FORMULIR PELAPORAN KASUS DBD

Poli :............................................. Tanggal :....................................

Nama Penderita : ..........................................................................................................................

NIK : ..........................................................................................................................
Tanggal Lahir : .....................................................................Usia : ...........................................
Jenis Kelamin : Laki-laki / Perempuan
Nama Orang Tua : ...........................................................................................................................
Alamat : ....................................................................RT:....................RW:.....................
Kelurahan : ...........................................................................................................................
Kecamatan : ...........................................................................................................................
No. Handphone :............................................................................................................................
Tanda dan Gejala :

 Demam * : ...................................................................................................
 Tanda Pendarahan** :....................................................................................................
Jumlah Trombosit : ............................................................................................................................
Rujuk RS : ...........................................................................................................................

Keterangan :
* : Mohon sebutkan onset demam
**: Mohon sebutkan jenis tanda pendarahan yang muncul

Petugas Pelapor

(.................................)
NIP.

NB : Apabila ada Kasus, mohon untuk menghubungi no WA salah satu yang tertera di bawah :
1. Bagus Kurniawan : 089681429960
2. dr. Anjung Sekar Arum : 087786568897