FORMAT PENGKAJIAN KEPE

DATA DEMOGRAFI

Sturuktur Keluarga Daftar Anggo

Suku/Bangsa
Pekerjaan
JK kepala
Nama KK

keluarga
Agama

Nama

Umur
Umur

Pend
No.

No
1 MR 5 1 1 1 1 1 1 IT 5
2 AW 3
3 BW 3
2 MA 5 1 1 1 2 1 1 YN 5
3 RHT 5 1 1 1 5 1 1 SD 5
2 MA 3
3 NW 3
4 BDG 6 1 1 4 3 1 1 HL 6
2 RH 3
5 SDR 5 1 2 4 4 1 1 SYR 4
6 IP 5 1 1 1 2 1 1 RA 5
2 AN 1
7 AN 5 2 1 3 2 1 1 SR 5
2 MY 5
3 HP 5
4 AI 5
8 HT 6 1 1 5 4 1 1 SR 5
2 HN 5
9 AKM 5 1 1 2 7 1 1 PP 5
2 KP 5
3 DS 5
4 MP 4
5 MK 2
10 MDR 6 1 1 3 6 1 1 STM 6
2 SYR 5
3 KS 5
4 DJ 5
5 KM 5
11 DDN 5 1 1 2 5 1 1 FI 5
2 RA 3
3 OF 3
 4 AI 2
12 MI 1 1 1 1 2 1 1 RO 5
2 AF 2
13 ROT 2 1 1 2 5 1 1 HJH 5
14 AM 5 1 1 4 3 1 1 FA 5
2 KH 2
15 RHY 5 1 1 3 4 1 1 SU 5
2 SC 5
3 JU 5
4 MIS 2
5 MIK 1
16 STN 5 1 1 3 4 1 1 MW 5
2 MRS 5
3 MRU 5
4 WY 5
5 IS 5
6 NH 4
17 HDM 5 1 1 2 2 1 1 MAI 5
2 NR 3
3 RM 3
4 MA 3
5 MC 2
18 RDS 5 1 1 2 3 1 1 FTM 5
2 NN 3
3 RR 3
4 NB 2
19 ADR 5 1 1 2 2 1 1 KK 5
2 KE 5
20 ABR 5 1 1 4 7 1 1 JHJH 5
2 MAR 5
3 DW 5
21 JM 6 2 1 1 6 1 1 PP 5
22 KUR 5 1 1 2 2 1 1 DKP 5
2 APP 3
23 UDN 5 1 1 3 2 1 1 RM 5
2 FTM 5
3 IR 5
4 MIR 5
5 NUR 4
6 IRF 4
7 IRS 3
8 NUN 3
24 HSN 6 1 1 3 2 1 1 HJI 6
2 HN 5
3 MF 5
 4 RA 5
5 HS 3
25 BDB 6 1 1 4 3 1 4 J 6
R 5
U 5
26 MDL 5 1 1 4 2 1 5 N 5
P 5
A 5
M 4
27 DL 5 1 1 4 3 1 6 L 5
M 4
P 4
A 3
C 2
28 JP 5 1 1 4 3 1 7 M 5
F 5
F 5
F 5
F 5
F 5
29 HDT 6 1 1 4 4 1 3 R 5
M 3
30 SDS 5 1 1 5 3 1 4 S 5
M 3
M 2
31 DS 5 1 1 2 2 1 5 E 5
A 5
S 5
P 4
32 AE 5 1 1 2 2 1 4 M 5
A 3
P 5
33 GL 5 1 1 2 3 1 4 N 5
S 5
R 3
34 HD 6 1 1 2 6 1 3 A 5
P 5
35 R 5 1 1 3 5 1 4 G 5
E 5
A 5
36 AKG 6 1 1 4 5 1 1
37 I 5 1 1 3 3 1 5 R 5
A 4
U 4
M 3
38 NR 5 1 1 3 4 1 1 0 0
39 OJ 5 2 1 2 2 4 4L 4
V 3
M 3
40 NS 5 1 1 2 4 1 Y 5
Y 5
Y 5
F 4
41 DA 5 1 1 2 5 1 F 5
H 5
A 3
A 3
42 HR 5 1 1 2 5 1 S 5
H 2
43 E 5 1 1 2 3 1 N 5
AH 3
AR 3
44 WDT 6 1 2 4 4 1 Y 5
D 5
S 5
R 5
45 H 6 1 1 3 3 1 R 5
46 F 5 1 1 4 3 1 WG 5
NAA 3
48 SA 5 1 1 2 2 1 M 5
MYNR 3
MNZA 3
49 DR 6 1 1 4 5 1 DG 5
HS 5
H 5
50 AR 5 1 1 2 5 1 A 5
NAR 4
FAR 3
51 SDS 5 1 1 4 3 1 B 5
B 3
R 3
52 BDG 6 1 1 4 3 1 H 6
H 5
R 2
53 MS 5 1 1 3 5 1 M 5
T 3
A 6
ML 5
54 AE 6 1 1 2 5 1 N 5
APP 3
55 TML 6 2 2 4 7 1 S 5
Y 5
56 RT 6 1 1 2 2 1 HR 6
57 SN 6 1 2 3 4 1 M 5
MR 5
MR 5
W 5
I 5
N 5
58 AA 5 1 1 3 2 1 N 5
AA 5
AA 5
AA 4
59 ZDB 5 1 1 2 2 1 R 5
S 5
R 5
RIS 4
60 DWM 5 1 1 2 7 1 R 5
U 4
H 3
GKAJIAN KEPERAWATAN KOMUNITAS

