2. Anamnesa
a. Keluhan Utama :
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b. Riwayat Menstruasi
1) Umur menarche : _____ tahun
2) Lamanya haid : _____ hari
3) Jumlah darah haid : _____ kali ganti pembalut
4) Haid terakhir : _____________________
5) Gangguan haid : _____________________
6) Flour Albous :______________________
3. Pemeriksaan Penunjang
a. Laboratorium
- Darah: _________
- Urin : _________
b. Diagnostik
- CTG: __________
- USG: __________
c. Lain –Lain :__________
C. ANALISA (A)
a. Diagnosa_____________________________________________________________
____________________________________________________________________
b. Masalah_____________________________________________________________
____________________________________________________________________
c. Kebutuhan ___________________________________________________________
____________________________________________________________________
Mengetahui,
Mahasiswa Pelaksana
(Nining Andriani)
(_______________________________) (_______________________________)