sukamanah III Umery Lathifa 01 2 10 PNS
292 SDN Sukamanah III Audhy Ramadhani 02 1 11 TNI
293 SDN Sukamanah III Firyal Fakhri Ramadha 03 1 10 POLRI
294 SDN Sukamanah III Nicken Shaquilla 04 2 10 Swasta
295 SDN Sukamanah III Dimas Kalimasyada 05 1 9 Lain-lain
296 SDN Sukamanah III Inez Al-Mughny 06 2 9 Swasta
297 SDN Sukamanah III Salma Hanifatul Kamila07 2 10 POLRI
298 SDN Sukamanah III Fauzi Rabbani 08 1 11 Lain-lain
299 SDN Sukamanah III Aliza Kusuma 09 1 9 PNS
300 SDN Sukamanah III Bakti Islam Santoso 10 1 10 POLRI
301 SDN Sukamanah IV Annisa A 01 2 10 PNS
302 SDN Sukamanah IV Anggara Putra 02 1 11 TNI
303 SDN Sukamanah IV Nursoffa jovi 03 1 10 POLRI
304 SDN Sukamanah IV Bagas Ruari 04 2 10 Swasta
305 SDN Sukamanah IV elfrida swandi 05 1 9 Lain-lain
306 SDN Sukamanah IV Aldi bagas 06 2 9 Swasta
307 SDN Sukamanah IV reki aditya 07 2 10 POLRI
308 SDN Sukamanah IV Ayu dwi audisa 08 1 11 Lain-lain
309 SDN Sukamanah IV astri miastari 09 1 9 PNS
310 SDN Sukamanah IV neki aji nur 10 1 10 POLRI
311 SDN Sukamanah IV Astri Yulianda A001 2 11 Buruh
312 SDN Sukamanah IV Ayu Gita Rahayu A002 2 8 Lain-lain
313 SDN Sukamanah IV Asep Hadiansyah A003 1 6 Buruh
314 SDN Sukamanah IV Astri Yulianda D001 2 7 Buruh
315 SDN Sukamanah IV Evan Erydian Deni E001 1 10 TNI
316 SDN Sukamanah IV Fathia Nurul A F001 2 11 Swasta
317 SDN Sukamanah IV Luthfi Fahan L001 1 9 Swasta
318 SDN Sukamanah IV Mutiara Maghfira P M002 2 7 PNS
319 SDN Sukamanah IV Nisa Diwani N001 2 9 IRT
320 SDN Sukamanah IV Rizki Fauzi M H R001 1 9 Buruh
321 SDN Sukamanah IV wayan semprina 01 1 6 PNS
322 SDN Sukamanah IV arya wiguna santoso 02 1 12 IRT
323 SDN Sukamanah IV lina bayau putri 03 2 12 TNI
324 SDN Sukamanah IV deva mahendra koenel 04 1 8 PNS
325 SDN Sukamanah IV rina multazam 05 2 11 TNI
326 SDN Sukamanah IV erau mahendra 06 1 11 PNS
327 SDN Sukamanah IV rustandi 07 1 8 Swasta
328 SDN Sukamanah IV desi dwi astut 08 2 7 POLRI
329 SDN Sukamanah IV lulu linggar puteri 09 2 10 TNI
330 SDN Sukamanah IV yanna purwanto 10 1 8 PNS
331 SDN Sukamanah IV CICI 001 2 7 Wiraswasta
332 SDN Sukamanah IV zaky 002 1 8 PNS
333 SDN Sukamanah IV ratna 003 2 8 PNS
334 SDN Sukamanah IV agus ='RESP (41 6 PNS
335 SDN Sukamanah IV indah 005 2 8 TNI
336 SDN Sukamanah IV juned 006 1 9 TNI
337 SDN Sukamanah IV SARI 007 2 8 POLRI
338 SDN Sukamanah IV lucky 008 1 9 Swasta
339 SDN Sukamanah IV mirna 009 2 9 Wiraswasta
340 SDN Sukamanah IV bagus 010 1 7 PNS
341 SDN Sukamanah IV rido 07 1 10 Lain-lain
342 SDN Sukamanah IV divana 10 2 12 Lain-lain
343 SDN Sukamanah IV ADISTY 07 2 11 PNS
344 SDN Sukamanah IV Dillan adea 06 1 12 PNS
345 SDN Sukamanah IV ilham 08 1 12 Lain-lain
346 SDN Sukamanah IV indar 12 2 12 guru
347 SDN Sukamanah IV lliana 09 2 10 PNS
348 SDN Sukamanah IV bryan 10 1 12 TNI
349 SDN Sukamanah IV khusunu qurbaa 09 2 10 PNS
350 SDN Sukamanah IV Aleaa 08 1 10 PNS
351 SDN Sukamanah IV Irfan N.201 2 10 Swasta
352 SDN Sukamanah IV gunawan A.355 2 7 PNS
353 SDN Sukamanah IV ucul H.555 1 10 TNI
354 SDN Sukamanah IV abbel A.300 1 11 POLRI
355 SDN Sukamanah IV sandi F.165 1 12 PNS
356 SDN Sukamanah IV osol H.228 2 8 Wiraswasta
357 SDN Sukamanah IV bian M.124 2 11 PNS
358 SDN Sukamanah IV ciput T.200 2 9 POLRI
359 SDN Sukamanah IV tresar D.176 1 11 Swasta
360 SDN Sukamanah IV jungkuk M.205 1 12 POLRI
361 SDN Sukamanah IV Derryawan Hamidi 01 1 9 PNS
362 SDN Sukamanah IV Thomson Aji 02 1 10 TNI
363 SDN Sukamanah IV Welly Gita Pratiwi 03 2 10 TNI
364 SDN Sukamanah IV Ana Dina Sakinah 04 2 8 Wiraswasta
365 SDN Sukamanah IV Reza Ardhiansyah 05 1 11 Lain-lain
366 SDN Sukamanah IV Adhi Putra Pangestu 06 1 11 Lain-lain
367 SDN Sukamanah IV Dea Amalia Putri Pratti 07 2 8 IRT
368 SDN Sukamanah IV Dewi Puji Astuti 08 2 12 Lain-lain
369 SDN Sukamanah IV Deni Surya 09 1 10 Swasta
370 SDN Sukamanah IV Rezkyansah 10 1 8 PNS
371 SDN Sukamanah IV Asep 01 1 12 Swasta
372 SDN Sukamanah IV dadan 02 1 12 PNS
373 SDN Sukamanah IV agustia 04 1 12 Wiraswasta
374 SDN Sukamanah IV agung 03 1 12 POLRI
375 SDN Sukamanah IV maman 02 1 12 Swasta
376 SDN Sukamanah IV ucup 06 1 12 Wiraswasta
377 SDN Sukamanah IV mu'min 03 1 12 Wiraswasta
378 SDN Sukamanah IV aris 03 1 12 Swasta
379 SDN Sukamanah IV daud 02 1 12 TNI
380 SDN Sukamanah IV agus 03 1 12 PNS
381 SDN Sukamanah IV agus 03 1 12 PNS
382 SDN Sukamanah IV maman 05 1 12 Swasta
383 SDN Sukamanah IV edrik 03 1 12 Swasta
384 SDN Sukamanah IV edrik 04 1 12 Swasta
385 SDN Sukamanah IV yosep 07 1 12 Swasta
386 SDN Sukamanah IV gusnaldi 07 1 12 Swasta
387 SDN Sukamanah IV cahya 08 1 12 Swasta
388 SDN Sukamanah IV ucup 02 1 12 Swasta
389 SDN Sukamanah IV Cepi 03 1 12 Swasta
390 SDN Sukamanah IV agus 04 1 12 Swasta
391 SDN Sukamanah IV erik 05 1 12 Swasta
392 SDN Sukamanah IV agus 06 1 12 Swasta
393 SDN Sukamanah IV gustavo 10 1 12 Swasta
394 SDN Sukamanah IV kaka 09 1 12 Swasta
395 SDN Sukamanah IV ICANG 28 1 12 Swasta
396 SDN Sukamanah IV mnama 08 1 12 Swasta
397 SDN Sukamanah IV reki aditya 07 1 12 Swasta
398 SDN Sukamanah IV aldi 06 1 12 Swasta
399 SDN Sukamanah IV Nursoffa jovi 03 1 12 Swasta
400 SDN Sukamanah IV putra 02 1 12 Swasta
STATUS KESEHATAN GIGI
Alamat RT RW Kel d e f def-t D M F