OGRAFI

Data
Daftar Anggota Keluarga
ekonomi Perumahan

Tipe Rumah
kepemilikan
Penghasilan
Pekerjaan

Ket Fisik

Perbulan
Hub.klg

Agama

Lantai
Status
Pend

Ket
Jk

2 1 1 1 2 1 3 3 1 3
2 2 1 4 7 1
2 2 1 6 7 1
2 1 1 1 5 1 2 3 1 3
2 1 1 1 5 1 2 3 1 3
1 2 1 4 7 1
2 2 1 4 7 1
2 1 1 4 4 1 1 3 1 3
1 2 1 6 7 1
1 2 1 5 7 1 1 3 1 3
2 1 1 2 4 1 2 2 1 3
2 2 1 6 7 1
2 1 2 3 4 2 2 3 2 1
2 2 2 1 7 1
1 2 2 3 7 1
1 2 2 6 7 1
2 2 1 2 5 1 2 3 1 3
2 2 1 2 5 1
2 1 2 3 4 1 2 3 1 4
2 2 2 2 7 1
1 2 1 2 7 1
2 2 2 3 7 1
2 2 2 3 7 1
2 1 1 4 4 1 2 3 1 3
1 2 1 1 7 1
2 2 1 1 7 1
1 2 1 2 7 1
1 2 1 4 7 1
2 1 1 2 4 1 3 3 1 3
1 2 1 4 7 1
1 2 1 6 7 1
2 2 1 6 7 1
2 1 1 2 4 1 2 2 1 3
2 2 1 7 7 1
2 1 1 3 4 1 2 3 1 3
2 1 1 3 4 1
2 2 1 6 7 1 1 2 1 4
2 1 1 4 7 1 1 1 1 3
2 2 1 6 7 1
1 2 1 3 7 1
1 2 1 6 7 1
1 2 1 6 7 1
2 1 1 2 7 1 1 3 1 3
1 2 1 3 2 1
1 2 1 2 7 1
2 2 1 2 7 1
2 2 1 2 7 1
2 2 1 5 7 1
2 1 1 2 4 1 2 3 2 4
2 2 1 4 7 1
1 2 1 4 7 1
2 2 1 6 7 1
1 2 1 6 7 1
2 1 1 2 4 1 1 1 2 4
2 2 1 3 7 1
1 2 1 3 7 1
2 2 1 6 7 1
2 3 1 2 2 1 2 3 1 3
2 3 1 2 2 1
2 1 1 3 4 2 Stroke 1 3 2 2
1 2 1 2 7 1
1 2 1 2 7 1
2 3 1 2 4 1 2 3 1 3
2 1 1 2 4 1 2 1 1 3
1 3 1 6 7 1
2 1 1 3 4 1 2 3 3 2
2 2 1 3 7 1
1 2 1 5 7 1
2 2 1 5 7 1
2 2 1 5 7 2 PAROTITIS
1 2 1 6 7 1
1 2 1 6 7 1
2 2 1 6 7 1
2 1 1 2 4 1 3 3 2 3
2 2 1 1 5 1
1 3 1 4 7 1
 2 3 1 2 7 1
2 3 1 3 7 1
2 1 1 4 4 2 KK 1 2 3 1 3
2 2 1 2 7 1
2 3 1 4 3 1
2 1 1 4 4 2 KK 2 2 3 1 1
2 2 1 2 5 1
2 2 1 2 5 1
2 2 1 2 5 1
2 1 1 2 4 2 KK 3 2 1 1 3
1 2 1 1 7 1
2 2 1 2 7 1
2 2 1 2 7 1
2 3 1 4 7 1
2 1 1 2 4 2 KK 4 2 3 1 4
1 2 1 2 7 1
1 2 1 2 5 1
2 2 1 2 7 1
1 2 2 1 2 1
2 2 1 2 7 1
1 2 1 2 2 2 KK 5 1 3 1 3
1 3 1 3 7 2
2 1 1 4 4 1 KK 6 2 3 1 3
1 2 1 4 7 1
1 2 1 6 7 1
2 1 1 2 4 2 KK 7 2 3 1 3
1 2 1 2 7 1
2 2 1 2 7 1
2 2 1 6 7 1
2 1 1 2 4 1 KK 8 3 3 1 3
1 2 1 6 7 1
1 2 1 6 7 1
2 1 1 2 4 2 KK 9 2 3 1 3
1 2 1 2 3 1
1 2 1 6 7 1
2 1 1 2 4 2 KK 10 3 3 1 3
1 2 1 6 7 1
2 1 1 2 4 1 KK 11 1 3 1 3
1 2 1 2 7 1
1 2 1 7 7 1
2 KK 12 1 3 1 4
2 1 1 2 4 1 KK 13 2 3 1 3
2 2 1 2 7 1
2 2 1 2 7 1
1 2 1 6 7 1
0 0 0 0 0 1 KK 14 1 2 1 3
2 1 2 2 4 1 KK 15
2 2 2 4 7 1
1 2 2 4 7 1
2 2 1 2 7 KK 16 1 1 2 4
1 2 1 2 7
2 2 1 2 7
2 2 1 6 7
2 1 1 2 4 KK 17 3 3 1 3
2 3 1 4 4
1 2 1 4 7
1 2 1 6 7
2 1 1 2 7
1 2 1 6 7
2 1 1 3 4 2 3 2 2
1 2 1 4 7
1 2 1 4 7
2 2 1 2 7 1 3 1 4
2 2 1 3 7
1 2 1 4 7
1 2 1 4 7
2 1 1 5 4 2 3 1 3
2 1 1 4 4 2 3 1 3
2 2 1 4 7
2 1 1 2 4 2 3 1 3
1 2 1 2 7
1 2 1 2 7
2 1 1 4 4 2 3 1 4
1 2 1 2 7
2 2 1 4 7
2 1 1 2 1 3 3 1 3
2 2 1 2 7
2 2 1 3 7
2 1 1 3 4 2 3 1 3
1 2 1 3 7
1 2 1 4 7
2 1 1 4 4 1 3 1 4
1 2 1 2 7
1 2 1 3 7
2 2 1 1 1 3 3 1 3
1 2 1 3 7
2 3 1 2 6
1 3 1 2 5
2 1 1 2 4 2 3 1 4
1 2 1 3 7 2 3 1 4
2 3 2 3 7
2 3 1 3 7
2 1 1 3 4 2 3 1 3
2 2 1 2 7 2 3 1 3
1 2 1 3 2
1 2 1 2 7
2 2 1 2 7
2 2 1 2 7
2 2 1 2 7
2 1 1 3 4 2 3 1 3
2 2 1 3 7
2 2 1 3 7
2 2 1 4 7
2 1 1 2 7 2 3 1 4
1 2 1 4 7
1 2 1 4 7
2 2 1 4 7
2 1 1 4 4 1 3 2 4
1 2 1 4 7
2 2 1 4 7
 LINGKUNGAN FISIK

