FORMAT PENDATAAN KELUARGA SEHAT (KS)

PUSKESMAS KAMPALA

DESA : KAMPALA 1 = Ya
DUSUN : KAMPALA RT 04/RW 02 2 = Tidak

Indikator keluarga Sehat

Akses
Nama KK/Anggota
No Urut Keluarga

Akses SAB Gangguan Jiwa TB Paru Hipertensi

No Urut Rumah

Anggot Ibu Imunis

Pendidikan
Jamban Keluarga

Pekerjaan
a Wanita Melahi asi Balita
Hasil Dasar Bayi
JK Tgl. Lahir NIK NO JKN ASI Timban
peng.Teka keluarg 10 - 54 rkan di EKS 7-
a Thn Fasyan Lengka 23 bln g < 5
nan Darah Merok
Hub. Keluarga
Jamba BAB di Di Obat AK Di Obat Di Ikut KB gkes < p 12- thn
Terse Terlin Tersed Obat ok 12 bln 23 bln
Keluarga n Jamba Diagn Teratu dipas Diag Teratu Diagnos Teratur
dia dung ia saniter n osa r ung nosa r a

115 134 BAHAR L 1 `08-10-1964 7307030810640001 0000928780209 4 5 1 1 1 2 2 2 2 2 130/100 1 2

YASMI P 2 `03-05-1975 `7310064305750004 000093143552 3 1 1 1 1 2 2 2 2 2 120/70 2 2
HERO P 6 `31-12-1937 `7307037112370065 0000928778488 2 1 1 1 1 2 2 2 2 2 120/60 2

116 135 MANSIR L 1 `05-07-1977 `7307030507750002 0002365930315 4 1 1 1 1 1 2 2 2 2 2 130/70 1

HAMRAH P 2 31-3/973 `7307034303730001 TIDAK ADA 4 1 1 1 1 1 2 2 2 2 2 90/70 2 2

117 136 GENO P 1 31/12/1938 `7307037112380037 000128582256 5 4 1 1 1 2 2 2 2 2 160/100 2

JUMAIN L 2 01/09/1983 `73070301010983001 TIDAK ADA 3 1 1 1 1 2 2 2 2 2 2

118 137 SUDIRMAN L 1 29/07/1984 7307032907840004 0000929652085 4 6 1 1 1 1 1 2 2 2 2 2 100/70 2

NURAENI P 2 9/9/1990 7307034909900004 0000929652794 3 1 1 1 1 1 1 2 2 2 2 2 90/70 2

AINUN FAJRIANSYAH P 3 1/6/2010 7307030106100001 TIDAK ADA 1 1 1

NURUL FARHANATUL KAMILA P 3 26/10/2013 7307036610130001 0001563806823 1 1 1

119 138 Hume P 1 31/12/1947 7307037112470067 0000929653997 3 1 1 1 1 1 1 2 2 1 1 1150/90 2 N

Safiah P 7 31/12/1969 7307037112690028 0000929653097 3 6 1 1 1 1 1 2 2 2 2 130/80 2 N

139 Akmal L 1 23-01-1994 7303012301940002 0000929654313 5 9 1 1 1 2 2 2 2 2 120/70 2 1

RIska Amalia P 2 28-02-1997 7307036802970002 0002365936659 5 1 1 1 1 2 2 2 2 2 120/70 2 1
Rafa Muzzam P 3 1 1 1 1 2 2 2 2 2 2 1
120 140 SABONTA L 1 31/12/1956 7307033112560043 00001286606446 6 6 1 1 1 1 1 2 2 1 1 150/80 2 N
NILAWATI 31/12/1968 7307037112680086 0000009698174 5 1 1 1 1 1 1 2 2 2 120/80 2 N

121 141 SUARDI L 1 `31-12-1962 `7307033112620084 0002365936672 1 6 1 1 1 2 2 2 2 2 120/60 2 2

RAMLAH P 2 `31-12-1974 `7307037112740060 TIDAK ADA 3 1 1 1 1 2 2 2 2 2 120/60 2 2
RUSNI P 3 `09-02-1993 `7307034902930001 0002365936705 7 1 1 1 1 2 2 2 2 2 110/60 2
RUKMAWATI P 3 `23-11-1996 `7307036311960001 0002365936683 5 2 1 1 1 2 2 2 2 2 2
NURFATIMAH P 3 `04-03-2009 `7307030403090001 TIDAK ADA 2 2 1 1 1 2 2 2 2 2 2