Kp. Babakan 01 12 Majasetra 3 1 0 4 2 0 0
Kp. Manirancan 01 12 Majasetra 4 0 0 4 0 0 0
Kp. Sukamanah 04 06 Majasetra 4 0 0 4 0 0 0
Jln. Sukajadi No. 40 04 01 Bandung 2 0 0 2 0 0 0
Jln. Kartini II No. 21 01 11 Bandung 0 0 0 0 0 0 0
Jln. Raya No. 5 03 11 Tanjungsari 0 0 0 0 5 0 0
Jln. Pondok Indah No. 3 01 01 Sukajadi 0 0 1 1 2 1 0
Jln. Sarijadi No. 10 01 01 Sarijadi 1 0 0 1 1 0 0
Jln. Raya Antapani no.235 15 01 Antapani 0 0 0 0 5 1 0
Jln. Sripemandang No. 8 04 06 Baleendah 0 0 0 0 2 0 0
Jln. Suramadu No. 87 09 08 Bandung 0 0 0 0 0 0 0
Jln. Lalangbuana No. 53 02 01 Bandung 0 0 0 0 2 3 0
Jln. Cibarengkok No. 56 07 01 Bandung 0 0 0 0 4 1 0
Jl. Tanjakan mama utara no02 03 Padalarang 2 0 0 2 0 0 0
Jl. Raya Padalarang no 87 02 05 Padalarang 0 4 0 4 1 0 0
Jl. Puri Fajar no 67 05 10 Cimahi 8 1 0 9 0 0 0
Jl. Cihampelas no 77 03 10 Sukajadi 0 1 0 1 1 0 0
Jl. Cibarengkok no 89 03 12 Sukabungah 1 2 0 3 0 0 0
Jl. Ciburial no 7 03 14 Ngamprah 4 0 1 5 0 0 0
Jl. Talang Atas no 98 04 02 Ngamprah 2 2 0 4 1 0 0
Jl. Raya Cipatat no 88 04 04 Cipatat 2 2 0 7 0 0 0
Jl. Raya Ciburuy no 98 05 02 Ciburuy 3 0 0 3 0 0 0
Gg. Asri 1 no 67 06 02 Sukabungah 1 1 0 2 0 0 0
Jl. Siliwangi No. 10 01 01 Baleendah 4 7 0 11 4 0 0
Kp. Jawa No. 03 01 02 dayeuhkolot 0 0 0 0 3 0 0
Kp. CIGADO No. 11 11 07 BALEENDAH2 0 1 3 2 0 0
Kp. CIGADO No. 11 11 07 BALEENDAH0 0 0 0 4 0 0
GIRI HARJA 03 11 08 BALEENDAH0 0 0 0 7 0 0
Jl. Sukajadi 01 01 01 Sukajadi 1 0 0 1 2 0 0
Jl. Tamansari no. 43 Bandu01 04 Taman Sari 5 0 0 5 2 0 0
Gg. Utama NO. 392 Sukaja02 03 Pasteur 6 0 0 6 2 0 0
Jl. Taman Cinta no. 100 T 03 04 Cibodas 2 2 1 5 2 1 0
Jl. Kesehatan blok A3 Ecy 06 05 Sukajadi 4 0 0 4 3 0 0
Jl. Pasir Layung no 108 Ba 01 05 Padasuka 3 1 0 4 2 1 0
Grand. City View blok A 13 03 05 Padasuka 0 0 0 0 4 0 0
Komp. Asri blok G6 Sukaga04 01 Sederhana 2 1 1 4 0 1 0
JL. Suka galih no 13 Suka 03 04 Sederhana 1 0 0 1 1 1 0
JL. Caringin no 88 Pangheg02 07 Panghegar 2 0 0 2 2 0 0
Jl. Cisaranten n0 99 Bandu02 04 Ujung Berung3 0 0 3 2 0 0
Sukajadi bandung 02 01 sukajadi 1 0 0 1 2 0 0
Sukajadi bandung 03 02 Sukajadi 0 0 0 0 2 0 0
Sarijadi bandung 05 03 Sarijadi ban 3 0 0 3 0 0 0
Kurnia jaya manggar 09 02 manggar 1 0 0 1 1 0 0
padang raya sukawarna 10 08 Sukawarna 3 0 0 3 1 0 0
Sarijadi bandung 04 10 sarijadi 1 0 0 1 2 0 0
jalan sudirman no 4 02 01 gajah mada 1 0 0 1 1 0 0
jalan sarijadi bandung 09 06 sarijadi 1 0 0 1 1 0 0
Jl. Eyckman no 40 08 03 Sukajadi 3 0 0 3 0 0 0
Jl. Muwardi no 1 16 20 Sukajadi 3 1 0 4 2 0 0
Jl. Kesehatan No 2 14 03 Sukajadi 3 0 1 4 0 0 1
Jl. Solo no 1 05 01 Sukajadi 2 1 0 3 1 0 1
Jl. Merak no 2 16 18 Mekarwangi 0 0 0 0 3 0 0
jl.Eyckman no 3 01 02 sukajadi 1 0 0 1 1 0 0
Sukajadi 01 01 sukajadi 0 0 0 0 1 0 0
Jl. Eyckman No 5 01 01 Sukajadi 2 0 0 2 0 0 0
Sukajadi 01 01 Sukajadi 1 0 2 3 0 0 0
Sukajadi 02 01 Sukajadi 2 0 1 3 0 0 0
Jl.Sudirman NO.40 Bandun03 11 Sukabungah 1 1 0 2 1 0 0
Kp.Sukamanah 11 04 Majakerta 2 1 0 3 3 1 0
Margaraya 05 12 Sukatani 4 0 0 4 3 0 0
Kp.Namicalung 06 01 Panyadap 3 2 0 5 0 0 0
Majakerta 01 10 Majasetra 3 1 0 4 0 1 0
Kp.Bojong 05 15 Bojong 3 0 1 4 1 0 0
Majasetra 06 18 Majasetra 3 0 0 3 1 0 0
Cicalengka No.02 02 01 Padasuka 1 2 0 3 1 0 1
Kp.Panggilingan 06 13 Ibun 2 1 0 3 1 0 0
Kp.Namicalung 03 11 Bojong 2 1 0 3 0 0 1
Jln. Pagarsih No. 20 04 01 Pagarsih 0 0 0 0 0 0 0
Jln. Sukajadi No.22 02 05 Sukajadi 0 0 0 0 1 0 0
Jln. Cianjur No.24 05 03 Ahmad Yani 2 0 1 3 2 0 0
Jln. Cikutra No. 41 09 01 Cikutra Lama0 0 0 0 1 0 0
Jln. Mekar Hegar 1 No.15 05 03 Cijerah 0 0 0 0 1 0 0
Jln. Bukit Resik 1 No.05 02 01 Ciumbuleuit 0 0 0 0 4 0 0
Jln. IR. H. Juanda NO.56 10 08 Dago 0 0 0 0 4 0 0
Jln. Kopo No.56 07 10 Kopo 0 3 0 3 3 0 0
Jln. Sari Asih No.10 01 02 Sarijadi 1 3 1 5 3 0 0
Jln. Sukagalih No.15 01 06 Sukajadi 0 0 0 0 0 0 0
SP.1 Tahap 1 Tana Lia 07 01 Tanah Merah8 0 0 8 0 0 0
Jalan Dermaga 01 01 Tanah Merah6 0 1 7 3 0 0
Jalan Anggur langgar Al-Aa01 01 tanah merah 2 0 1 3 5 0 1
Pangkalan 1 04 06 Tanah Marah6 0 1 7 3 0 1
Jalan Setia 02 05 Tanah Merah7 0 5 12 4 0 0
JL. DERMAGA 1 NO. 24 01 01 TANAH MER1 0 0 1 3 0 1
JALAN JATI NO.123 07 01 TANAH MER4 0 3 7 0 0 0
Jl. Soma No.41 Bandung 04 03 Kiaracondon 5 1 0 6 3 0 0
Jl. Ahmad Yani No.23 Band02 03 Babakan Sur12 0 1 13 0 0 0
Jl. Soma No.4B Bandung 03 02 Kiaracondon 5 0 0 5 0 0 0
Jl. Lengkong Barat NO.12 04 04 Lengkong 9 0 3 12 0 0 0
Jl. Purwakarta Timur No.2A01 06 Antapani 10 2 1 13 4 0 0
Jl. Cimenyan No. 23 03 04 Cimenyan 8 0 0 8 3 0 0
Jl. Gatot Soebroto No.14 05 02 Maleer 9 0 2 11 4 0 0
Jl. Senam VII No. 8 10 11 Antapani 6 1 0 7 5 0 0
JL. Laswi No.43 04 03 Cikudapateu 5 0 1 6 11 0 0
Jl. Pacuan Kuda No.12 05 12 Antapani 3 1 0 4 12 0 0
Bojong Soang 01 03 Cianjur 1 0 0 1 2 0 0
Tanjung Raya 03 04 Sukau 1 0 0 1 3 0 0
Kembahang 07 01 Balik Bukit 1 0 0 1 2 0 0
Tanjung Kemala 03 04 Sukau 2 0 0 2 6 0 0
Gg.Eme no.5 02 03 Sukabungah 1 0 0 1 1 0 0
Tanjung Raya 02 05 Tanah Merah1 0 0 2 6 0 0
Tanjung Raya 07 06 Cianjur 1 0 1 2 2 0 0
Tanjung Raya 10 11 Cianjur 1 0 0 1 2 0 0
Jln. Raya Tanjungsari No.2 ='RE04 Tanjungsari 1 0 0 1 2 0 0
Jln. Raya Tanjungsari No.2 02 04 Tanjungsari 1 0 0 1 2 0 0
Jln. Raya Tanjungsari No.2 02 04 Tanjungsari 2 0 0 2 1 0 0
Jalan sukajadi gang eme 01 01 Sukajadi 1 0 0 1 2 0 0
Jalan sarijadi no.22 01 01 sarujadi 1 0 0 1 2 0 0
Jl. Raya Antapani no.24 10 02 Antapani 1 0 0 1 2 0 0
Sungai Liat 04 06 Sungai Liat 1 0 0 1 2 0 0
Jalan Ibrahim No 34 Bandu01 01 Sukabungah 0 1 0 1 1 0 0
Jalan Adjie Mubarok No 12 04 02 Sukahati 3 0 1 4 3 0 0
Margajaya Bandung 08 06 Sukarajin 3 0 0 3 1 0 0
Sukamalas 10 14 Haurkuning 1 1 0 2 1 0 0
Sukamakan 05 10 Cijambu 3 5 0 8 0 0 0
Karasak 05 15 Rawabinong 5 0 1 6 0 0 0
Tanjungsari 01 01 Situ 3 0 0 3 1 0 0
Cipayung 08 09 Bojong Nang2 0 0 2 0 0 0
Depok 09 10 Lanjung 4 0 0 4 1 0 0
Gudang 11 12 Kenanga 0 0 0 0 4 0 0
Jalan Cinunuk no 107 12 02 Cileunyi 3 1 0 4 2 0 0
Jalan Cileunyi 05 06 Cinunuk 4 0 0 4 0 0 0
Jl. Marga asih 06 03 Sukabungah 7 0 0 7 0 0 0
Jl. Cileunyi Raya 02 01 Cileunyi 4 0 0 4 1 0 0
Jl. Manisi 08 01 Ujungberung 1 0 0 1 3 0 0
Jl. Jambina 10 04 Bandung 0 0 0 0 5 0 0
Jl. Peta 06 04 Bandung 2 0 0 2 2 0 0
Jl. Rumah Sakit 03 07 Ujung Berung3 0 0 3 1 0 0
Jl. Caringin 08 01 Cibiru 1 0 0 1 2 0 0
Jl. India 12 06 Sukamiskin 2 0 0 2 2 0 0
Komp. Citra no. 17A 05 15 Antapani Kidu3 0 1 4 0 0 0
Jl. Kadipaten 11 no. 265 04 14 Sulaksana 7 2 0 9 1 0 0
Jl. Cigadung no. 167 Band 03 04 Rancabolang2 2 1 5 2 1 0
Jl. Gumuruh VII no. 19 Ba 06 05 Sukamaju 4 1 0 5 4 0 0
Jl. Margahayu Raya blok. 04 09 Rancabolang11 1 0 12 0 0 0
Jl. Kemangi no. 154C Band18 10 Padasuka 0 0 0 0 5 0 0
Komp. Setiabudhi no. 1A B 07 09 Setiabudhi 5 1 1 7 0 0 0
JL. Gurame no. 15 Bandun 03 04 Buahbatu 4 1 0 5 3 1 0
JL. Kawaluyaan no 29 Ban 02 07 Cidurian 4 0 0 4 0 0 0
Jl. Semarang no. 21 Bandu02 04 Antapani 6 1 0 7 2 0 0
JL. ANGGREK N0.2 02 06 SUKAJADI 1 0 0 1 0 0 0
JL. KENCANA NO.18 05 08 CIBUBUR 1 0 0 1 0 0 0
JL. KENCANA NO.22 08 08 CIBUBUR 0 0 0 0 1 0 0
JL. CITARUM NO.25A 09 12 CIBEUNYING1 0 1 2 0 0 0
JL. BANJARAN NO 12 12 01 BALEENDAH1 0 0 1 0 0 0
JL. PADASUKA NO 25 08 04 CIBEUNYING0 0 0 0 0 0 0
JL. PADASUKA NO 15 10 04 CIBEUNYING0 0 0 0 2 0 0
JL. CIMUNCANG NO.085 14 05 CIBEUNYING2 0 1 3 2 0 0
JL. JATINANGOR NO. 32 09 04 JATINANGO 4 0 0 4 0 0 0
JL. SUNDA NO. 09 12 10 CIDURIAN 5 0 1 6 0 0 0
Jln. Terusan Perintis No. 1 05 03 Cijerokaso 7 1 0 8 0 0 0
Jln. Babakan Loa No.04 06 02 Gunung Batu4 1 1 6 0 0 0
Jln. Soekarno Hatta No.04 18 04 Cibatu 4 1 0 5 0 0 0
jln. Sukajadi No.20- Bandu 12 01 Sukajadi 7 0 4 11 0 0 0
Jln. Jendral Ahmad Yani N 04 07 Cicadas 6 0 1 7 0 0 0
Jln. Utama No.28 Sukajadi 13 05 Sukajadi 5 1 2 8 0 0 0
Jln. Cijerokaso No.14-Ban 08 05 Sarijadi 5 2 2 9 0 0 0
Jln. Jendral Sudirmah No. 02 06 Cimahi 4 0 1 5 0 0 0
Jln. Sukajadi N0.12-Bandu 06 05 Sukajadi 5 0 1 6 0 0 0
Jln. Babakan Loa No. 30-B 13 09 Gunung Batu4 2 3 9 0 0 0
Jln. Terusan Perintis No.50 13 03 sarijadi 6 0 0 6 0 0 0
Jln. Sarijadi No 10 06 02 Sarijadi 4 0 1 5 0 0 0
kp. Gelarmulya Desa. Sukam 13 04 Cianjur 0 0 1 1 1 0 0
jln. Sukajadi No. 6- Bandun12 01 Sukajadi 7 0 4 11 0 0 0
Jln. Jendral Ahmad Yani N 04 07 Cicadas 5 0 1 6 0 0 0
Jln. Cibolang Parigi Cianjur02 04 Parigi 4 1 0 5 0 0 0
Jln. Sukamulya Desa. Sukam 03 05 Leles 6 0 0 6 0 0 0
Gg. Utama No. 2 Sukajadi 01 01 Sukajadi 5 0 0 5 0 0 0
Cibolang Padangsari Leles 04 03 Padang Sari 4 0 0 4 0 0 0
Cibogo Karawang 07 06 Teluk Jambe 5 0 0 5 0 0 0
Sukajadi 05 02 Pasteur 3 3 2 8 1 0 0
Sukagalih 08 02 Pasteur 7 0 2 9 2 0 0
Jl.Bojong Kenyot 06 01 Bojong Kone 2 0 2 4 2 0 0
Jl. Terusan Perintis 03 01 Sarijadi 3 0 2 5 1 0 0
Cibogo 05 02 Margamulya 3 0 1 4 1 0 0
Jl.Jendral Sudirman 13 08 Palawati 4 0 3 7 0 0 0
Jl.Cikeris 07 04 Bojong Sawit3 0 0 3 2 0 1
Jl. Sawit 10 03 Darangdan 3 0 3 6 1 0 0
Jl.Tunggakjati 06 03 Tanjung Pura3 0 1 4 1 0 0
Gang Sawo 17 05 Klari 2 0 0 2 3 0 1
Jln. Waluran No. 15 02 01 Waluran 0 0 0 0 0 0 0
jalan dermaga 06 0 Tanah Merah1 0 0 1 1 0 0
Jalan Anggur langgar Al-Aa05 0 Tanah Merah1 0 0 1 1 0 0
pangkalan 1 10 0 Tanah Merah0 3 0 3 2 0 0
jalan setia 04 0 Tanah Merah1 2 0 2 3 0 0
jalan dermaga 1 no. 24 02 0 Tanah Merah1 3 1 5 3 0 0
jalan jati no 123 09 6 Tanah Merah0 0 0 0 0 0 0
Pasanggrahan indah blok 204 14 Pasanggraha3 0 0 3 2 0 0
Tubagus Ismail no.3 B Dag 10 02 Dago 3 0 0 3 1 0 0
Cibiru hilir no.87 bandung 10 02 Cileunyi 3 0 0 3 0 0 0
Cilengkrang 2 no.30 01 05 Cisurupan 4 0 0 4 0 0 0
Jl. AH Nasution no.54 01 08 Ujungberung 3 0 0 3 0 0 0
Jl,ciporeat no.28, Ujungber 07 18 Pasirjati 3 0 0 3 2 0 0
Jl. Gegerkalong no.40 16 07 Lembang 3 0 0 3 1 0 0
Taman Kopo Indah 3 no.15 14 01 Kopo 2 0 0 2 0 0 0
Jl. Alun Alun Utara no,90 13 05 Cigending 3 0 0 3 0 0 0
Panghegar permai 12 no.3 05 08 Gede Bage 3 0 0 3 0 0 0
Komplek Permata Biru Blok04 15 Cinunuk Cibi 0 0 0 0 4 0 0
Manglayang Regency 1A no05 08 Cinunuk Cibi 2 0 0 2 1 0 0
Jl. Mawar No.5 08 03 Sukajadi 3 0 0 3 0 0 0
Jl. Anggur No.17 16 20 Sukajadi 3 1 0 4 2 0 0
Jl. Anggrek No.40 14 03 Sukajadi 3 0 1 4 0 0 1
Jl. Sukajadi No.39 05 01 Sukajadi 2 1 0 3 1 0 1
Jl. Mekarjaya No. 34 16 18 Mekarwangi 0 2 0 2 2 0 2
Jl. Mekarjaya No.56 34 30 Mekarwangi 6 0 1 7 0 0 0
Jl. Sukasana No.14 12 10 Sukasini 5 0 0 5 0 0 0
Jl. Sukasuka No.30 30 31 Sukasuka 4 0 0 4 0 0 1
jl. setiabudi no 7 02 01 wangunsari 4 1 1 6 2 0 0
BUAH BATU NO. 7 02 01 SUKASARI 2 2 0 6 2 0 0
JL. MAWAR NO 6 08 08 CIBINONG 1 0 0 1 1 0 0
JL.SUKAMULYA NO 8 16 05 PONDOK BI 3 2 0 5 0 0 0
JL. CIPICUNG NO 9 05 02 CIOMAS 7 0 0 7 4 0 0
JL. KOTA BATU NO 9 10 07 CIBEREUM 4 0 1 5 0 0 0
JL. RAMBUTAN NO. 10 08 07 CICAHEUM 1 0 0 1 2 0 0
JL. TAMAN SARI NO 13 11 01 CIAPUS 0 0 0 0 2 0 0
SUKAWANA 01 09 KARYAWANG6 0 0 6 3 0 0
SERANG 07 11 CIJAMBE 5 0 0 5 0 0 0
jl. Kartini no 32 kabupate 04 02 cipamempek 2 0 1 3 0 0 0
Ciparay ='RE12 Ciparay 8 0 1 9 0 0 0
Perum Tanjung Indah Blok 01 02 Tanjung Kam8 1 0 9 2 0 0
Perum Bumi Asri Blok K.02 02 0 Tanjung Pera0 1 0 1 8 0 0
Perum Bumi Cempaka Asri 03 0 Sucinaraja 9 0 1 10 1 0 0
Perumahan Al-Azhar Blok C04 0 Tanah Abang7 0 3 10 2 0 0
Perumahan Cibiru Blok K.005 0 Cibiru Utara 6 0 2 8 1 0 0
Intan Balarea Blok C.10 No06 0 Simpang Lim7 0 2 9 0 0 0
Jl.Terusan Pembanguna No07 0 Cimanuk 8 3 4 15 1 0 0
Jl.Patriot No.07 03 0 Pasanggiri 9 0 5 11 2 0 0
Perum Jati Indah Blok.K10 02 0 Tarogong Kal9 0 1 10 1 0 0
Jl. Bank No.17 01 9 Pataruman 5 0 4 9 3 0 0
kp.bobojong cidaun 01 02 cimaragang 8 1 0 9 2 0 0
kp haur wangi 02 0 agrabinta 0 1 0 1 8 0 0
bojong terong 03 0 suryakencan 9 0 1 10 1 0 0
perum gading asri 04 0 kertajadi 7 0 3 10 2 0 0
Perumahan Cibiru Blok K.005 0 pelabuhan ra6 0 2 8 1 0 0
cimahi bandung 06 0 simpang 7 0 2 9 0 0 0
Jl.Terusan Pembanguna No07 0 sindangbaran8 3 4 15 1 0 0
jl sukaraja 03 0 cidaun 9 0 5 11 2 0 0
jl salabintana 02 0 naringgul 9 0 1 10 1 0 0
Jl. Bank No.17 01 9 kebonkopi 5 0 4 9 3 0 0
Kp. Sekecengek 02 02 Galanggang 4 0 0 4 2 0 0
Kp. Sinarmukti 03 03 Selacau 4 0 1 5 0 0 0
Selacau 02 04 Selacau 8 0 0 8 0 0 0
Cihampelas 01 05 Cihampelas 4 0 1 5 1 0 0
Kopassus 05 03 Batujajar 1 0 0 1 3 0 0
Perum Kota Mas 11 06 Cimahi 0 0 0 0 5 0 0
Jl. Terusan SMP 04 04 Batujajar 2 0 0 2 2 0 0
Jl. Terusan SMP 02 05 Batujajar 3 0 0 3 1 0 0
Gg. Lurah No.36 02 03 Selacau 1 0 0 1 2 0 0
Gg. H Amir 07 03 Galanggang 2 0 0 2 2 0 0
kampung serang kongsi 10 02 sukasari 8 0 0 8 0 0 0
serang baru 08 02 sukamahi 0 0 0 0 2 0 2
cikarang selatan 08 03 sukadami 0 0 0 0 2 0 0
jalan cibarusah 03 03 sukadami 5 0 2 7 3 0 0
jalan cibarusah 02 04 sukatani 0 0 1 2 5 0 1
cibarusah 08 02 sukatani 0 0 0 0 4 0 1
cijambe 04 07 ciasem 4 0 2 6 2 0 1
jalan turunan 02 05 cijampang 3 0 4 8 4 0 0
jalan tanjakan 01 04 cibarembol 1 0 0 1 2 0 1
jalan mantan 07 01 terkasih 0 0 4 4 0 0 0
jl.pasir kaliki no.26 Bandun 01 04 Sukajadi 5 0 0 5 4 0 0
jl.citra padalarang indah b 04 01 padalarang 7 0 0 7 3 0 0
jl.sukasirna no 5 03 03 sukasirna 6 0 0 6 3 0 0
jl.indah no 10 01 01 Sukajadi 5 1 0 6 4 0 0
jl.mawar no 4 03 04 sukawana 5 0 1 6 4 0 0
jl.asri 3 04 03 warnasari 6 0 0 4 5 0 0
jn.merdeka 03 02 merdeka 3 0 0 3 3 0 0
jl.melati no 12 02 02 pagarsih 4 0 0 4 4 0 0
ln.gunungbatu no 15 04 04 wanayasa 7 0 0 7 4 0 0
jl. Badak putih 06 03 badak putih 6 0 2 8 5 0 0
jl. Anugrah 03 02 simah 1 0 0 1 4 0 0
riwangan 05 04 galingan 1 0 0 1 3 0 0
Jl,karie 05 04 galangan 3 0 0 3 2 0 0
Jln. Milka 06 03 Cigambi 1 0 0 1 1 0 0
Jl. Radjiman 10 02 sagiarsi 1 0 0 1 2 0 0
Jl. Sarijadi 09 01 sarijadi 1 0 0 1 2 0 0
jln. subroto 01 03 banyu biru 2 0 0 2 4 0 0
jln. asri 01 02 radjiman 5 0 4 9 3 0 0
Jl.pandean 06 05 trenggalek 8 3 4 15 1 0 0
asrian 02 08 pandean 9 0 1 10 1 0 0
Sukajadi 05 02 Pasteur 3 3 2 8 1 0 0
Sukagalih 08 02 Pasteur 7 0 2 9 2 0 0
Jl.Bojong Kenyot 06 01 Bojong Kone 2 0 2 4 2 0 0
Jl. Terusan Perintis 03 01 Sarijadi 3 0 2 5 1 0 0
Cibogo 05 02 Margamulya 3 0 1 4 1 0 0
Jl.Jendral Sudirman 13 08 Palawati 4 0 3 7 0 0 0
Jl.Cikeris 07 04 Bojong Sawit3 0 0 3 2 0 1
Jl. Sawit 10 03 Darangdan 3 0 3 6 1 0 0
Jl.Tunggakjati 06 03 Tanjung Pura3 0 1 4 1 0 0
Gang Sawo 17 05 Klari 2 0 0 2 3 0 1
Jl. Raya Gading Tutuka 1 n08 04 Cingcin 7 0 0 7 0 0 0
jl. Cessna 2 no.10, Lanud 02 02 Angkasa 0 0 0 0 2 0 2
Jl. Otter no.2, Lanud Sulai 07 03 Angkasa 0 0 0 0 1 0 0
Jl. Permai 21 blok 33/34, 01 01 Margahayu 6 0 1 7 3 0 0
Jl. Raya Katapang No. 53, 04 01 Katapang 0 0 2 2 4 0 0
Jl. Taman Kopo Indah no.1 07 03 Margaasih 0 0 0 0 3 0 0
Jl. Cilampeni no.36 04 02 Cilampeni 6 0 0 6 4 0 0
Jl. Bojong no.33, Soreang 02 01 Soreang 0 0 0 0 4 0 0
JL. Cingcin Permata Indah 01 01 Cingcin 0 0 0 0 2 0 2
Jl. Kenangan no.90 07 01 Padasuka 3 5 0 8 0 0 0
kp.sirnabakti 02 03 kp.sirnabakti 7 1 0 8 3 0 0
kp.sirnabakti 02 03 kp.sirnabakti 11 0 1 12 0 0 0
jl sirnabakti 02 03 sirnabakti 6 0 1 7 0 0 0
sirnabakti 02 03 sirnabakti 5 0 1 6 11 0 0
jl cimangkok rt/rw 02/02 02 03 sirnabakti 3 0 0 4 12 0 0
sirnbakti 02 03 sirnabakti 10 2 0 13 5 0 0
sirnbakti 02 03 sirnabakti 10 2 0 3 5 1 2
jl.sirnabakti 02 03 sirnabakti 4 0 3 4 4 0 1
Jl. Sukajadi 3 02 03 sirnabakti 2 0 1 3 1 0 0
JL SIRNABAKTI 02 03 sirnabakti 2 0 0 3 4 0 0
jl sirna bakti 02 03 sirnabakti 3 0 0 1 2 0 0
kp.sirnabakti 02 03 sirnabakti 0 1 0 0 3 0 0
168 0.14 229 158 0.05