Pembuangan
Perumahan Sumber Air Pembuangan Sampah
Limbah

mandi/mencuci

Penampiungan
Jendela setiap

Jarak dengan
pencahayaan

Pembuangan

Membuang
sumber air

Kebiasaan
airminum

Keadaan
tetangga

Sampah

Sampah

Kondisi
Dimana
Sumber

sampah
tempat
rumah

rumah

Air
1 1 2 3 1 1 5 1 1 1 1

1 1 2 3 1 1 5 1 1 1 1
1 1 2 3 1 1 5 1 1 1 1

2 1 2 3 1 1 5 1 1 1 1

1 1 1 3 1 1 5 1 1 1 1
2 2 1 3 1 1 5 1 1 1 1

2 2 2 3 1 1 5 2 1 1 1

2 2 2 3 1 1 5 1 2 1 1

1 1 1 3 1 1 5 1 1 1 1

1 1 3 3 1 1 5 1 1 1 1

1 1 2 3 1 1 5 1 1 1 1
1 2 1 3 1 1 5 1 1 1 1

1 1 2 3 1 1 5 1 1 1 1

1 1 2 3 1 1 5 1 2 1 1
1 1 2 3 1 1 5 1 2 1 1

1 1 2 3 1 1 5 1 2 1 1

1 2 2 3 1 3 5 1 1 1 1

1 1 1 3 1 1 5 1 1 1 1

1 1 2 3 1 1 5 2 2 1 1

1 2 2 3 1 3 5 1 1 1 1

1 1 1 3 2 3 5 1 1 1 1
1 1 2 3 1 2 5 1 1 1 1

1 2 1 3 2 3 5 1 1 1 1

1 2 2 3 1 1 5 1 2 1 1
1 1 2 3 1 1 1 1 1 1 1

1 1 1 3 1 1 1 1 2 1 1

1 2 1 3 1 3 1 1 1 1 2

1 1 2 3 1 1 1 2 2 1 1

1 1 1 3 1 3 1 1 2 5 2

1 1 1 3 1 3 1 1 1 1 1

1 1 2 3 1 1 1 1 2 1 1

1 1 3 3 1 1 1 1 2 1 1

1 2 1 3 2 3 1 1 2 1 1

1 2 1 3 1 1 1 1 2 1 1

1 1 1 3 1 1 1 1 2 1 1

1 3 1 3 1 3 1 1 2 1 1
1 2 2 3 1 1 1 1 1 1 1
1 1 1 3 1 3 1 1 2 1 1

1 2 1 3 1 1 1 1 2 1 1

1 1 3 3 1 1 1 1 2 1 1

1 2 1 3 1 3 1 1 1 1 1

2 2 1 3 2 3 1 1 1 1 1

1 2 1 3 2 3 1 1 1 1 1
1 1 1 3 1 3 1 1 1 1 1

1 1 1 3 1 3 1 1 1 1 1

1 3 1 3 1 3 1 1 2 1 1

1 1 2 3 1 1 1 1 1 1 1

1 1 1 3 1 1 1 1 1 1 1

1 1 2 3 1 3 1 1 1 1 1

1 1 2 3 1 1 1 1 1 1 1

1 1 2 3 1 2 1 1 1 1 1
1 1 2 3 1 2 1 1 1 1 1
1 1 2 3 1 1 1 1 1 1 1
1 1 2 3 1 1 1 1 1 1 1

