Formulir E-Ppgbm Ibu Hamil - Des Olohuta
Formulir E-Ppgbm Ibu Hamil - Des Olohuta
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Rizal LihawaJudul Asli
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Format Tersedia
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Format Tersedia
Formulir E-Ppgbm Ibu Hamil - Des Olohuta
Formulir E-Ppgbm Ibu Hamil - Des Olohuta
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Rizal LihawaHak Cipta:
Format Tersedia
KABUPATEN / KOTA Bone Bolanggo/Gorontalo
PUSKESMAS Kabila Bone
PETUGAS ENTRI/TPG Nurhayati Ali
BERAT TANGGAL UKUR
TINGGI BUKU KIA*
BADAN HPHT PENGGUNAAN RIWAYAT
NO KEHAMILAN KE TANGGAL BADAN GOLONGAN RIWAYAT TELP/HP KAB / KOTA* KECAMATAN* PUSKESMAS DESA/KELURA POSYANDU ALAMAT
NOMOR KK* NIK* NAMA* AWAL AWAL HAMIL (DD-MM- HB KONTRASEPSI SEBELUM PENYAKIT YANG NAMA SUAMI* NIK SUAMI* PROVINSI* RT RW
BERAPA* LAHIR HAMIL YYYY)* DARAH KEHAMILAN INI DIDERITA IBU ALERGI SUAMI* PEMBINA* HAN* PEMBINA LENGKAP*
(CM JAN FEB MAR APR MEI JUN JUL
(Kg)
YA TIDAK
FORMAT ELEKTRONIK PELAPORAN PENCATATAN GIZI BERBASIS MASYARAKAT (E-PPGBM)
PENGUKURAN
UKUR BERAT BADAN TINGGI BADAN LILA IMT TINDAKAN TANGGAL PEMERIKSAAN
OKT NOV DES OKT NOV DES OKT NOV DES OKT NOV DES OKT NOV DES OKT NOV DES
AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT
PEMERIKSAAN
KELUHAN SEKARANG TEKANAN DARAH UMUR KEHAMILAN TINGGI FUNDUS LETAK JANIN
OKT NOV DES OKT NOV DES OKT NOV DES OKT NOV DES OKT NOV DES
JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN
PMT
LETAK JANIN DENYUT JANTUNG JANIN/MENIT
SUMBER PMT
OKT NOV DES OKT NOV DES PEMBERIAN PUSAT PEMBERIAN DAERAH
FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT
TANGGAL PEMBERIAN JUMLAH PEMBERIAN TAHUN TANGGAL PEMBERIAN KE JUMLAH PEMBERIAN (KALORI)
PEMBERIAN KE (BUNGKUS) PRODUKSI PEMBERIAN
FORMAT ELEKTRONIK PELAPORAN PENCATATAN GIZI BERBASIS MASYARAKAT (E-PPGBM)
KABUPATEN / KOTA Bone Bolanggo/Gorontalo
PUSKESMAS Kabila Bone
PETUGAS ENTRI/TPG Nurhayati Ali
BERAT
TINGGI BUKU KIA*
BADAN HPHT PENGGUNAAN RIWAYAT
NO KEHAMILAN KE TANGGAL BADAN GOLONGAN RIWAYAT NAMA TELP/HP PROVINSI* KAB / KOTA* KECAMATAN* PUSKESMAS DESA/KELURA POSYANDU ALAMAT
NOMOR KK* NIK* NAMA* AWAL AWAL HAMIL (DD-MM- HB KONTRASEPSI SEBELUM PENYAKIT YANG NIK SUAMI* RT RW
BERAPA* LAHIR HAMIL YYYY)* DARAH KEHAMILAN INI DIDERITA IBU ALERGI SUAMI* SUAMI* PEMBINA* HAN* PEMBINA LENGKAP*
(CM
(Kg)
YA TIDAK
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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FORMAT ELEKTRONIK PELAPORAN PENCATATAN GIZI BERBASIS MASYARAKAT (E-PPGBM)
KABUPATEN / KOTA Bone Bolanggo/Gorontalo
PUSKESMAS Kabila Bone
PETUGAS ENTRI/TPG Nurhayati Ali
PENGUKURAN
TANGGAL UKUR BERAT BADAN TINGGI BADAN LILA IMT TINDAKAN
NO NAMA*
JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
FORMAT ELEKTRONIK PELAPORAN PENCATATAN GIZI BERBASIS MASYARAKAT (E-PPGBM)
KABUPATEN / KOTA Bone Bolanggo/Gorontalo
PUSKESMAS Kabila Bone
PETUGAS ENTRI/TPG Nurhayati Ali
PEMERIKSAAN
TANGGAL PEMERIKSAAN KELUHAN SEKARANG TEKANAN DARAH UMUR KEHAMILAN TINGGI FUNDUS LETAK JANIN DENYUT JANTUNG JANIN/MENIT
NO NAMA*
JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT JAN FEB MAR APR MEI JUN JUL AGST SEPT
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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FORMAT ELEKTRONIK PELAPORAN PENCATATAN GIZI BERBASIS MASYARAKAT (E-PPGBM)
KABUPATEN / KOTA Bone Bolanggo/Gorontalo
PUSKESMAS Kabila Bone
PETUGAS ENTRI/TPG Nurhayati Ali
PMT
SUMBER PMT
NO NAMA*
PEMBERIAN PUSAT PEMBERIAN DAERAH
TANGGAL PEMBERIAN JUMLAH PEMBERIAN TAHUN TANGGAL
PEMBERIAN KE JUMLAH PEMBERIAN (KALORI)
PEMBERIAN KE (BUNGKUS) PRODUKSI PEMBERIAN
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