342 0.5 421 317 0.05
299 0.57 387 143 0.08
381 1.04 490 283 0.17
Keadaan Gigi
GT
Kriteria
DMF-T DI CI OHI-S 0 1 2 3 4 5 6 7 8
OHI-S
2 0.6667 0.6667 1.333 SEDANG 26 1 1 0 0 0 0 0 0
0 1.6667 0.6667 2.333 SEDANG 6 0 0 0 0 0 0 0 0
0 2.3333 1 3.333 BURUK 10 0 0 0 0 0 0 0 0
0 1 0.6667 1.667 SEDANG 12 0 0 0 0 0 0 0 0
0 1 0.6667 1.667 SEDANG 16 0 0 0 0 0 0 0 0
0 1.1667 0 1.167 BAIK 20 0 0 0 0 0 0 0 0
2 1 0 1 BAIK 21 2 0 0 0 0 3 0 0
0 0.6667 0 0.667 BAIK 6 0 0 0 0 0 0 0 0
0 1.6667 0.6667 2.333 SEDANG 6 0 0 0 0 0 0 0 0
0 0.3333 0 0.333 BAIK 10 0 0 0 0 0 0 0 0
0 0.5 0.6667 1.167 BAIK 15 0 0 0 0 0 0 0 0
0 0.3333 0.5 0.833 BAIK 4 0 0 0 0 0 0 0 0
5 0 1 1 BAIK 17 5 0 0 0 0 0 0 0
3 0.8333 0 0.833 BAIK 19 2 0 0 1 0 0 0 0
1 0.8333 2 2.833 SEDANG 11 1 0 0 0 0 3 0 0
6 1.5 2.1667 3.667 BURUK 7 5 0 0 1 0 6 0 0
2 0.8333 0.5 1.333 SEDANG 14 2 0 0 0 0 3 0 0
0 1.8333 2.1667 4 BURUK 9 0 0 0 0 0 0 0 0
5 1.1667 1.1667 2.333 SEDANG 7 2 0 0 3 0 4 0 0
5 0.6667 0.8333 1.5 SEDANG 10 4 0 0 1 1 4 0 0
0 0.17 0.00 0.17 BAIK 2 0 0 0 0 0 0 0 0
1 0.50 0.00 0.50 BAIK 21 1 0 0 0 0 0 0 0
0 0.33 0.00 0.33 BAIK 11 0 0 0 0 0 0 0 0
1 0.83 0.00 0.83 BAIK 21 1 0 0 0 0 0 0 0
0 0.83 0.00 0.83 BAIK 20 0 0 0 0 0 0 0 1
0 0.83 0.00 0.83 BAIK 18 0 0 0 0 0 0 0 1
1 1.67 0.00 1.67 SEDANG 23 1 0 0 0 0 0 0 0
0 2.00 0.00 2.00 SEDANG 14 0 0 0 0 0 0 0 0
0 0.17 0.00 0.17 BAIK 14 0 0 0 0 0 0 0 0
0 1.50 0.00 1.50 SEDANG 14 0 0 0 0 0 0 0 0
4 0.6667 0.6667 1.333 SEDANG 16 4 0 0 0 0 0 0 0
3 1 0.8333 1.833 SEDANG 3 3 0 0 0 0 0 0 0
4 0.6667 0.1667 0.833 BAIK 0 4 0 0 0 0 0 0 0
2 0.3333 0.1667 0.5 BAIK 0 1 1 0 0 0 6 0 0
2 1 0.5 1.5 SEDANG 0 2 0 0 0 0 0 0 0
4 1.3333 0.6667 2 SEDANG 0 4 0 0 0 0 1 0 0
7 1.5 0.5 2 SEDANG 1 7 0 0 0 0 1 0 0
5 1.5 0.5 2 SEDANG 0 5 0 0 0 0 0 0 0
3 1 0.5 1.5 SEDANG 0 3 9 0 0 0 0 0 0
4 1 0 1 BAIK 0 4 0 0 0 0 8 0 0
2 0.6667 0.8333 1.5 SEDANG 25 2 0 0 0 0 0 0 0
2 0.6667 0.5 1.167 BAIK 24 2 0 0 0 0 0 0 0
1 0.8333 1 1.833 SEDANG 24 1 0 0 0 0 1 0 0
2 0.5 0.8333 1.333 SEDANG 23 2 0 0 0 0 1 0 0
2 1 0.8333 1.833 SEDANG 22 1 1 0 0 0 0 0 0
2 2 2.1667 4.167 BURUK 24 2 0 0 0 0 1 0 0
2 1.1667 1.3333 2.5 SEDANG 25 2 0 0 0 0 0 0 0
4 1.6667 1.1667 2.833 SEDANG 16 4 0 0 0 0 0 0 0
1 0.8333 1 1.833 SEDANG 23 0 0 1 0 0 0 0 0
4 1.3333 1.8333 3.167 BURUK 25 4 0 0 0 0 0 0 0
2 0.8333 0.3333 1.167 BAIK 10 2 0 0 0 0 0 0 0
2 0.6667 0.5 1.167 BAIK 7 1 1 0 0 0 0 0 0
3 1 0.3333 1.333 SEDANG 16 2 0 0 1 0 0 0 0
3 1 1 2 SEDANG 21 3 0 0 0 0 0 0 0
3 0.6667 0.6667 1.333 SEDANG 10 2 0 0 1 0 0 0 0
4 1.1667 0.6667 1.833 SEDANG 23 3 1 0 0 0 0 0 0
1 0.8333 0.3333 1.167 BAIK 9 0 0 0 1 0 0 0 0
2 1.1667 0.8333 2 SEDANG 24 1 0 0 1 0 0 0 0
2 1.1667 0.8333 2 SEDANG 18 1 1 0 0 0 0 0 0
2 0.5 0.1667 0.667 BAIK 8 2 0 0 0 0 0 0 0
2 0.6667 0.5 1.167 BAIK 25 2 0 0 0 0 0 0 0
2 0.3333 0 0.333 BAIK 25 2 0 0 0 0 0 0 0
2 1.1667 0.6667 1.833 SEDANG 18 2 0 0 0 0 0 0 0
1 0.6667 0.5 1.167 BAIK 21 1 0 0 0 0 0 0 0
0 1 0.8333 1.833 SEDANG 25 0 0 0 0 0 0 0 0
1 1.3333 0.6667 2 SEDANG 26 1 0 0 0 0 0 0 0
1 1.1667 0.5 1.667 SEDANG 25 1 0 0 0 0 0 0 0
2 0.8333 0.6667 1.5 SEDANG 25 2 0 0 0 0 0 0 0
1 0.6667 0.5 1.167 BAIK 25 1 0 0 0 0 0 0 0
1 0.6667 0.5 1.167 BAIK 17 1 0 0 0 0 8 0 0
0 0.5 0.6667 1.167 BAIK 12 0 0 0 0 0 0 0 0
2 0.8333 0.6667 1.5 SEDANG 20 2 0 0 0 0 0 0 0
1 1 0.8333 1.833 SEDANG 9 0 0 0 0 0 1 0 0
2 0.3333 0.3333 0.667 BAIK 23 1 0 0 0 0 1 0 0
3 0.3333 0.3333 0.667 BAIK 15 3 0 0 0 0 0 0 0
1 0.5 0 0.5 BAIK 11 1 0 0 0 0 0 0 0
1 0 0 0 BAIK 24 1 0 0 0 0 1 0 0
0 0.3333 0 0.333 BAIK 4 0 0 0 0 0 0 0 0
0 0.3333 0.3333 0.667 BAIK 18 0 0 0 0 0 0 0 0
0 0.1667 0.3333 0.5 BAIK 14 0 0 0 0 0 0 0 0
1 0.6667 0.8333 1.5 SEDANG 11 1 0 0 0 0 1 0 0
4 0.8333 1.3333 2.167 SEDANG 20 2 1 0 1 0 0 0 0
3 0.3333 0.5 0.833 BAIK 0 3 0 0 0 0 0 0 0
0 0.3333 0.5 0.833 BAIK 0 0 0 0 0 0 0 0 0
1 0.5 0.3333 0.833 BAIK 1 0 0 0 1 0 0 0 0
1 0.8333 1.1667 2 SEDANG 0 1 0 0 0 0 0 0 0
1 1.5 1.3333 2.833 SEDANG 1 1 0 0 0 0 1 0 0
2 0.5 0.5 1 BAIK 1 1 0 0 0 1 1 1 0
1 0.5 0.3333 0.833 BAIK 0 1 0 0 0 1 1 0 0
1 0.8333 0.8333 1.667 SEDANG 8 0 0 0 0 1 1 1 0
0 1.5 0.5 2 SEDANG 26 0 0 0 0 0 0 0 0
1 0.333 0 0.333 BAIK 25 2 0 0 0 0 0 0 0
2 2 0.6667 2.667 SEDANG 20 2 0 0 0 0 0 0 0
1 1.5 1.5 3 SEDANG 24 1 0 0 0 0 0 0 0
1 1 1 2 SEDANG 26 1 0 0 0 0 0 0 0
4 2 2 4 BURUK 24 4 0 0 0 0 0 0 0
4 3 2 5 BURUK 26 4 0 0 0 0 0 0 0
3 1 1.1667 2.167 SEDANG 25 3 0 0 0 0 0 0 0
3 2 0.6667 2.667 SEDANG 25 3 0 0 0 0 0 0 0
0 0.3333 0.1667 0.5 BAIK 12 0 0 0 0 0 0 0 0
0 2 2.1667 4.167 BURUK 6 0 0 0 0 0 0 0 0
2 2.6667 2.5 5.167 BURUK 19 2 2 0 0 0 1 0 0
2 1 0.8333 1.833 SEDANG 17 2 0 0 0 0 1 0 0
3 0.3333 0.8333 1.167 BAIK 8 3 0 0 0 0 1 0 0
6 0.3333 0.8333 1.167 BAIK 19 5 0 1 0 0 1 0 0
5 1.1667 0.8333 2 SEDANG 19 4 0 1 0 0 0 0 0
4 1 0.3333 1.333 SEDANG 8 2 1 1 0 0 0 0 0
4 0.6667 0.5 1.167 BAIK 4 4 0 0 0 0 0 0 0
4 0.8333 0.5 1.333 SEDANG 16 2 1 1 0 0 0 0 0
0 0.5 0.3333 0.833 BAIK 10 0 0 0 0 0 0 0 0
3 0.1667 0.1667 0.333 BAIK 29 3 0 0 0 0 0 0 0
0 1.5 0.1667 1.667 SEDANG 0 0 0 0 0 0 0 0 0
0 1.5 0.6667 2.167 SEDANG 0 0 0 0 0 0 0 0 0
0 1.1667 0.6667 1.833 SEDANG 0 0 0 0 0 0 0 0 0
4 1.3333 0.3333 1.667 SEDANG 24 4 0 0 0 0 2 0 2
3 1 1 2 SEDANG 25 3 0 0 0 0 2 0 2
4 2.5 1.1667 3.667 BURUK 22 4 0 0 0 0 3 0 3
5 0.8333 0.3333 1.167 BAIK 23 5 0 0 0 0 0 0 4
11 1.3333 0.5 1.833 SEDANG 18 11 0 0 0 0 0 0 3
12 2.5 0.6667 3.167 BURUK 15 12 0 0 0 0 1 0 4
2 2.3333 2.3333 4.667 BURUK 24 2 0 0 0 0 0 0 0
3 1.3333 0.8333 2.167 SEDANG 24 3 0 0 0 0 0 0 0
2 1 2.1667 3.167 BURUK 19 2 0 0 0 0 0 0 0
6 1.1667 1.5 2.667 SEDANG 21 5 0 0 0 0 0 0 0
1 1.3333 1.5 2.833 SEDANG 23 1 0 0 0 0 2 0 0
4 1.1667 0.8333 2 SEDANG 23 4 0 0 0 0 0 0 0
4 1.1667 0.8333 2 SEDANG 23 4 0 0 0 0 0 0 0
6 0.6667 1.6667 2.333 SEDANG 20 6 0 0 0 0 0 0 0
2 0.8333 0.6667 1.5 SEDANG 24 2 0 0 0 0 2 0 0
2 0.5 0.3333 0.833 BAIK 26 2 0 0 0 0 0 0 0
2 0.5 0.8333 1.333 SEDANG 25 2 0 0 0 0 0 0 0
2 1 0.6667 1.667 SEDANG 24 2 0 0 0 0 0 0 0
1 1.1667 1.3333 2.5 SEDANG 24 1 0 0 0 0 1 0 0
2 0.8333 1.1667 2 SEDANG 23 2 0 0 0 0 1 0 0
2 1 0.8333 1.833 SEDANG 22 1 1 0 0 0 0 0 0
2 2 2.1667 4.167 BURUK 24 2 0 0 0 0 1 0 0
2 1.1667 1.3333 2.5 SEDANG 25 2 0 0 0 0 0 0 0
4 1.6667 1.1667 2.833 SEDANG 16 4 0 0 0 0 0 0 0
1 0.8333 1 1.833 SEDANG 23 0 0 1 0 0 0 0 0
4 1.3333 1.8333 3.167 BURUK 25 4 0 0 0 0 0 0 0
1 0.6667 0.8333 1.5 SEDANG 17 1 0 0 0 0 1 0 0
3 0.8333 1.3333 2.167 SEDANG 21 2 1 0 0 0 0 0 0
1 0.3333 0.5 0.833 BAIK 0 1 0 0 0 0 0 0 0
1 0.3333 0.5 0.833 BAIK 0 0 1 0 0 0 0 0 0
0 0.5 0.3333 0.833 BAIK 0 0 0 0 0 0 4 0 0
0 0.8333 1.1667 2 SEDANG 0 0 0 0 0 0 0 0 0
1 1.5 1.3333 2.833 SEDANG 1 1 0 0 0 0 1 0 0
0 0.5 0.5 1 BAIK 0 0 0 0 0 0 0 0 0
1 0.5 0.3333 0.833 BAIK 0 1 0 0 0 0 0 0 0
4 0.8333 0.8333 1.667 SEDANG 8 4 0 0 0 0 0 0 0
2 0.5 0.3333 0.833 BAIK 26 1 1 0 0 0 0 0 0
0 0.8333 0.6667 1.5 SEDANG 12 0 0 0 0 0 0 0 0
0 1.6667 0.6667 2.333 SEDANG 8 0 0 0 0 0 0 0 0
1 0.3333 0 0.333 BAIK 9 1 0 0 0 0 0 0 0
3 0.3333 0.1667 0.667 BAIK 17 3 0 0 0 0 0 0 0
5 0.5 0.3333 1 BAIK 21 5 0 0 0 0 0 0 0
2 0.6667 0.1667 0.167 BAIK 14 2 0 0 0 0 0 0 0
1 0 0.3333 1.833 SEDANG 8 1 0 0 0 0 0 0 0
2 1.5 0.5 1.667 SEDANG 14 2 0 0 0 0 0 0 0
2 1.1667 0.3333 1.667 SEDANG 14 2 0 0 0 0 0 0 0
0 1.3333 1.1667 2.5 SEDANG 10 0 0 0 0 0 0 0 0
1 2 1.8333 3.833 BURUK 5 0 1 0 0 0 0 0 0
3 1.1667 0.6667 1.833 SEDANG 16 2 0 0 1 0 0 0 0
4 1 0.5 1.5 SEDANG 21 4 0 0 0 0 2 0 0
0 0.6667 0.6667 1.333 SEDANG 0 0 0 0 0 0 0 0 0
5 1.3333 0.3333 1.667 SEDANG 22 2 3 0 0 0 0 0 0
0 1.1667 1.3333 2.5 SEDANG 13 0 0 0 0 0 0 0 0
4 2 1.3333 3.333 BURUK 17 2 1 0 1 0 0 0 0
0 1.1667 0.6667 1.833 SEDANG 16 0 0 0 0 0 0 0 0
2 1 0.5 1.5 SEDANG 6 2 0 0 0 0 0 0 0
0 0.8333 0.3333 1.167 BAIK 20 0 0 0 0 0 2 0 0
0 0.8333 0.3333 1.17 BAIK 10 0 0 0 0 0 0 0 0
1 0.6667 0.5 1.17 BAIK 26 1 0 0 0 0 1 0 0
0 0.6667 0.5 1.17 BAIK 16 0 0 0 0 0 0 0 0
0 1 0.5 1.50 SEDANG 15 0 0 0 0 0 1 0 0
0 1.1667 0.5 1.67 SEDANG 25 0 0 0 0 0 2 0 0
2 1.1667 0.6667 1.83 SEDANG 20 2 0 0 0 0 6 0 0
2 0.8333 0.6667 1.50 SEDANG 19 2 0 0 0 0 4 0 0
0 0.8333 0.6667 1.50 SEDANG 9 0 0 0 0 0 2 0 0
0 0.8333 0.5 1.33 SEDANG 10 0 0 0 0 0 0 0 0
0 0.5 0.5 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.8333 0.3333 1.167 BAIK 16 0 0 0 0 0 0 0 0
0 0.3333 0.5 0.833 BAIK 21 0 0 0 0 0 0 0 0
0 0.6667 0.5 1.167 BAIK 10 0 0 0 0 0 0 0 0
0 0.8333 0.3333 1.167 BAIK 16 0 0 0 0 0 0 0 0
0 1.5 0.8333 2.333 SEDANG 18 0 0 0 0 0 0 0 0