2 2 2 3 1 3 1 1 1 1 1

2 2 2 3 1 2 3 1 1 1 1

2 2 1 3 2 3 3 1 1 1 1
 KONDISI KESEHATAN UMUM

Pasangan Usia
Kandang Ternak Pelayanan Kesehatan Ibu Hamil
Subur

Masalah
sebelum Ke Pel

data ibu hamil

kehamilan Ke
Kepemilikan

Pemeriksaan
Kesehatan

aksektor KB

Kontrasepsi
pendanaan
Kebiasaan

Kebiasaan

kehamilan
Keluarga
Kondisi

Sumber
Khusus

Jenis
kes

1 2 2 1 0 2 0 1 0 0

2 2 1 0 2 1 1 0 0
1 2 2 1 0 2 1 1 0 0

1 2 2 1 Hemodialisa

1 2 2 1 0 1 0 1 0 0
1 1 1 2 0 2 2 1 0 0

1 2 2 1 artritis 1 0 1 0 0

2 1 2 2 1 Gastritis 1 0 1 0 0

1 2 2 1 0 1 0 1 0 0

2 3 2 0 1 0 1 0 0

1 2 2 2 Batuk pilek 2 2 1 0 0
1 0 2 2 1 0 2 3 1 0 0

1 0 1 1 1 0 1 0 1 0 0

1 0 2 1 2 0 2 2 1 0 0
1 0 2 1 2 0 2 2 1 0 0

1 0 2 1 2 HIPERTENSI 1 0 0 0 0

2 1 2 1 2 0 2 2 0 0 0

1 0 2 1 2 0 1 0 0 0 0

1 0 2 1 1 0 1 0 1 0 0

1 0 2 1 2 Stroke 1 0 1 0 0

2 1 2 1 2 Stroke 1 0 1 0 0
2 1 3 1 1 HT + DM 1 0 1 0 0

1 0 2 1 2 PAROTITIS 1 0 1 0 0

1 2 2 1 0 1 0 1 0 0
1 0 1 1 2 Hipertensi 1 0 1 0 0

1 0 2 1 1 Batuk, Pilek 1 0 1 0 0

1 0 2 1 2 Batuk, Pilek 1 0 0 0 0

1 0 1 2 2 Skizofrenia 1 3 1 0 0

1 0 2 1 2 Hipertensi 1 0 1 0 0
Asam Urat
1 0 2 1 2 0 2 2 1 0 0

2 1 3 1 3 HT 1 0 1 0 0

1 0 2 1 1 0 1 0 1 0 0

1 0 2 1 2 Asam urat 1 0 1 0 0

1 0 1 2 1 HT, DM 1 0 1 0 0

2 1 2 1 2 0 1 0 1 0 0

2 1 2 1 2 Ginjal 1 0 1 0 0
1 0 2 2 2 0 1 0 1 0 0
1 0 2 1 2 0 1 0 1 0 0

1 0 2 1 2 0 1 0 1 0 0

1 0 1 1 2 skizofrenia 1 0 1 0 0

1 0 2 1 2 0 1 0 1 0 0

1 0 2 1 2 0 1 0 1 0 0

1 0 2 1 2 0 2 2 1 0 0
1 0 2 1 2 0 2 2 1 0 0

1 0 2 1 2 0 2 2 1 0 0

2 1 2 1 2 0 2 3 1 0 0

1 0 2 1 1 0 2 2 1 0 0

1 0 2 1 1 0 2 3 1 0 0

1 0 2 1 2 0 0 0 0 0 0

1 0 2 1 1 0 2 2 0 0 0

2 1 2 1 2 0 0 0 0 0
2 1 2 1 2 0 0 0 0 0
2 1 2 1 2 0 0 0 0 0
2 1 2 1 2 HT 1 0 1 0 0

2 1 2 1 2 1 0 1 0 0

1 0 2 1 2 1 0 1 0 0

1 0 2 1 2 1 0 1 0 0
 IBU HAMIL & MENYUSUI

Ibu Menyusui lama menyusui Balita Anak & Remaja Usia Lanjut
menyusui anak

Jenis Penyakit
Kondisi Anak
Penimbangan

Kepemilikan

Data Lansia
Pendidikan
Usia Anak
Imunisasi
Buteki

Balita

KMS
1 0 0 2 2 2 0 0 0 1 0

1 0 0 1 0 0 0 0 0 1 0
1 0 0 1 0 0 2 2 1 1 0

1 0 0 1 0 0 0 0 0 1 0
2 2 4 2 2 0 0 0 0 1 0

1 0 0 2 1 1 0 0 0 2 2

1 0 0 2 1 1 0 0 0 2 2

1 0 0 1 0 0 2 3 3 1 0

1 0 0 1 0 0 0 0 0 1 0

1 0 0 1 0 0 2 1 1 1 0
2 2 4 2 2 2 0 0 0 1 0

1 0 0 1 0 0 2 1 1 1 0

1 1 2 2 2 2 0 0 0 1 0
2 2 3 2 2 2 3 5 1 1 0

1 0 0 1 0 0 0 0 0 2 3

1 0 0 2 2 2 2 2 1 1 0

1 0 0 2 2 2 3 2 1 1 0

1 0 0 1 0 0 0 0 0 1 0

1 0 0 1 0 0 0 0 0 2 stroke

1 0 0 1 0 0 0 0 0 1 0
1 0 0 1 0 0 1 1 1 1 0

1 0 0 2 2 2 3 3 2 1 0

1 0 0 1 0 0 2 2 1 2 1
1 0 0 1 0 0 0 0 0 2 HT

1 0 0 1 0 0 0 0 0 1 0

1 0 0 1 0 0 2 1 1 1 0

1 0 0 1 0 0 2 3 1 1 0

1 0 0 1 0 0 1 1 1 2 HT

2 2 3 2 2 2 2 1 1 1 0

1 0 0 1 0 0 0 0 0 1 0

1 0 0 1 0 0 1 1 1 1 0

1 0 0 1 0 0 2 1 1 1 0

1 0 0 1 0 0 0 0 0 2 DM

1 0 0 1 0 0 2 3 1 1 0

1 0 0 1 0 0 3 3 1 2 0
1 0 0 1 0 0 2 1 1 1 0
1 0 0 1 0 0 0 0 0 1 0

1 0 0 1 0 0 3 3 1 1 0

1 0 0 0 0 0 1 1 1 1 0

1 0 0 1 0 0 1 1 1 1 0

1 0 0 1 0 0 1 0 1 2 0

1 0 0 1 0 0 1 0 1 2 0
1 0 0 1 0 0 1 4 1 1 0

1 0 0 1 0 0 2 2 1 1 0

1 0 0 1 0 0 1 0 0 2 0

1 0 0 1 0 0 3 2 0 1 0

0 0 0 0 0O 2 3 0 0 0

0 0 0 0 0 2 3 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 3 3 0 1 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 2 HT