142 RUSDI L 1 `28-01-1988 `7307032801880001 0002365930629 7 6 1 1 1 2 2 2 2 2 110/60 2 2

HERAWATI P 2 `22-06-1988 `7307036206880002 0002365930645 5 1 1 1 1 2 2 2 2 2 2 2
ZAIRATUL L 3 `29-08-2015 `7307036908150001 0002365930631 1 2 1 1 1 2 2 2 2 2 2 1

122 143 MUH. JAFAR L 1 `31-12-1963 `7307033112630082 0001936966241 3 6 1 1 1 2 2 2 2 2 110/80 2 2

MARYAM P 2 `31-12-1967 `7307037112670115 0001936966252 3 5 1 1 1 2 2 2 2 2 110/70 2 2
BACOA L 3 ` 2 2 1 1 1 2 2 2 2 2 1

123 144 SAENUDDIN L 1 `10-07-1975 `7307032107750001 0001563806856 3 6 1 1 1 2 2 2 2 2 120/70 2 2

HARTANI P 2 `04-02-1984 `7307035402840001 0000194637879 4 2 1 1 1 2 2 2 2 2 110/60 2 2
NURUL HIKMAH P 3 27/01/2006 `7307036701060001 0001563806867 3 2 1 1 1 2 2 2 2 2 2
ISMAIL HASAN L 3 30/01/2008 `7307033001080001 0001563806878 2 1 1 1 2 2 2 2 2 2
TENE P 6 31/12/1946 `7307037112460044 000156380689 2 1 1 1 2 2 2 2 2 140/90 2

124 145 NORMA P 1 31/12/1960 7307037112600082 0001479055994 5 1 1 1 2 2 2 2 2ADA SAMA K EBNG2 N

HIJRA P 3 05/10/2008 7307036006030002 0000928671761 2 1 1 1 2 2 2 2 2 100/70 2 N

125 146 MUH. JAMIL L 1 `16-05-1974 `7307031605740001 0001936965745 3 6 1 1 1 2 2 2 2 2 120/80 2 2

NURJANAH P 2 `15-04-1972 `7307035504720001 0001940637857 3 1 1 1 1 2 2 2 2 2 110/70 2 2
ARI ARDIANSYAH L 3 `27-06-2002 `7307033005040003 TIDAK ADA 5 2 1 1 1 2 2 2 2 2 100/70 2
NURAZIZAH JAMIL P 3 `30-05-2004 `7307036706020001 TIDAK ADA 3 2 1 1 1 2 2 2 2 2 2
MUH. AL-AZHAR A L 3 `21-05-2006 `7307032105080003 0001936965778 3 2 1 1 1 2 2 2 2 2 2
RUDI ALAMSYAH L 3 `12-08-2008 `7307031206080001 0001936965789 3 2 1 1 1 2 2 2 2 2 2
ZULFIKAR JAMIL L 3 `04-10-2010 `7307030411100001 0001936965791 3 2 1 1 1 2 2 2 2 2 2
NURFAIKAH JAMIL P 3 `12-10-2012 `7307035210120001 0001936965802 1 2 1 1 1 2 2 2 2 2 2
 RESKI RAMADHANI L 3 `11-07-2015 `7307035107150001 0001936965813 1 2 1 1 1 2 2 2 2 2 2

126 147 HASYIM L 1 31/12/1962 7307033112620075 0001563807058 3 6 1 1 1 2 2 2 2 2 130/90 1

SIBA P 31/12/1968 7307037112680025 0001563807069 3 1 1 1 1 2 2 2 2 2 140/100
' FAJAR MENYINSIR L 20/03/1998 7307032003980001 0001563807071 1 1 1 1 2 2 2 2 2 1