0 0.8333 0.5 1.333 SEDANG 17 0 0 0 0 0 0 0 0
0 0.8333 0.5 1.333 SEDANG 19 0 0 0 0 0 0 0 0
0 0.8333 0.6667 1.5 SEDANG 20 0 0 0 0 0 0 0 0
0 1 1.1667 2.167 SEDANG 19 0 0 0 0 0 0 0 0
0 0.6667 0.5 1.167 BAIK 13 0 0 0 0 0 0 0 0
0 0.5 0.5 1 BAIK 18 0 0 0 0 0 0 0 0
1 0.6667 0.5 1.333 SEDANG 22 1 0 0 0 0 0 0 0
0 0.6667 0.6667 1.167 BAIK 10 0 0 0 0 0 0 0 0
0 1.1667 0.5 1.667 SEDANG 8 0 0 0 0 0 0 0 0
0 0.6667 0.5 1 BAIK 13 0 0 0 0 0 0 0 0
0 1 0.3333 1 BAIK 15 0 0 0 0 0 0 0 0
0 0.8333 0.1667 1 BAIK 8 0 0 0 0 0 0 0 0
0 1 0 1 BAIK 16 0 0 0 0 0 0 0 0
0 0.5 0.1667 0.667 BAIK 10 0 0 0 0 0 0 0 0
1 1.5 0.6667 2.167 SEDANG 15 1 0 0 0 0 0 0 0
2 0.5 0 1.167 BAIK 8 1 1 0 0 0 0 0 0
2 1 0.6667 1.667 SEDANG 18 2 0 0 0 0 0 0 0
1 1.1667 1 2.167 SEDANG 15 1 0 0 0 0 0 0 0
1 1.3333 0.3333 1.667 SEDANG 19 0 1 0 0 0 0 0 0
0 0.5 0.5 1 BAIK 12 0 0 0 0 0 0 0 0
3 0.8333 1 1.833 SEDANG 17 0 2 1 0 0 0 0 0
1 0.5 1 1.5 SEDANG 13 0 1 0 0 0 0 0 0
1 0.3333 0.3333 0.667 BAIK 19 0 1 0 0 0 0 0 0
4 1.3333 1.1667 2.5 SEDANG 20 3 0 1 0 0 0 0 0
0 1.3333 1.5 2.833 SEDANG 26 0 0 0 0 0 0 0 0
1 0.3333 0 0.333 BAIK 25 2 0 0 0 0 0 0 0
1 2 0.6667 2.667 SEDANG 21 1 0 0 0 0 0 0 0
1 0.6667 0.5 1.167 BAIK 25 1 0 0 0 0 0 0 0
1 1.5 1.1667 2.667 SEDANG 26 1 0 0 0 0 0 0 0
2 0.8333 0.6667 1.5 SEDANG 26 2 0 0 0 0 0 0 0
2 1.8333 1.5 3.333 BURUK 28 2 0 0 0 0 0 0 0
3 1.1667 0.3333 1.5 SEDANG 25 3 0 0 0 0 0 0 0
3 1.5 0.1667 1.667 SEDANG 25 3 0 0 0 0 0 0 0
0 0.3333 0.1667 0.5 BAIK 12 0 0 0 0 0 0 0 0
2 0.5 0.3333 0.833 BAIK 0 2 0 0 0 0 0 0 0
1 0.6 0 0.6 BAIK 0 1 0 0 0 0 0 0 0
0 0.4 0 0.4 BAIK 0 0 0 0 0 0 0 0 0
0 0.5 0 0.5 BAIK 0 0 0 0 0 0 0 0 0
0 0.5 0 0.5 BAIK 0 0 0 0 0 0 0 0 0
2 0.3333 0.3333 0.667 BAIK 0 2 0 0 0 0 0 0 0
1 0.6 0 0.6 BAIK 0 1 0 0 0 0 0 0 0
0 0.3333 0 0.333 BAIK 0 0 0 0 0 0 0 0 0
0 0.5 0 0.5 BAIK 0 0 0 9 0 0 0 0 0
0 0.6667 0 0.667 BAIK 0 0 0 0 0 0 0 0 0
2 0.6667 0.8333 1.5 SEDANG 25 2 0 0 0 0 0 0 0
2 0.6667 0.5 1.167 BAIK 24 2 0 0 0 0 0 0 0
1 0.8333 1 1.833 SEDANG 24 1 0 0 0 0 1 0 0
2 0.5 0.8333 1.333 SEDANG 23 2 0 0 0 0 1 0 0
2 1 0.8333 1.833 SEDANG 22 1 1 0 0 0 0 0 0
2 2 2.1667 4.167 BURUK 24 2 0 0 0 0 1 0 0
2 1.1667 1.3333 2.5 SEDANG 25 2 0 0 0 0 0 0 0
4 1.6667 1.1667 2.833 SEDANG 16 4 0 0 0 0 0 0 0
1 0.8333 1 1.833 SEDANG 23 0 0 1 0 0 0 0 0
4 1.3333 1.8333 3.167 BURUK 25 4 0 0 0 0 0 0 0
4 0,33 0,50 0,83 BAIK 23 3 0 0 0 0 0 0 4
4 0,2 0,33 0,50 BAIK 24 4 0 0 0 0 0 0 4
2 0,2 0,33 0,50 BAIK 26 2 0 0 0 0 0 0 4
1 0,2 0,2 0,4 BAIK 24 1 0 0 0 0 0 0 4
4 0,50 0,50 1,17 BAIK 25 1 0 0 0 0 0 0 4
2 0,50 0,50 1,17 BAIK 22 3 0 0 0 0 0 0 4
3 0,50 0,50 1,17 BAIK 23 0 0 0 0 0 0 0 4
2 0,33 0,50 0,83 BAIK 21 3 0 0 0 0 0 0 4
4 0,50 0,50 1,17 BAIK 24 2 0 0 0 0 0 0 4
1 0,67 0,50 0,83 BAIK 23 1 0 0 0 0 1 0 4
0 0.5 0.6667 1.167 BAIK 12 0 0 0 0 0 0 0 0
2 0.8333 0.6667 1.5 SEDANG 20 2 0 0 0 0 0 0 0
1 1 0.8333 1.833 SEDANG 9 0 0 0 0 0 1 0 0
2 0.3333 0.3333 0.667 BAIK 23 1 0 0 0 0 1 0 0
4 0.3333 0.1667 0.5 BAIK 22 2 0 0 0 0 2 0 0
0 0.5 0.5 1 BAIK 12 0 0 0 0 0 0 0 0
0 0.8333 0.3333 1.167 BAIK 20 0 0 0 0 0 0 0 0
0 0.8333 0.5 1.333 SEDANG 3 0 0 0 0 0 0 0 0
0 0.5 0.3333 0.833 BAIK 17 0 0 0 0 0 0 0 0
1 0.3333 0.1667 0.5 BAIK 13 0 0 0 0 0 1 0 0
2 0.3333 0.1667 0.5 BAIK 26 2 0 0 0 0 0 0 0
2 0.5 0.5 1 BAIK 19 1 0 0 0 1 1 1 0
1 0.50 0.17 0.67 BAIK 26 1 0 0 0 0 1 0 0
0 0.8333 0.6667 1.5 SEDANG 0 0 0 0 0 0 0 0 0
4 0.5 1.1667 1.667 SEDANG 22 4 0 0 0 0 3 0 3
0 1.1667 0.5 1.667 SEDANG 12 0 0 0 0 0 0 0 0
2 1.1667 0.5 1.667 SEDANG 14 2 0 0 0 0 0 0 0
2 1.17 0.67 1.83 SEDANG 19 2 0 0 0 0 6 0 0
3 0 0.8333 0.833 BAIK 10 3 0 0 0 0 0 0 0
0 0.6667 0.1667 0.833 BAIK 10 0 0 0 0 0 0 0 0
0 0.6667 0.3333 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.3333 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.3333 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.3333 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.3333 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.3333 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.3333 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.3333 1 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.33331 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.33331 BAIK 13 0 0 0 0 0 0 0 0
0 0.6667 0.66671.333 SEDANG 8 0 0 0 0 0 0 0 0
3 0.8333 0.33331.167 BAIK 0 3 0 0 0 0 0 0 0
4 1.1667 0.66671.833 SEDANG 0 4 0 0 0 0 0 0 0
2 1.1667 0.16671.333 SEDANG 0 2 0 0 0 0 0 0 0
0 1 0.16671.167 BAIK 0 0 0 0 0 0 0 0 0
5 1.1667 1 2.167 SEDANG 0 5 0 0 0 0 0 0 0
0 1.5 0.16671.667 SEDANG 0 0 0 0 0 0 0 0 0
2 1 0.16671.167 BAIK 0 2 0 0 0 0 0 0 0
3 1 1 2 SEDANG 8 3 0 0 0 0 0 0 0
0 1 1 2 SEDANG 8 0 0 0 0 0 0 0 0
2 2 1.16673.167 BURUK 0 2 0 0 0 0 0 0 0
8 2.5 2 4.5 BURUK 0 8 0 0 0 0 0 0 0
1 1.3333 1 2.333 SEDANG 2 1 0 0 0 0 0 0 0
2 1 1 2 SEDANG 2 2 0 0 0 0 0 0 0
1 0.5 1 1.5 SEDANG 0 1 0 0 0 0 0 0 0
0 0.8333 0.33331.167 BAIK 2 0 0 0 0 0 0 0 0
1 1 0.5 1.5 SEDANG 2 1 0 0 0 0 0 0 0
2 0.5 0.5 1 BAIK 2 2 0 0 0 0 0 0 0
1 1 0.33331.333 SEDANG 3 1 0 0 0 0 0 0 0
3 0.5 0.33330.833 BAIK 5 3 0 0 0 0 0 0 0
2 2 1.16673.167 BURUK 0 2 0 0 0 0 0 0 0
8 2.5 2 4.5 BURUK 0 8 0 0 0 0 0 0 0
1 1.3333 1 2.333 SEDANG 2 1 0 0 0 0 0 0 0
2 1 1 2 SEDANG 2 2 0 0 0 0 0 0 0
1 0.5 1 1.5 SEDANG 0 1 0 0 0 0 0 0 0
0 0.8333 0.33331.167 BAIK 2 0 0 0 0 0 0 0 0
1 1 0.5 1.5 SEDANG 2 1 0 0 0 0 0 0 0
2 0.5 0.5 1 BAIK 2 2 0 0 0 0 0 0 0
1 1 0.33331.333 SEDANG 3 1 0 0 0 0 0 0 0
3 0.5 0.33330.833 BAIK 5 3 0 0 0 0 0 0 0
2 0.8333 0.5 1.333 SEDANG 26 1 1 0 0 0 0 0 0
0 0.8333 0.5 1.5 SEDANG 12 0 0 0 0 0 0 0 0
0 1.3333 0.33331.667 SEDANG 8 0 0 0 0 0 0 0 0
1 0.3333 0 0.333 BAIK 9 1 0 0 0 0 0 0 0
3 0.3333 0.16670.667 BAIK 17 3 0 0 0 0 0 0 0
5 0.5 0.83332.167 SEDANG 21 5 0 0 0 0 0 0 0
2 1.3333 0.16670.5 BAIK 14 2 0 0 0 0 0 0 0
1 0.3333 0.5 2 SEDANG 8 1 0 0 0 0 0 0 0
2 1.5 0.5 1.667 SEDANG 14 2 0 0 0 0 0 0 0
2 1.1667 0.5 1 BAIK 14 2 0 0 0 0 0 0 0
0 2 2.1667 4.33 BURUK 6 0 0 0 0 0 0 0 0
4 3 2.5 5.00 BURUK 19 2 2 0 0 0 1 0 0
2 1 1 2.17 SEDANG 17 2 0 0 0 0 1 0 0
3 0 0.8333 1.17 BAIK 8 3 0 0 0 0 1 0 0
6 0 0.8333 1.17 BAIK 19 5 0 1 0 0 1 0 0
5 1 0.8333 2.00 SEDANG 19 4 0 1 0 0 0 0 0
3 1 0.3333 1.33 SEDANG 8 2 1 1 0 0 0 0 0
4 1 0.5 1.17 BAIK 4 4 0 0 0 0 0 0 0
3 1 0.5 1.33 SEDANG 16 2 1 1 0 0 0 0 0
0 1 0.3333 0.83 BAIK 10 0 0 0 0 0 0 0 0
4 1.3333 0.8333 2.167 SEDANG 9 4 0 0 0 0 0 0 0
3 1.3333 1 2.333 SEDANG 9 3 0 0 0 0 0 0 0
3 1 1 2 SEDANG 9 3 0 0 0 0 0 0 0
4 1.5 0.6667 2.167 SEDANG 11 4 0 0 0 0 0 0 0
4 1 1 2 SEDANG 20 4 0 0 0 0 0 0 0
5 1.8333 1 2.833 SEDANG 11 5 0 0 0 0 0 0 0
3 1.5 1.1667 2.667 SEDANG 17 3 0 0 0 0 0 0 0
4 1.5 1.3333 2.833 SEDANG 14 4 0 0 0 0 0 0 0
4 1.8333 1 2.833 SEDANG 20 4 0 0 0 0 0 0 0
5 1.1667 1 2.167 SEDANG 7 5 0 0 0 0 0 0 0
4 1.5 1.3333 2.833 SEDANG 8 4 0 0 0 0 0 0 0
3 1.3333 0.8333 2.167 SEDANG 24 3 0 0 0 0 0 0 0
2 0.3333 0.3333 0.667 BAIK 10 2 0 0 0 0 0 0 0
1 1 1 2 SEDANG 26 1 0 0 0 0 0 0 0
2 2 2.3333 4.333 BURUK 24 2 0 0 0 0 1 0 0
2 1 0.8333 1.833 SEDANG 22 1 1 0 0 0 0 0 0
4 1.3333 1.8333 3.167 BURUK 25 4 0 0 0 0 0 0 0
3 0.5 0.3333 0.833 BAIK 5 3 0 0 0 0 0 0 0
1 1 0.5 1.5 SEDANG 2 1 0 0 0 0 0 0 0
1 1 0.3333 1.333 SEDANG 3 1 0 0 0 0 0 0 0
1 1.5 0.6667 2.167 SEDANG 15 1 0 0 0 0 0 0 0
2 0.5 0 1.167 BAIK 8 1 1 0 0 0 0 0 0
2 1 0.6667 1.667 SEDANG 18 2 0 0 0 0 0 0 0
1 1.1667 1 2.167 SEDANG 15 1 0 0 0 0 0 0 0
1 1.3333 0.3333 1.667 SEDANG 19 0 1 0 0 0 0 0 0
0 0.5 0.5 1 BAIK 12 0 0 0 0 0 0 0 0
3 0.8333 1 1.833 SEDANG 17 0 2 1 0 0 0 0 0
1 0.5 1 1.5 SEDANG 13 0 1 0 0 0 0 0 0
1 0.3333 0.3333 0.667 BAIK 19 0 1 0 0 0 0 0 0
4 1.3333 1.1667 2.5 SEDANG 20 3 0 1 0 0 0 0 0
0 1.3333 0.5 1.833 SEDANG 8 0 0 0 0 0 0 0 0
4 1.6667 1.1667 2.833 SEDANG 19 2 2 0 0 0 1 0 0
1 1 0.1667 1.167 BAIK 17 1 0 0 0 0 3 0 0
3 0.3333 0.8333 1.167 BAIK 8 3 0 0 0 0 1 0 0
4 0.3333 0.5 0.833 BAIK 19 4 0 0 0 0 5 0 0
3 1.3333 0.5 1.833 SEDANG 18 3 0 0 0 2 1 0 0
4 1.1667 0.5 1.667 SEDANG 8 4 0 0 0 0 0 0 0
4 0.6667 0.5 1.167 BAIK 18 4 0 0 0 0 2 0 0
4 0.8333 0.5 1.333 SEDANG 16 2 2 0 0 1 0 0 0
0 0.5 0.3333 0.833 BAIK 8 0 0 0 0 0 4 0 0
3 2 0.5 3.00 SEDANG 29 3 0 0 0 0 0 0 0
0 2 0.6667 2.67 SEDANG 0 0 0 0 0 0 0 0 0
0 1 1.1667 2.50 SEDANG 0 0 0 0 0 0 0 0 0
0 1 1 2.17 SEDANG 0 0 0 0 0 0 0 0 0
4 2 0.5 2.00 SEDANG 0 4 0 0 0 0 0 0 2
3 2 1.6667 3.33 BURUK 0 3 0 0 0 0 0 0 2
4 2 1.1667 3.00 SEDANG 3 4 0 0 0 0 0 0 3
5 1 0.8333 1.83 SEDANG 0 5 0 0 0 0 0 0 4