1 0 0 1 0 0 1 3 1 1 0

1 0 0 1 0 0 4 3 1 1 0

1 0 0 1 0 0 3 3 1 1 0
Usia Lanjut
Kegiatan Lansia
Pengobatan

jk kepala
keluarga
Upaya

0 0 1
1
1
0 0 1
0 0 1
2
1
2
1
0 0 1
0 0 2
1
Reumatik 3 1
2
1
1
Reumatik 3 1
1
0 0 1
1
1
1
1
0 0 1
1
2
2
1
0 0 1
1
1
 1
0 0 1
1
0 0 2
2
0 0 1
0 0 1

1 1

0 0

0 0

0 0

1 4

0 0
0 0

0 0

0 0
1 2

0 0

0 0

0 0

3 1

0 0

0 0

0 0

0 0

1 2

0 0

3 1
0 0
0 0

0 0

0 0

0 0

0 0

0 0
0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0
0 0
0 0
2 0

0 0

0 0

0 0
umur agama jk kk pendidikanpekerjaan
5 1 1 1 1
5 1 1 1 2
5 1 1 1 5
6 1 1 4 3
5 1 2 4 4
5 1 1 1 2
5 2 1 3 2
6 1 1 5 4
5 1 1 2 7
6 1 1 3 6
5 1 1 2 5
1 1 1 1 2
2 1 1 2 5
5 1 1 4 3
5 1 1 3 4
5 1 1 3 4
5 1 1 2 2
5 1 1 2 3
5 1 1 2 2
5 1 1 4 7
6 2 1 1 6
5 1 1 2 2
5 1 1 3 2
6 1 1 3 2
6 1 1 4 3
5 1 1 4 2
5 1 1 4 3
5 1 1 4 3
6 1 1 4 4
5 1 1 5 3
5 1 1 2 2
5 1 1 2 2
5 1 1 2 3
6 1 1 2 6
5 1 1 3 5
6 1 1 4 5
5 1 1 3 3
5 1 1 3 4
5 2 1 2 2
5 1 1 2 4
5 1 1 2 5
5 1 1 2 5
5 1 1 2 3
6 1 2 4 4
6 1 1 3 3
5 1 1 4 3
5 1 1 2 2
6 1 1 4 5
5 1 1 2 5
5 1 1 4 3
6 1 1 4 3
5 1 1 3 5
6 1 1 2 5
6 2 2 4 7
6 1 1 2 2
6 1 2 3 4
5 1 1 3 2
5 1 1 2 2
5 1 1 2 7
5 1 2 1 2
3 1 2 4 7
3 1 2 6 7
5 1 2 1 5
5 1 2 1 5
3 1 1 4 7
3 1 2 4 7
6 1 2 4 4
3 1 1 6 7
4 1 1 5 7
5 1 2 2 4
1 1 2 6 7
5 2 2 3 4
5 2 2 1 7
5 2 1 3 7
5 2 1 6 7
5 1 2 2 5
5 1 2 2 5
5 2 2 3 4
5 2 2 2 7
5 1 1 2 7
4 2 2 3 7
2 2 2 3 7
6 1 2 4 4
5 1 1 1 7
5 1 2 1 7
5 1 1 2 7
5 1 1 4 7
5 1 2 2 4
3 1 1 4 7
3 1 1 6 7
2 1 2 6 7
5 1 2 2 4
2 1 2 7 7
5 1 2 3 4
5 1 2 3 4
2 1 2 6 7
5 1 2 4 7
5 1 2 6 7
5 1 1 3 7
2 1 1 6 7
1 1 1 6 7
5 1 2 2 7
5 1 1 3 2
5 1 1 2 7
5 1 2 2 7
5 1 2 2 7
4 1 2 5 7
5 1 2 2 4
3 1 2 4 7
3 1 1 4 7
3 1 2 6 7
2 1 1 6 7
5 1 2 2 4
3 1 2 3 7
3 1 1 3 7
2 1 2 6 7
5 1 2 2 2
5 1 2 2 2
5 1 2 3 4
5 1 1 2 7
5 1 1 2 7
5 1 2 2 4
5 1 2 2 4
3 1 1 6 7
5 1 2 3 4
5 1 2 3 7
5 1 1 5 7
5 1 2 5 7
4 1 2 5 7
4 1 1 6 7
3 1 1 6 7
3 1 2 6 7
6 1 2 2 4
5 1 2 1 5
5 1 1 4 7
5 1 2 2 7
3 1 2 3 7
6 1 2 4 4
5 1 2 2 7
5 1 2 4 3
5 1 2 4 4
5 1 2 2 5
5 1 2 2 5
4 1 2 2 5
5 1 2 2 4
4 1 1 1 7
4 1 2 2 7
3 1 2 2 7
2 1 2 4 7
5 1 2 2 4
5 1 1 2 7
5 1 1 2 5
5 1 2 2 7
5 2 1 1 2
5 1 2 2 7
5 1 1 2 2
3 1 1 3 7
5 1 2 4 4
3 1 1 4 7
2 1 1 6 7
5 1 2 2 4
5 1 1 2 7
5 1 2 2 7
4 1 2 6 7
5 1 2 2 4
3 1 1 6 7
5 1 1 6 7
5 1 2 2 4
5 1 1 2 3
3 1 1 6 7
5 1 2 2 4
5 1 1 6 7
5 1 2 2 4
5 1 1 2 7
5 1 1 7 7
5 1 2 2 4
4 1 2 2 7
4 1 2 2 7
3 1 1 6 7
4 2 2 2 4
3 2 2 4 7
3 2 1 4 7
5 1 2 2 7
5 1 1 2 7
5 1 2 2 7
4 1 2 6 7
5 1 2 2 4
5 1 2 4 4
3 1 1 4 7
3 1 1 6 7
5 1 2 2 7
2 1 1 6 7
5 1 2 3 4
3 1 1 4 7
3 1 1 4 7
5 1 2 2 7
5 1 2 3 7
5 1 1 4 7
5 1 1 4 7
5 1 2 5 4
5 1 2 4 4
3 1 2 4 7
5 1 2 2 4
3 1 1 2 7
3 1 1 2 7
5 1 2 4 4
5 1 1 2 7
5 1 2 4 7
5 1 2 2 1
4 1 2 2 7
3 1 2 3 7
5 1 2 3 4
3 1 1 3 7
3 1 1 4 7
6 1 2 4 4
5 1 1 2 7
2 1 1 3 7
5 1 2 1 1
3 1 1 3 7
6 1 2 2 6
5 1 1 2 5
5 1 2 2 4
3 1 1 3 7
5 2 2 3 7
5 1 2 3 7
6 1 2 3 4
5 1 2 2 7
5 1 1 3 2
5 1 1 2 7
5 1 2 2 7
5 1 2 2 7
5 1 2 2 7
5 1 2 3 4
5 1 2 3 7
5 1 2 3 7
4 1 2 4 7
5 1 2 2 7
5 1 1 4 7
5 1 1 4 7
4 1 2 4 7
5 1 2 4 4
4 1 1 4 7
3 1 2 4 7
 Status kepemilikan