127 148 ARNI P 1 `15-05-1982 `7307035150820001 TIDAK ADA 4 1 1 1 1 2 2 2 2 2 100/90 2

ANRI SETIAWAN L 3 `02-06-2001 `7307030206010003 0001069997556 5 2 1 1 1 2 2 2 2 2 90/70 2
ASTIANI ADRIANI P 3 `23-03-2003 `7300703230303005 TIDAK ADA 4 2 1 1 1 2 2 2 2 2 2
FADIL L 3 `02-03-2006 `7307030203060001 0001069997578 3 2 1 1 1 2 2 2 2 2 2
SALWAH NADIA P 3 `24-01-2009 `7307036401090002 0001069997589 2 2 1 1 1 2 2 2 2 2 2

128 149 SAKKA L 1 `01-07-1959 `7307030107590024 0000929808729 3 6 1 1 1 2 2 2 2 2 120/90 2 2

HALIJA P 2 `01-07-1972 `7307034107720038 0000929809067 3 1 1 1 1 2 2 2 2 2 110/80 2 2
WAHIDA P 3 `12-12-1993 `730703521930006 0000929810158 5 1 1 1 1 2 2 2 2 2 100/70 2
FAHMI L 3 `07-04-1997 `7307030704970005 0000929810891 5 1 1 1 1 2 2 2 2 2 100/60 2
NARTI P 3 `06-01-2000 `7307034601000001 0000929811554 2 2 1 1 1 2 2 2 2 2 100/60 2
IRWAN L 6 `12-12-1988 TIDAK ADA 6 5 1 1 1 2 2 2 2 2 2
ATIBA UFAIRAH P 5 `29-05-2016 TIDAK ADA 1 2 1 1 1 2 2 2 2 2 2

129 150 BAHRI L 1 2/7/1950 7307030702500001 0000128639823 4 3 1 1 1 2 2 2 1 1 150/100 1 N

HUDAYA P 2 5/15/1957 7307035505570001 0000128639834 3 1 1 1 1 2 2 2 1 1 170/110 2

130 151 ZULKIFLI L 1 23/09/1981 7307032309810001 0001101996011 7 3 1 1 1 2 2 2 2 2 110/70 1 1

SURIATI P 2 20/10/1981 7307036010810001 0002365933228 7 3 1 1 1 2 2 2 2 2 100/70 2
PUTRI SALSABILA P 3 01/04/2010 7307031041000001 0000196302598 2 1 1 1 2 2 2 2 2 2
NUR ABDILA P 3 15/04/2017 7307031504170001 0002365933239 1 1 1 2 2 2 2 2 2 1 1 1 1

131 152 TAJUDDIN L 1 `31-12-1966 7307033112660062 0000936966138 1 5 1 1 1 2 2 2 2 2 120/70 1 2

NURASIA P 2 `31-12-1965 7307037112650004 0000936966149 4 9 1 1 1 2 2 2 2 2 `130/80 2 2
RISKA SATRI P 3 `12-02-1998 7307035202980005 0000936966151 6 2 1 1 1 2 2 2 2 2 90/70 2
SAKIA BAIDURI P 3 `10-10-2002 7307035010020002 0000936966162 5 2 1 1 1 2 2 2 2 2 90/70 2

132 153 GENO P 2 `31-12-1958 `7307037112580076 0000928834885 3 1 1 1 1 2 2 2 2 2 140/80 2 2

134 154 MUH. TAHIR L 1 `05-01-1975 7307030501750003 TIDAK ADA 5 3 1 1 1 2 2 2 2 2 133/82 2 2
MILDAYANTI P 2 `31-12-1980 7307037112800002 000162947457 2 1 1 1 1 2 2 2 2 2 110/69 2 2
AMAL TAHIR L 3 `26-03-2004 7307032603040002 0000162947452 4 2 1 1 1 2 2 2 2 2 100/60 2
AGUN ANUGRAH L 3 `27-03-2005 7307032703050001 0000162847578 4 2 1 1 1 2 2 2 2 2 90/60 2
FATAHILLAH L 3 `05-01-2008 7307030504060001 TIDAK ADA 3 2 1 1 1 2 2 2 2 2 106/79 2
AL MUZAQIR L 3 `07-04-2012 7307030704120001 0002365931913 2 1 1 1 2 2 2 2 2 88/65 2