11 1 1.1667 2.33 SEDANG 3 11 0 0 0 0 0 0 3
12 3 0.6667 3.17 BURUK 0 12 0 0 0 0 0 0 4
12 3 0.6667 3.17 BURUK 0 12 0 0 0 0 0 0 4
4 2 0.5 3.17 BURUK 0 4 0 0 0 0 0 0 2
8 1 1.8333 2.00 BURUK 0 0 0 0 0 0 0 0 0
8 1 1.8333 2.50 SEDANG 0 5 0 0 0 0 0 0 0
2 2 1.3333 2.83 SEDANG 0 1 0 0 0 0 0 0 0
4 1 1.5 2.83 SEDANG 0 4 0 0 0 0 0 0 0
2 1 1.1667 2.17 SEDANG 0 2 0 0 0 0 0 0 0
2 1 0.5 1.17 BAIK 0 2 0 0 0 0 0 0 0
2 1 1.1667 2.17 SEDANG 0 2 0 0 0 0 0 0 0
1 1 0.8333 1.33 SEDANG 0 1 0 0 1 0 0 0 0
4 2 1.6667 3.17 BURUK 0 4 1 0 0 0 0 0 0
2 2 2.1667 4.17 BURUK 0 1 0 1 0 0 0 0 0
3 1 0.5 1.67 SEDANG 0 2 0 0 0 0 0 0 0
3 1 0.5 1.17 BAIK 0 3 0 0 0 0 0 0 0
3 1 0.5 1.17 BAIK 0 3 0 0 0 0 0 0 0
7 1 0.6667 2.00 SEDANG 0 0 0 0 0 0 0 0 0
6 1 0.5 1.67 SEDANG 0 7 0 0 0 0 0 0 0
6 2 0.8333 2.33 SEDANG 0 6 0 0 0 0 0 0 0
4 1 0.6667 1.83 SEDANG 0 6 0 0 0 0 0 0 0
7 1 1.6667 3.00 SEDANG 0 7 0 0 0 0 0 0 2
175
181
151
306
GS
Keadaan Patologi Kel.
9 A B C D E F G
Periodontal Mulut Dentofacial
0 16 3 0 0 1 0 0 1 0 0
0 14 4 0 0 0 1 0 0 0 0
0 13 4 0 0 0 1 0 2 0 0
0 16 2 0 0 0 1 0 2 0 0
0 16 2 0 0 0 1 0 2 0 0
0 17 2 0 0 0 0 0 2 0 0
0 15 0 0 0 0 0 0 1 0 0
0 12 5 0 1 0 2 0 0 0 0
0 17 2 0 0 0 1 0 0 0 0
0 12 4 0 0 0 3 0 1 0 0
17 5 2 0 0 0 0 0 0 0 0
28 11 0 0 0 0 0 0 3 0 0
10 4 0 0 0 0 0 0 0 0 0
10 4 0 0 1 0 0 0 0 0 0
16 4 1 0 0 0 0 0 2 0 0
13 4 0 0 0 0 0 0 3 0 0
13 4 0 0 0 0 0 0 2 0 0
23 11 0 0 0 0 0 0 2 0 0
16 5 0 0 0 0 0 0 2 0 0
0 3 0 0 0 0 0 0 2 0 0
0 17 2 0 0 0 0 0 0 0 0
0 3 0 0 0 4 0 0 0 0 0
0 7 3 0 0 1 0 0 0 0 0
0 2 0 0 0 1 0 0 0 0 0
0 2 1 0 0 2 0 0 0 0 0
0 2 3 1 0 0 0 0 0 0 0
0 0 2 0 0 2 0 0 0 0 0
0 4 5 0 1 2 0 0 0 0 0
0 3 3 0 0 0 0 0 0 0 0
0 0 1 0 0 1 0 0 0 0 0
0 8 4 0 0 7 0 0 2 0 0
0 2 0 0 0 0 0 0 2 0 0
0 1 0 0 1 0 0 0 2 0 0
0 0 0 0 0 0 0 0 2 0 0
0 6 2 0 1 0 0 0 2 0 0
0 2 0 0 0 0 0 0 2 0 0
0 1 0 0 0 0 0 0 2 0 0
0 2 2 0 0 1 0 0 2 0 0
0 4 2 0 0 2 0 0 2 0 0
0 4 2 0 0 2 0 0 2 0 0
2 0 1 0 0 0 0 0 0 0 0
6 1 1 0 0 0 0 0 3 0 0
6 0 2 0 0 0 0 0 3 0 0
6 1 1 0 0 0 0 0 0 0 0
8 2 1 0 0 0 0 0 0 0 0
5 1 1 0 0 0 0 0 3 0 0
5 0 1 0 0 0 0 0 0 0 0
12 4 0 0 0 0 0 0 2 0 0
8 1 3 0 0 0 0 0 2 0 0
3 1 2 0 0 0 0 0 3 0 0
0 13 5 0 0 0 0 0 1 0 0
0 12 4 2 0 0 0 0 2 0 0
0 2 2 0 1 2 0 0 2 0 0
0 2 2 2 0 0 0 0 1 0 0
0 10 3 0 0 1 0 0 1 0 0
0 1 0 0 0 0 0 0 2 0 0
0 11 2 0 1 1 0 0 1 0 0
0 2 1 0 0 0 0 0 2 0 0
0 5 2 0 0 0 0 0 2 0 0
0 13 3 0 0 0 0 0 2 0 0
0 0 1 0 0 0 0 0 2 0 0
0 0 0 0 0 0 0 0 1 0 0
0 1 1 0 0 0 0 0 2 0 0
0 0 2 0 0 0 0 0 1 0 0
0 1 3 0 0 0 0 0 1 0 0
0 0 1 0 0 0 0 0 1 0 0
0 0 3 0 0 0 0 0 2 0 0
0 0 1 0 0 0 0 0 2 0 0
0 2 1 0 0 0 0 0 2 0 0
0 1 1 0 0 0 0 0 0 0 0
0 5 3 0 0 0 0 0 0 0 0
0 2 3 0 0 1 0 0 0 0 0
0 6 3 0 0 0 1 0 0 0 0
0 0 2 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 6 1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 14 2 0 0 0 0 0 0 0 0
0 4 1 0 1 0 1 0 0 0 0
0 4 2 0 1 0 0 0 0 0 0
0 5 1 0 0 1 0 0 2 0 0
8 8 2 0 0 1 0 0 2 0 0
19 0 4 0 0 0 0 0 2 0 0
32 0 3 0 0 2 0 0 2 0 0
8 1 3 0 0 1 0 0 2 0 0
23 0 3 0 1 0 0 0 2 0 0
8 0 3 0 0 0 0 0 2 0 0
9 0 1 0 0 2 0 0 2 0 0
19 0 2 0 0 1 0 0 2 0 0
8 0 2 0 0 1 0 0 2 0 0
0 1 0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0 0 0
0 2 0 0 0 0 0 0 2 0 0
0 1 2 0 1 0 0 0 1 0 0
0 2 1 0 0 0 0 0 0 0 0
0 2 0 0 0 0 0 0 0 0 0
0 4 0 0 0 3 0 0 0 0 0
0 1 0 0 0 3 0 0 0 0 0
0 4 1 0 1 3 0 0 1 0 0
0 1 0 0 0 0 0 0 0 0 0
0 10 8 0 0 0 1 0 3 0 0
0 0 0 0 0 0 0 0 4 0 0
0 0 0 0 0 0 0 0 4 0 0
0 1 5 1 0 0 1 0 3 0 0
0 0 2 0 1 0 0 0 2 0 0
0 0 0 0 0 0 0 0 3 0 0
0 6 4 2 1 0 0 0 3 0 0
0 5 3 4 5 0 0 0 2 0 0
0 2 1 0 0 0 0 0 2 0 0
0 5 0 4 3 0 0 0 4 0 0
0 14 5 0 0 1 0 0 2 0 0
0 10 12 0 1 0 0 0 2 0 0
0 16 5 0 0 0 0 0 2 0 0
0 13 9 0 3 0 0 0 3 0 0
0 10 10 0 1 2 0 0 2 0 0
0 14 8 0 0 0 0 0 2 0 0
0 11 9 0 2 0 0 0 2 0 0
0 15 6 0 0 1 0 0 1 0 0
0 18 5 0 1 0 0 0 2 0 0
0 18 3 0 0 1 0 0 2 0 0
0 0 1 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 4 0 0
0 0 1 0 0 0 0 0 0 0 0
0 0 2 0 1 0 0 0 1 0 0
0 2 1 0 0 0 0 0 1 0 0
0 1 1 0 0 0 0 0 0 0 0
0 1 1 0 0 0 0 0 0 0 0
0 2 2 0 0 0 0 0 2 0 0
0 0 1 0 1 0 0 0 2 0 0
0 2 1 0 0 0 0 0 1 0 0
2 0 1 0 0 0 0 0 0 0 0
6 1 1 0 0 0 0 0 3 0 0
6 0 2 0 0 0 0 0 3 0 0
6 1 1 0 0 0 0 0 0 0 0
8 2 1 0 0 0 0 0 0 0 0
5 1 1 0 0 0 0 0 3 0 0
5 0 1 0 0 0 0 0 0 0 0
12 4 0 0 0 0 0 0 2 0 0
8 1 3 0 0 0 0 0 2 0 0
3 1 2 0 0 0 0 0 3 0 0
0 3 0 0 0 1 0 0 2 0 0
8 8 3 0 1 0 0 0 2 0 0
19 0 3 0 0 0 2 0 2 0 0
0 0 1 0 0 1 0 0 2 0 0
20 5 3 0 0 5 0 0 2 0 0
0 0 5 0 1 0 2 0 2 0 0
8 0 3 0 0 0 0 0 2 0 0
0 0 2 0 0 0 0 0 2 0 0
14 0 3 1 0 0 0 0 2 0 0
8 0 0 0 0 0 0 0 2 0 0
0 16 3 0 0 1 0 0 2 0 0
0 8 4 0 0 0 0 0 2 0 0
0 9 7 0 0 0 0 0 2 0 0
0 10 4 0 0 0 0 0 2 0 0
0 17 1 0 0 0 0 0 2 0 0
0 15 0 0 0 0 0 0 2 0 0
0 17 2 0 0 0 0 0 2 0 0
0 17 3 0 0 0 0 0 2 0 0
0 19 1 0 0 0 0 0 2 0 0
0 18 2 0 0 0 0 0 2 0 0
0 5 2 1 1 0 3 0 2 0 0
0 5 3 4 0 2 0 0 3 0 0
0 2 1 1 1 2 0 0 2 0 0
0 2 2 2 0 1 0 0 1 0 0
0 10 9 2 0 1 0 0 1 0 0
0 0 0 0 0 0 0 0 3 0 0
0 5 3 2 1 1 0 0 0 0 0
0 1 2 2 0 1 0 0 4 0 0
0 3 2 2 0 0 0 0 2 0 0
0 6 3 3 0 1 0 0 2 0 0
0 3 1 0 0 0 0 0 2 0 0
0 12 1 0 0 0 0 0 2 0 0
0 1 0 0 0 0 0 0 2 0 0
0 4 0 1 1 0 0 0 2 0 0
0 4 1 0 0 0 1 0 2 0 0
0 2 0 0 0 0 0 0 2 0 0
0 1 0 0 0 0 0 0 2 0 0
0 1 1 1 1 0 0 0 2 0 0
0 8 3 1 0 0 1 0 2 0 0
0 8 4 1 1 0 2 0 2 0 0
0 1 5 2 0 1 0 0 1 0 0
0 0 4 2 0 1 0 0 2 0 0
0 0 2 2 0 1 0 0 2 0 0
0 4 6 1 4 0 0 0 2 0 0
0 2 4 2 1 0 0 0 2 0 0
0 1 4 1 2 1 0 0 2 0 0
0 0 4 1 2 2 0 0 2 0 0
0 0 3 1 1 0 0 0 2 0 0
0 0 4 1 1 0 0 0 2 0 0
0 0 2 2 3 2 0 0 2 0 0
0 3 4 2 0 0 0 0 1 0 0
0 0 4 1 0 0 0 0 2 0 0
0 0 0 0 1 0 0 0 2 0 0
0 4 6 1 4 0 0 0 2 0 0
0 13 5 0 1 0 0 0 2 0 0
0 8 4 0 0 1 0 0 2 0 0
0 4 6 0 0 0 0 0 2 0 0
0 13 5 0 0 0 0 0 2 0 0
0 6 4 0 0 0 0 0 2 0 0
0 10 3 2 0 0 0 0 2 0 0
0 5 3 0 2 3 0 0 2 0 0
0 7 6 1 2 0 0 0 1 0 0
0 10 2 0 2 0 0 0 3 0 0
0 10 2 1 2 0 0 0 3 0 0
0 6 1 2 1 0 0 0 1 0 0
0 6 2 2 3 0 0 0 2 0 0
0 9 2 1 0 0 0 0 3 0 0
0 9 2 1 3 0 0 0 2 0 0
0 8 2 1 1 0 0 0 2 0 0
0 8 2 0 0 0 0 0 3 0 0
0 1 0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0 0
0 1 1 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0 0 0
0 3 0 0 0 3 0 0 0 0 0
0 1 0 0 0 2 0 0 0 0 0
0 4 1 0 1 3 0 0 0 0 0
0 1 0 0 0 0 0 0 0 0 0
0 0 3 0 0 0 0 0 2 0 0
0 0 3 0 0 0 0 0 2 0 0
0 0 3 0 0 0 0 0 2 0 0
0 0 4 0 0 0 0 0 2 0 0
0 0 3 0 0 0 2 0 2 0 0
0 0 3 0 0 0 0 0 2 0 0
0 0 3 0 0 0 0 0 2 0 0
0 0 2 0 0 0 1 0 2 0 0
0 0 3 0 0 0 1 0 2 0 0
0 0 3 0 0 0 2 0 2 0 0
2 0 1 0 0 0 0 0 0 0 0
6 1 1 0 0 0 0 0 3 0 0
6 0 2 0 0 0 0 0 3 0 0
6 1 1 0 0 0 0 0 0 0 0
8 2 1 0 0 0 0 0 0 0 0
5 1 1 0 0 0 0 0 3 0 0
5 0 1 0 0 0 0 0 0 0 0
12 4 0 0 0 0 0 0 2 0 0
8 1 3 0 0 0 0 0 2 0 0
3 1 2 0 0 0 0 0 3 0 0
0 0 0 0 0 0 0 0 2 0 0
0 0 0 0 0 0 0 0 1 0 0
0 0 1 0 0 0 0 0 0 0 0
0 0 2 0 0 0 0 0 0 0 0
0 1 2 0 0 0 0 0 2 0 0
0 0 2 0 0 0 0 0 2 0 0
0 3 0 0 0 0 0 0 2 0 0
0 0 1 0 0 0 0 0 2 0 0
0 1 1 0 0 0 0 0 2 0 0
0 0 2 0 0 0 0 0 1 0 0
0 5 3 0 0 0 0 0 0 0 0
0 2 3 0 0 1 0 0 0 0 0
0 6 3 0 0 0 1 0 0 0 0
0 0 2 0 0 1 0 0 0 0 0
0 0 0 0 0 2 0 0 0 0 0
0 4 4 0 0 0 0 0 0 0 0
0 0 4 0 0 1 0 0 0 0 0
0 13 6 0 0 0 1 0 0 0 0
0 1 5 0 0 0 0 0 0 0 0
0 4 4 0 0 0 0 0 0 0 0
0 7 4 0 1 1 0 0 2 0 0
9 3 2 0 0 2 0 0 2 0 0
0 2 1 0 0 0 0 0 2 0 0
32 16 3 0 0 2 0 0 2 0 0
0 14 7 0 0 0 0 0 2 0 0
0 9 4 0 1 0 0 0 2 0 0
0 19 1 0 0 0 0 0 2 0 0
0 2 0 0 0 0 0 0 2 0 0
19 3 6 0 0 0 0 0 2 0 0
0 10 3 2 0 0 0 0 2 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
19 9 2 0 1 0 0 0 1 0 0
0 9 8 0 1 0 0 0 2 0 0
0 14 5 0 0 1 0 0 2 0 0
0 15 5 0 0 1 0 0 2 0 0
0 13 6 0 0 1 0 0 2 0 0
0 12 7 0 1 1 0 0 2 0 0
0 14 5 0 1 1 0 0 2 0 0
0 15 5 0 0 1 0 0 2 0 0
0 14 5 0 0 1 0 0 2 0 0
16 8 3 1 0 1 0 0 2 0 0
0 9 4 0 0 1 0 0 2 0 0
0 9 8 0 0 1 1 0 1 0 0
0 5 0 0 0 1 0 0 1 0 0
0 9 9 0 1 0 0 0 0 0 0
0 9 7 0 3 0 0 0 0 0 0
0 13 6 0 2 0 0 0 0 0 0
0 12 7 0 1 0 0 1 0 0 0
0 6 8 0 4 3 0 0 2 0 0
0 8 6 0 5 0 0 0 2 0 0
0 7 9 0 1 0 0 0 2 0 0
0 7 5 0 4 0 0 0 2 0 0
0 9 8 0 0 1 1 0 1 0 0
0 5 0 0 0 1 0 0 1 0 0
0 9 9 0 1 0 0 0 0 0 0
0 9 7 0 3 0 0 0 0 0 0
0 13 6 0 2 0 0 0 0 0 0
0 12 7 0 1 0 0 1 0 0 0
0 6 8 0 4 3 0 0 2 0 0
0 8 6 0 5 0 0 0 2 0 0
0 7 9 0 1 0 0 0 2 0 0
0 7 5 0 4 0 0 0 2 0 0
0 16 4 0 0 0 0 0 2 0 0
0 8 4 0 1 0 0 0 2 0 0
0 9 8 0 0 0 0 0 2 0 0
0 10 4 0 1 0 0 0 2 0 0
0 17 1 0 0 0 0 0 2 0 0
0 15 0 0 0 0 0 0 2 0 0
0 17 2 0 0 0 0 0 2 0 0
0 17 3 0 0 0 0 0 2 0 0
0 19 1 0 0 0 0 0 2 0 0
0 18 2 0 0 0 0 0 2 0 0
0 10 8 0 0 0 0 1 3 0 0
0 0 0 0 0 0 0 0 4 0 0
0 0 0 0 0 0 0 0 4 0 0
0 1 5 1 0 0 0 1 3 0 0
0 0 1 0 1 0 0 0 2 0 0
0 0 0 0 0 0 0 0 3 0 0