Penampiungan Air
Jendela setiap

Jarak dengan
pencahayaan
Tipe Rumah
Penghasilan

jika di PAM
Sumber air
Perbulan

tetangga

tempat
Lantai

rumah

rumah
1 1 1

3 3 1 3 1 1 2
2 3 1 3 1 1 2 1 1 1
2 3 1 3 1 1 2 1 1 1
1 3 1 3 2 1 2 1 1 1
1 3 1 3 1 1 1 1 1 1
2 2 1 3 2 2 1 1 1 1
2 3 2 1 2 2 2 1 1 1
2 3 1 3 2 2 2 1 1 1
2 3 1 4 1 1 1 1 1 1
2 3 1 3 1 1 3 1 1 1
3 3 1 3 1 1 2 1 1 1
2 2 1 3 1 2 1 1 1 1
2 3 1 3 1 1 2 1 1 1
1 2 1 4 1 1 2 1 1 1
1 1 1 3 1 1 2 1 1 1
1 3 1 3 1 1 2 1 1 1
2 3 2 4 1 2 2 1 1 3
1 1 2 4 1 1 1 1 1 1
2 3 1 3 1 1 2 1 1 1
1 3 2 2 1 2 2 1 1 3
2 3 1 3 1 1 1 1 2 3
2 1 1 3 1 1 2 1 1 2
2 3 3 2 1 2 1 1 2 3
3 3 2 3 1 2 2 1 1 1
2 3 1 3 1 1 2 1 1 1
2 3 1 1 1 1 1 1 1 1
2 1 1 3 1 2 1 1 1 3
2 3 1 4 1 1 2 1 1 1
1 3 1 3 1 1 1 1 1 3
2 3 1 3 1 1 1 1 1 3
2 3 1 3 1 1 2 1 1 1
3 3 1 3 1 1 3 1 1 1
2 3 1 3 1 2 1 1 2 3
3 3 1 3 1 2 1 1 1 1
1 3 1 3 1 1 1 1 1 1
1 3 1 4 1 3 1 1 1 3
2 3 1 3 1 2 2 1 1 1
1 2 1 3 1 1 1 1 1 3
1 1 2 4 1 2 1 1 1 1
3 3 1 3 1 1 3 1 1 1
2 3 2 2 1 2 1 1 1 3
1 3 1 4 2 2 1 1 2 3
2 3 1 3 1 2 1 1 2 3
2 3 1 3 1 1 1 1 1 3
2 3 1 3 1 1 1 1 1 3
2 3 1 4 1 3 1 1 1 3
3 3 1 3 1 1 2 1 1 1
2 3 1 3 1 1 1 1 1 1
1 3 1 4 1 1 2 1 1 3
3 3 1 3 1 1 2 1 1 1
2 3 1 4 1 1 2 1 1 2
2 3 1 4 1 1 2 1 1 2
2 3 1 3 1 1 2 1 1 1
2 3 1 3 1 1 2 1 1 1
2 3 1 3 2 2 2 1 1 3
2 3 1 4 2 2 2 1 1 2
1 3 2 4 2 2 1 1 2 3
3 1 3 1 1 2 1 1 1 1
2 2 1 3 2 2 1 1 1 1
 Membuang sampah