135 155 PT DOLO L 31-12-1934 7307033112350017 TIDAK ADA 5 6 1 1 1 2 2 2 2 2 140/90

HANIA P 31-12-1942 7307037112420039 0000929317656 2 1 1 1 1 2 2 2 2 2 110/80

136 156 IMRAN L 1 `07-08-1979 `7307030788790003 TIDAK ADA 3 5 1 1 1 2 2 2 2 2 160/80 1 2

MISBAH P 2 `03-12-1981 `7301014312810001 TIDAK ADA 6 5 1 1 1 2 2 2 2 2 110/80 2 2
SANDI SAPUTRA L 3 `08-12-2006 7307030812060000 TIDAK ADA 3 2 1 1 1 2 2 2 2 2 2
ALYA FAZILA P 3 `22-09-2012 7307036209120000 TIDAK ADA 3 2 1 1 1 2 2 2 2 2 2

137 157 MUHANI P 1 `31-12-1942 `7307037112420113 0000928654907 3 1 1 1 1 2 2 2 2 2 130/90 2

RUDDING L 3 `10-071972 `7307031007720004 0000928655109 8 1 1 1 2 2 2 2 2 120/80 2

138 158 AGUS L 1 `15-08-1995 `7307031508950002 0000929810676 2 6 1 1 1 2 2 2 2 2 120/80 1 2

ARDA P 2 `23-12-1996 `7307036312980001 TIDAK ADA 2 9 1 1 1 2 2 2 2 2 130/10 2 2
ST. HAJAR P 3 `01-07-2016 ` 2 1 1 1 2 2 2 2 2 2

139 159 DEWA L 1 `31-12-1978 7307030107830042 PBI 6 6 1 1 1 2 2 2 2 2 120/70 1 2

SUNARTI P 2 `31-12-1984 7307037112840073 PBI 6 6 1 1 1 2 2 2 2 2 120/90 2 1
AL MAUMMAR L 3 `03-06-2005 7307030306050002 PBI 4 2 1 1 1 2 2 2 2 2 2
HAERUL M L 3 `15-10-2006 7307031510060001 PBI 4 2 1 1 1 2 2 2 2 2 2
SAHWAL L 3 `29-10-2007 7307032910070001 PBI 3 2 1 1 1 2 2 2 2 2 2
WAHYU AL QADRI L 3 `18-02-2015 7307031802150001 PBI 2 1 1 1 2 2 2 2 2 2
ENRE L 6 `31-12-1947 7307033112470064 0000928637594 1 1 1 1 1 2 2 2 2 2 2

140 160 SYAMSUL ALAM L 1 `30-10-1969 7307030109690002 0001563806531 6 1 1 1 2 2 2 2 2 130/90 1 2

ST. RIANG P 2 `24-10-1974 7307036410740002 PBI 1 1 1 1 2 2 2 2 2 140/90 2 1
ASRUL L 3 `26-05-2001 7307032605010001 0001936966307 6 2 1 1 1 2 2 2 2 2 130/80 2
ST AISYAH P 3 `23-06-2009 7307036306090002 0001563806553 2 1 1 1 2 2 2 2 2 2
AL VIKA P 3 `06-04-2013 7307036604130002 PBI 2 1 1 1 2 2 2 2 2 2
141 161 SUARDI L 1 `10-08-1995 `7307034412990002 0002444191503 3 6 1 1 1 2 2 2 2 2 120/80 2
IRMAWATI P 2 `04-12-1999 `7307031008950002 0002444191413 2 1 1 1 1 2 2 2 2 2 110/70 2
RAHMAT HIDAYAT L 3 `19-09-2015 TIDAK ADA 1 2 1 1 1 2 2 2 2 2 2

162 NURBAYA P 1 `31-12-1971 `7307037112710058 0001069999492 3 1 1 1 1 2 2 2 2 2 130/80 2

INRAWATI P 3 `31-12-1988 `7307031205010002 TIDAK ADA 3 2 1 1 1 2 2 2 2 2 130/70 2
SYAHRUL L 3 `12-05-2001 `7307031205010002 0002365937651 3 2 1 1 1 2 2 2 2 2 110/70 2
SYAHRIL L 3 `05-06-2007 TIDAK ADA 2 2 1 1 1 2 2 2 2 2 2

142 163 TIDAK MAU BUKA PINTU

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