0 6 4 2 1 0 0 0 3 0 0
0 5 3 4 6 0 0 0 2 0 0
0 2 1 0 0 0 0 0 2 0 0
0 5 0 4 3 0 0 0 4 0 0
0 9 5 0 0 0 1 0 4 0 0
0 6 7 0 0 0 0 0 4 0 0
0 6 6 0 0 0 0 0 3 0 0
0 14 5 0 0 1 0 0 4 0 0
0 7 5 0 1 0 0 0 2 0 0
0 6 4 0 0 0 0 0 4 0 0
0 9 3 0 0 0 0 0 3 0 0
0 6 4 0 0 0 0 0 2 0 0
0 4 7 0 0 0 0 0 4 0 0
0 9 6 0 2 0 0 0 4 0 0
0 6 0 0 0 0 0 0 2 0 0
0 1 0 0 0 0 0 0 4 0 0
0 10 3 0 0 0 0 0 2 0 0
0 2 1 0 0 0 0 0 0 0 0
5 1 1 0 0 0 0 0 3 0 0
8 2 1 0 0 0 0 0 0 0 0
3 1 2 0 0 0 0 0 3 0 0
0 7 5 0 4 0 0 0 2 0 0
0 6 8 0 4 3 0 0 2 0 0
0 7 9 0 1 0 0 0 2 0 0
0 5 3 0 2 3 0 0 2 0 0
0 7 6 1 2 0 0 0 1 0 0
0 10 2 0 2 0 0 0 3 0 0
0 10 2 1 2 0 0 0 3 0 0
0 6 1 2 1 0 0 0 1 0 0
0 6 2 2 3 0 0 0 2 0 0
0 9 2 1 0 0 0 0 3 0 0
0 9 2 1 3 0 0 0 2 0 0
0 8 2 1 1 0 0 0 2 0 0
0 8 2 0 0 0 0 0 3 0 0
24 9 7 0 0 0 0 0 2 0 0
8 0 0 0 0 0 0 0 2 0 0
11 0 0 0 0 0 0 0 2 0 0
20 1 6 0 0 0 1 0 1 0 0
4 0 0 0 2 2 0 0 2 0 0
8 0 0 0 0 0 0 0 2 0 0
20 6 6 0 1 1 0 0 2 0 0
8 0 0 0 0 0 0 0 2 0 0
11 3 0 0 0 0 0 0 2 0 0
20 4 3 0 1 1 0 0 0 0 0
14 7 0 0 1 0 0 2 0 0
0 11 11 0 1 0 0 0 2 0 0
0 0 6 0 1 0 0 0 2 0 0
0 2 10 0 2 0 0 0 3 0 0
0 2 10 0 1 2 0 0 2 0 0
0 0 8 7 0 0 0 0 2 0 0
0 0 9 0 2 0 0 0 2 0 0
0 0 6 0 0 1 0 0 1 0 0
0 0 5 0 1 0 0 0 2 0 2
0 0 3 0 0 1 0 0 2 0 0
0 0 3 0 0 1 0 0 2 0 0
0 0 10 0 1 2 0 0 2 0
3 0 2 1 0 2 0 0 2 0 0
8 0 3 0 0 0 0 0 2 0 0
12 0 0 0 3 0 0 0 3 0 0
5 0 1 0 0 0 0 0 2 0 0
2 0 1 1 0 0 0 0 0 0 0
6 0 1 0 0 0 0 0 3 0 0
6 0 2 2 1 0 0 0 3 0 0
6 0 1 0 0 0 0 0 3 0 0
8 0 1 0 0 0 0 0 1 0 0
5 0 1 0 0 0 0 0 4 0 0
0 0 0 0 0 0 0 0 2 0 0
0 0 0 0 0 0 0 0 2 0 0
0 0 7 0 0 0 0 0 2 0 0
0 0 0 0 0 1 0 0 2 0 0
0 0 0 0 0 0 0 0 2 0 0
0 0 0 0 0 0 0 0 2 0 0
0 0 0 0 0 0 0 0 2 0 0
0 2 0 0 0 0 0 0 4 0 0
RENCANA PERAWATAN
Konservasi Pencabutan
Kebersihan Kebersihan
GT GS GT GS Observasi Dirujuk Ke Keterangan
Mulut Mulut
2 3 1 3 1 0 0 Puskesmas Exo
2 3 0 4 0 0 0 0 0
2 3 0 4 0 0 0 0 0
2 3 0 2 0 0 0 0 0
2 2 0 2 0 0 0 0 0
2 2 0 4 0 1 0 0 0
2 3 0 2 0 0 0 0 0
2 2 0 3 0 1 0 0 0
2 3 0 3 0 0 0 Puskesmas Sukajadi 0
2 3 0 0 0 0 0 Puskesmas Ciumbuleuit 0
2 1 0 0 1 0 0 0 0
2 3 3 4 1 5 0 Puskesmas 0
2 1 2 0 1 0 0 Puskesmas 0
2 1 2 0 1 0 0 Puskesmas 0
2 1 1 0 0 0 0 Puskesmas 0
2 1 0 1 0 1 0 Puskesmas 0
2 1 2 0 1 0 0 Puskesmas 0
2 1 2 0 3 0 0 Puskesmas 0
2 1 1 0 2 2 0 Puskesmas 0
2 1 1 0 2 2 0 Puskesmas 0
2 2 1 0 2 2 0 Puskesmas 0
2 3 1 1 1 1 0 Puskesmas 0
2 3 1 2 1 1 0 Puskesmas 0
2 3 2 1 1 1 0 Puskesmas 0
2 3 1 0 2 2 0 Puskesmas 0
2 3 1 2 1 1 0 Puskesmas 0
2 3 0 0 4 4 0 Puskesmas 0
2 3 2 1 0 0 0 Puskesmas 0
2 3 0 0 1 1 0 Puskesmas 0
2 3 0 2 1 1 0 Puskesmas 0
2 3 2 1 0 0 0 Puskesmas 0
0 3 0 1 1 0 0 Puskesmas 0
0 3 1 1 0 3 0 Puskesmas 0
0 3 2 1 0 1 0 Puskesmas 0
2 3 0 1 1 0 0 Puskesmas 0
2 2 0 1 3 3 0 Puskesmas 0
2 3 0 1 3 3 0 Puskesmas 0
2 3 0 1 0 2 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 3 2 0 0 Puskesmas 0
2 3 0 1 1 1 0 Puskesmas 0
2 3 0 1 1 0 0 Puskesmas 0
2 3 0 0 0 2 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
1 3 1 3 2 2 0 Puskesmas 0
2 2 0 4 0 6 0 Puskesmas 0
2 2 0 2 0 2 0 Puskesmas 0
2 2 0 4 0 3 0 Puskesmas 0
2 2 1 1 4 5 0 Puskesmas 0
2 2 0 4 3 1 0 Puskesmas 0
2 2 0 7 4 0 0 Puskesmas 0
2 2 0 2 5 0 0 Puskesmas 0
2 2 0 0 10 0 0 Puskesmas 0
2 2 0 0 11 0 0 Puskesmas 0
2 3 0 0 1 0 0 Puskesmas 0
2 2 0 1 1 1 0 Puskesmas 0
2 3 0 1 1 1 0 Puskesmas 0
2 3 0 1 1 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 4 0 1 0 Puskesmas 0
2 3 0 1 1 1 0 Puskesmas 0
2 3 0 2 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 0 2 0 0 Puskesmas 0
2 3 0 3 0 1 0 0 0
2 3 0 2 0 5 0 0 0
2 2 0 1 1 3 0 0 0
2 3 1 0 2 1 0 0 0
2 3 1 0 3 0 0 0 0
0 1 0 1 2 1 0 0 0
2 3 1 3 1 0 0 0 0
2 3 1 0 1 1 0 0 0
2 3 0 0 1 2 0 0 0
2 3 0 3 0 0 0 Puskesmas 0
2 3 0 4 0 1 0 Puskesmas 0
2 3 0 1 0 1 0 Puskesmas 0
2 3 1 0 2 0 0 Puskesmas 0
2 3 0 6 0 2 0 Puskesmas 0
2 3 1 0 3 0 0 Puskesmas 0
2 3 0 2 0 2 0 Puskesmas 0
2 3 1 1 1 1 0 Puskesmas 0
2 3 0 2 0 2 0 Puskesmas 0
2 3 2 2 0 3 0 Puskesmas 0
2 3 0 1 0 0 0 0 0
2 3 0 0 0 2 0 0 0
2 3 0 0 1 0 0 0 0
2 3 0 0 0 1 0 0 0
2 3 0 0 0 0 0 0 0
2 3 0 0 0 0 0 0 0
2 3 0 0 2 0 0 0 0
2 3 0 0 2 1 8 0 0
2 3 0 1 0 2 0 0 0
2 3 0 1 0 3 0 0 0
2 3 8 3 0 3 0 Puskesmas 0
2 3 0 1 0 3 0 Puskesmas 0
2 3 0 2 0 1 0 Puskesmas 0
2 3 0 4 0 3 0 Puskesmas 0
2 3 0 3 0 2 0 Puskesmas 0
2 3 0 2 0 2 0 Puskesmas 0
2 3 0 1 0 2 0 Puskesmas 0
2 3 0 1 0 3 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 1 0 Puskesmas 0
2 3 0 2 0 3 0 Puskesmas 0
2 3 0 1 0 2 0 Puskesmas 0
2 3 0 1 1 0 0 Puskesmas 0
2 3 0 3 0 4 0 Puskesmas 0
2 3 0 2 0 3 0 Puskesmas 0
2 3 0 3 0 0 0 Puskesmas 0
2 2 0 3 0 1 0 Puskesmas 0
2 3 0 2 0 3 0 Puskesmas 0
2 2 0 3 0 1 0 Puskesmas 0
2 3 0 1 0 2 0 Puskesmas 0
2 3 0 0 1 3 0 Puskesmas 0
2 3 0 6 1 0 0 Puskesmas 0
2 3 0 0 1 2 0 Puskesmas 0
2 3 0 0 1 2 0 Puskesmas 0
2 3 0 0 0 2 0 Puskesmas 0
2 3 0 0 0 4 0 Puskesmas 0
2 3 0 0 1 3 0 Puskesmas 0
2 3 0 1 1 2 0 Puskesmas 0
2 3 0 0 0 2 0 Puskesmas 0
2 3 0 0 1 2 0 Puskesmas 0
2 3 1 3 1 0 0 Puskesmas 0
2 2 1 3 0 0 0 Puskesmas 0
2 2 1 3 0 0 0 Puskesmas 0
2 2 0 4 0 0 0 Puskesmas 0
2 2 0 3 0 0 0 Puskesmas 0
2 3 1 3 1 0 0 Puskesmas 0
2 2 1 3 0 0 0 Puskesmas 0
2 2 1 2 0 0 0 Puskesmas 0
2 2 0 3 0 0 0 Puskesmas 0
2 2 0 3 0 0 0 Puskesmas 0
1 3 0 0 2 0 0 Puskesmas Endodontik
1 3 3 0 0 1 0 Puskesmas 0
0 3 2 1 0 1 0 Puskesmas 0
0 3 1 2 0 1 0 Puskesmas 0
0 1 2 1 0 1 0 Puskesmas 0
2 2 2 0 2 0 0 Puskesmas Endodontik
2 2 2 1 0 2 0 Puskesmas Exodontik
2 2 3 1 0 2 0 Puskesmas 0
1 1 3 1 0 1 0 Puskesmas 0
0 0 1 2 0 2 0 Puskesmas 0
0 3 0 1 1 0 0 Puskesmas 0
0 3 1 1 0 3 0 Puskesmas 0
0 3 2 1 0 1 0 Puskesmas 0
0 3 2 0 2 0 0 Puskesmas 0
0 3 0 0 0 4 0 Puskesmas 0
0 3 0 0 0 4 0 Puskesmas 0
0 3 0 1 0 6 0 Puskesmas 0
0 3 0 0 0 5 0 Puskesmas 0
0 3 0 2 1 2 0 Puskesmas 0
2 3 1 3 2 1 0 Puskesmas 0
2 3 0 2 1 0 0 Puskesmas 0
2 3 0 1 1 1 0 0 0
2 3 4 2 0 0 0 Puskesmas 0
2 3 0 3 4 2 0 Puskesmas 0
2 3 0 3 0 0 0 0 0
2 3 1 1 1 0 0 0 0
2 3 0 0 2 0 0 Puskesmas 0
0 1 0 0 3 3 0 Puskesmas 0
2 3 0 0 0 3 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 1 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 0 0 0 0 0 Puskesmas 0
2 3 2 9 0 0 0 Puskesmas Merpati 0
2 3 0 0 0 0 0 Puskesmas Cempaka 0
2 3 0 0 0 0 0 Puskesmas Mawar 0
2 3 0 0 0 0 0 Puskesmas Salamun 0
2 3 0 0 0 0 0 Puskesmas Langonsari 0
2 3 0 0 0 0 0 Puskesmas Ledeng 0
2 3 0 0 0 0 0 Puskesmas Trisakti 0
2 3 0 0 0 0 0 Puskesmas Cibatu 0
2 3 2 9 0 0 0 Puskesmas Merpati 0
2 3 0 0 0 0 0 Puskesmas Cempaka 0
2 3 0 0 0 0 0 Puskesmas Mawar 0
2 3 0 0 0 0 0 Puskesmas Salamun 0
2 3 0 0 0 0 0 Puskesmas Langonsari 0
2 3 0 0 0 0 0 Puskesmas Ledeng 0
2 3 0 0 0 0 0 Puskesmas Trisakti 0
2 3 0 0 0 0 0 Puskesmas Cibatu 0
2 3 1 3 1 0 0 Puskesmas Endo
2 3 0 3 0 1 0 0 0
2 3 0 2 0 5 0 0 0
2 2 0 1 0 3 0 0 0
2 3 1 0 2 1 0 0 0
2 3 1 0 3 0 0 0 0
1 3 0 1 2 1 0 0 0
2 3 1 1 1 2 0 0 0
2 3 1 0 1 1 0 0 0
2 3 0 0 1 2 0 0 0
2 3 3 4 1 0 0 Puskesmas 0
2 3 1 2 2 3 0 Puskesmas 0
2 3 1 2 1 4 0 Puskesmas 0
2 3 2 3 1 2 0 Puskesmas 0
2 3 3 4 1 1 0 Puskesmas 0
2 3 2 4 1 0 0 Puskesmas 0
2 3 1 3 1 0 0 Puskesmas 0
2 3 1 4 3 0 0 Puskesmas 0
2 3 2 4 2 2 0 Puskesmas 0
2 3 2 3 2 2 0 Puskesmas 0
2 3 1 0 3 0 0 Puskesmas Prahia
2 3 0 0 1 0 0 Puskesmas Prahia
2 3 1 3 1 0 0 Puskesmas
2 3 0 0 0 0 0 Puskesmas Ciumbuleuit
2 3 1 1 2 0 0 Puskesmas Sukajadi
2 3 2 2 1 3 0 Puskesmas Cibatu
2 3 1 2 0 7 0 Puskesmas Trisakt
2 3 0 0 1 3 0 Puskesmas 0
2 3 0 6 1 0 0 Puskesmas 0
2 3 0 0 1 2 0 Puskesmas 0
2 3 0 0 1 2 0 Puskesmas 0
2 3 0 0 0 2 0 Puskesmas 0
2 3 0 0 0 4 0 Puskesmas 0
2 3 0 0 1 3 0 Puskesmas 0
2 3 0 1 1 2 0 Puskesmas 0
2 3 0 0 0 2 0 Puskesmas 0
2 3 0 0 1 2 0 Puskesmas 0
2 3 0 4 1 1 0 Puskesmas 0
2 3 2 2 0 2 0 Puskesmas 0
2 3 0 1 0 2 0 Puskesmas 0
2 3 0 2 0 2 0 Puskesmas 0
2 3 1 2 4 3 0 Puskesmas 0
2 3 0 4 3 1 0 Puskesmas 0
2 3 0 6 4 1 0 Puskesmas 0
2 3 0 2 5 0 0 Puskesmas 0
2 3 0 0 10 0 0 Puskesmas 0
2 3 0 0 11 0 0 Puskesmas 0
2 3 0 0 11 0 0 Puskesmas 0
PTI RTI Prevalensi def-t
GS GT GS GT GS GT Prevalensi Karies
0.0006113537 0.0285714 1.68 1.58 2.29 1.75 #REF!
0.0011876485 0.0276243 3.42 3.17 4.21 1.81 #REF!
0.0014728682 0.0529801 2.99 1.43 3.87 1.51 #REF!
0.002122449 0.0555556 3.81 2.83 4.9 3.06 #REF!
def-t 2.29 SDN Sukamanah 1
4.21 SDN Sukamanah II
3.87 SDN Sukamanah III
4.9 SDN Sukamanah IV
4.9
4.21
3.87
SDN Sukamanah IV SDN Sukamanah III SDN Sukamanah II S
DMF-T 1.75 SDN Sukamanah 1