Keadaan Sampah
Pembuangan

Kepemilikan
Kebiasaan
Sampah

Dimana

Kondisi
Pasangan Usia
Ibu Hamil
Subur
Masalah
Kesehata
n Khusus

Kontrasepsi
aksektor

data ibu
hamil
Jenis
KB
5 1 1 1 1 1
5 1 1 1 1 1 0 2 1 1
5 1 1 1 1 1 0 2 1 1
5 1 1 1 1 1 0 1 0 1
5 1 1 1 1 1 0 1 0 1
5 1 1 1 1 1 0 2 2 1
5 2 1 1 1 1 0 1 0 1
5 1 2 1 1 2 1 1 0 1
5 1 1 1 1 1 0 1 0 1
5 1 1 1 1 1 0 1 0 1
5 1 1 1 1 1 0 2 2 1
5 1 1 1 1 1 0 2 3 1
5 1 1 1 1 1 0 1 0 1
5 1 2 1 1 1 0 2 2 1
5 1 2 1 1 1 0 2 2 1
5 1 2 1 1 1 0 1 0 0
5 1 1 1 1 2 1 2 2 0
5 1 1 1 1 1 0 1 0 0
5 2 2 1 1 1 0 1 0 1
5 1 1 1 1 1 0 1 0 1
5 1 1 1 1 2 1 1 0 1
5 1 1 1 1 2 1 1 0 1
5 1 1 1 1 1 0 1 0 1
5 1 2 1 1 1 0 1 0 1
1 1 1 1 1 1 0 1 0 1
1 1 2 1 1 1 0 1 0 1
1 1 1 1 2 1 0 1 0 0
1 2 2 1 1 1 0 1 3 1
1 1 2 5 2 1 0 1 0 1
1 1 1 1 1 1 0 2 2 1
1 1 2 1 1 2 1 1 0 1
1 1 2 1 1 1 0 1 0 1
1 1 2 1 1 1 0 1 0 1
1 1 2 1 1 1 0 1 0 1
1 1 2 1 1 2 1 1 0 1
1 1 2 1 1 2 1 1 0 1
1 1 1 1 1 1 0 1 0 1
1 1 2 1 1 1 0 1 0 1
1 1 2 1 1 1 0 1 0 1
1 1 2 1 1 1 0 1 0 1
1 1 1 1 1 1 0 1 0 1
1 1 1 1 1 1 0 1 0 1
1 1 1 1 1 1 0 2 2 1
1 1 1 1 1 1 0 2 2 1
1 1 1 1 1 1 0 2 2 1
1 1 2 1 1 2 1 2 3 1
1 1 1 1 1 1 0 2 2 1
1 1 1 1 1 1 0 2 3 1
1 1 1 1 1 1 0 0 0 0
1 1 1 1 1 1 0 2 2 0
1 1 1 1 1 2 1 0 0 0
1 1 1 1 1 2 1 0 0 0
1 1 1 1 1 2 1 0 0 0
1 1 1 1 1 2 1 1 0 1
1 1 1 1 1 2 1 1 0 1
3 1 1 1 1 1 0 1 0 1
3 1 1 1 1 1 0 1 0 1
1 1 1 1 1 0 2 2 0 0
5 1 1 1 1 1 0 2 2 1
Ibu Hamil Ibu Menyusui Balita Anak & Remaja

Kepemilika
Pemeriksaa

Penimbang

Pendidikan
Usia Anak
kehamilan

kehamilan

menyusui

Imunisasi
menyusui

an Balita

n KMS
Buteki

lama
anak
Ke

0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 2 2
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 0 0
0 0 2 2 4 2 2 0 0 0
0 0 1 0 0 2 1 1 0 0
0 0 1 0 0 2 1 1 0 0
0 0 1 0 0 1 0 0 2 3
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 2 1
0 0 2 2 4 2 2 2 0 0
0 0 1 0 0 1 0 0 2 1
0 0 1 1 2 2 2 2 0 0
0 0 2 2 3 2 2 2 3 5
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 2 2 2 2 2
0 0 1 0 0 2 2 2 3 2
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 1 1
0 0 1 0 0 2 2 2 3 3
0 0 1 0 0 1 0 0 2 2
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 2 1
0 0 1 0 0 1 0 0 2 3
0 0 1 0 0 1 0 0 1 1
0 0 2 2 3 2 2 2 2 1
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 1 1
0 0 1 0 0 1 0 0 2 1
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 2 3
0 0 1 0 0 1 0 0 3 3
0 0 1 0 0 1 0 0 2 1
0 0 1 0 0 1 0 0 0 0
0 0 1 0 0 1 0 0 3 3
0 0 1 0 0 0 0 0 1 1
0 0 1 0 0 1 0 0 1 1
0 0 1 0 0 1 0 0 1 0
0 0 1 0 0 1 0 0 1 0
0 0 1 0 0 1 0 0 1 4
0 0 1 0 0 1 0 0 2 2
0 0 1 0 0 1 0 0 1 0
0 0 1 0 0 1 0 0 3 2
0 0 0 0 0 0 0 O 2 3
0 0 0 0 0 0 0 2 3
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 3 3
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 1 0 0 1 3
0 0 1 0 0 1 0 0 4 3
0 0 1 0 0 1 0 0 3 3
0 0 0 0 0 0 0 0 0 0
0 0 2 2 4 2 2 0 0 0
Remaja Usia Lanjut
Data Lansia