Rata-Rata 1.81 SDN Sukamanah II
1.51 SDN Sukamanah III 3.5
3.06 SDN Sukamanah IV 3
2.5
1.75
2 1.81
1.5 1.5
1
0.5
0
SDN Sukamanah 1
SDN Sukamanah II
SDN Sukama
BAIK SEDANG BURUK

Kriteria OHSDN Sukam 43 50 7
SDN Sukam 34 56 10
SDN Sukama 55 40 5 KRITERIA O
SDN Sukam 24 63 13
50 56
70 7 10 55 40
60 43
50 5
40 34
30
20 2
10
0
1
ah II
an ah I II
m an ah IV
ka m an
h
Su ka m a na
N Su ka am
SD N Su k
SD N Su
SD N
SD
0
1
ah II
an ah I II
m an ah IV
ka m an
h
Su ka m a na
N Su ka am
SD N Su k
SD N Su
SD N
SD
PTI SDN Sukamanah 1

SDN Sukamanah II
SDN Sukamanah III
SDN Sukamanah IV
SDN Sukamanah 1
SDN Sukamanah II
SDN Sukamanah III
SDN Sukamanah IV
RTI SDN Sukamanah 1

SDN Sukamanah II
SDN Sukamanah III
SDN Sukamanah IV
2.83
3.17
1.43
3.5
3
2.5 1.58
2
1.5
1
0.5
0
Prevalensi SDN Sukam 326 326%

SDN Sukam
SDN Sukama
659
442
659%
442% PREVAL
SDN Sukam 664 664%
15.59%
31.76%
PREVAL
15.59%
31.76%
31.52%
21.14%
5
4.5
4
3.5
3
2.5
2
4.21 1.5
3.87
1
0.5
Rata-rata
0
2.29
def-t
ukamanah III SDN Sukamanah II SDN Sukamanah 1
3.06
1.81
1.51
Rata-Rata
SDN Sukamanah II
SDN Sukamanah III
SDN Sukamanah IV
DMF-T
KRITERIA OHI-S
50 56
63
7 10 55 40
5 13
34 BAIK
24 SEDANG
BURUK
BURUK
SEDANG
II BAIK
ah I II
an ah IV
am an ah
uk m an
ka a m
Su k
N Su
SD N
SD
BURUK
SEDANG
II BAIK
ah I II
an ah IV
am an ah
uk m an
ka a m
Su k
N Su
SD N
SD
PTI GT
RTI GT
2.83
SDN Sukamanah 1
3.17
SDN Sukamanah II
1.43
SDN Sukamanah III
SDN Sukamanah IV 4
3.5
.58 3
2.5
2
1.5
1
0.5
0
PREVALENSI KARIES
15.59% SDN Sukamanah 1

1.76% SDN Sukamanah II
SDN Sukamanah III
PREVALENSI KARIES
15.59% SDN Sukamanah 1

1.76% SDN Sukamanah II
SDN Sukamanah III
SDN Sukamanah IV
31.52%
21.14%
PTI GS
RTI GS
3.81
2.99 SDN Sukamanah 1

3.42 SDN Sukamanah II
SDN Sukamanah III
4 SDN Sukamanah IV
3.5
3
2.5 1.68
2
1.5
1
0.5
0
PTI GS
TI GS
ukamanah 1
ukamanah II
ukamanah III
ukamanah IV

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KEMENTERIAN KESEHATAN R.

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

NOSA LETAK CARIES

KARTU SURVEY KESEHATAN GIGI DAN MULUT

Keadaan gigi 9 9 9 0 9 9 0 0 0 0 9 9 9 9 9 9 0 0 0 KODE:

85 84 83 82 81 71 72 73 74 75 0 >0 0 KMP NON

Segment Segment Segment

1. DIAGNOSA 2. RENCANA PERAWATAN

1.5. Kebersihan Mulut :

KARTU SURVEY KESEHATAN GIGI DAN M

NAMA: Deva Budi Permata Gender: 2P= 1 No. Resp.:

Plaque Score Calculus Score

72 73 74 75 0 >0 0 KMP NONVITAL = PN PALATAL = P

2.3. Pencabutan : CE INF

2.5. Dirujuk ke : Puskesmas Sukajadi