Pengobatan

Kegiatan
Penyakit
Kondisi

Lansia
Upaya
Anak

Jenis

0 1 0 0 0
1 1 0 0 0
0 1 0 0 0
0 1 0 0 0
0 1 0 0 0
0 2 Reumatik 1 3
0 2 Reumatik 1 3
3 1 0 0 0
0 1 0 0 0
1 1 0 0 0
0 1 0 0 0
1 1 0 0 0
0 1 0 0 0
1 1 0 0 0
0 2 3 1 1
1 1 0 0 0
1 1 0 0 0
0 1 0 0 0
0 2 stroke 1 4
0 1 0 0 0
1 1 0 0 0
2 1 0 0 0
1 2 1 0 0
0 2 HT 1 2
0 1 0 0 0
1 1 0 0 0
1 1 0 0 0
1 2 HT 3 1
1 1 0 0 0
0 1 0 0 0
1 1 0 0 0
1 1 0 0 0
0 2 DM 1 2
1 1 0 0 0
1 2 0 3 1
1 1 0 0 0
0 1 0 0 0
1 1 0 0 0
1 1 0 0 0
1 1 0 0 0
1 2 0 0 0
1 2 0 0 0
1 1 0 0 0
1 1 0 0 0
0 2 0 0 0
0 1 0 0 0
0 0 0 0 0
0 1 0 0 0
0 1 0 0 0
0 1 0 0 0
0 0 0 0 0
0 0 0 0 0
0 2 HT 2 0
1 1 0 0 0
1 1 0 0 0
1 1 0 0 0
1 0 0 0 0
0 1 0 0 0
 Data
ekonomi Perumahan Sumber Air

Status kepemilikan

Penampiungan Air
Sumber airminum

mandi/mencuci
Jendela setiap

Jarak dengan
pencahayaan
Tipe Rumah
Penghasilan

sumber air
Perbulan

tetangga

tempat
Lantai

rumah

rumah
3 3 1 3 1 1 2 3 1 1
2 3 1 3 1 1 2 3 1 1
2 3 1 3 1 1 2 3 1 1
1 3 1 3 2 1 2 3 1 1
1 3 1 3 1 1 1 3 1 1
2 2 1 3 2 2 1 3 1 1
2 3 2 1 2 2 2 3 1 1
2 3 1 3 2 2 2 3 1 1
2 3 1 4 1 1 1 3 1 1
2 3 1 3 1 1 3 3 1 1
3 3 1 3 1 1 2 3 1 1
2 2 1 3 1 2 1 3 1 1
2 3 1 3 1 1 2 3 1 1
1 2 1 4 1 1 2 3 1 1
1 1 1 3 1 1 2 3 1 1
1 3 1 3 1 1 2 3 1 1
2 3 2 4 1 2 2 3 1 3
1 1 2 4 1 1 1 3 1 1
2 3 1 3 1 1 2 3 1 1
1 3 2 2 1 2 2 3 1 3
2 3 1 3 1 1 1 3 2 3
2 1 1 3 1 1 2 3 1 2
2 3 3 2 1 2 1 3 2 3
3 3 2 3 1 2 2 3 1 1
2 3 1 3 1 1 2 3 1 1
2 3 1 1 1 1 1 3 1 1
2 1 1 3 1 2 1 3 1 3
2 3 1 4 1 1 2 3 1 1
1 3 1 3 1 1 1 3 1 3
2 3 1 3 1 1 1 3 1 3
2 3 1 3 1 1 2 3 1 1
3 3 1 3 1 1 3 3 1 1
2 3 1 3 1 2 1 3 2 3
3 3 1 3 1 2 1 3 1 1
1 3 1 3 1 1 1 3 1 1
1 3 1 4 1 3 1 3 1 3
2 3 1 3 1 2 2 3 1 1
1 2 1 3 1 1 1 3 1 3
1 1 2 4 1 2 1 3 1 1
3 3 1 3 1 1 3 3 1 1
2 3 2 2 1 2 1 3 1 3
1 3 1 4 2 2 1 3 2 3
2 3 1 3 1 2 1 3 2 3
2 3 1 3 1 1 1 3 1 3
2 3 1 3 1 1 1 3 1 3
2 3 1 4 1 3 1 3 1 3
3 3 1 3 1 1 2 3 1 1
2 3 1 3 1 1 1 3 1 1
1 3 1 4 1 1 2 3 1 3
3 3 1 3 1 1 2 3 1 1
2 3 1 4 1 1 2 3 1 2
2 3 1 4 1 1 2 3 1 2
2 3 1 3 1 1 2 3 1 1
2 3 1 3 1 1 2 3 1 1
2 3 1 3 2 2 2 3 1 3
2 3 1 4 2 2 2 3 1 2
1 3 2 4 2 2 1 3 2 3
 Pembuangan
Pembuangan Sampah Kandang Ternak
Limbah

Membuang sampah

Keadaan Sampah
Pembuangan

Kepemilikan
Kebiasaan
Sampah

Dimana

Kondisi
5 1 1 1
5 1 1 1
5 1 1 1
5 1 1 1
5 1 1 1
5 1 1 1
5 2 1 1
5 1 2 1
5 1 1 1
5 1 1 1
5 1 1 1
5 1 1 1
5 1 1 1
5 1 2 1
5 1 2 1
5 1 2 1
5 1 1 1
5 1 1 1
5 2 2 1
5 1 1 1
5 1 1 1
5 1 1 1
5 1 1 1
5 1 2 1
1 1 1 1
1 1 2 1
1 1 1 1
1 2 2 1
1 1 2 5
1 1 1 1
1 1 2 1
1 1 2 1
1 1 2 1
1 1 2 1
1 1 2 1
1 1 2 1
1 1 1 1
1 1
1
1 1
1 1
1 1
1 1
1 1
1 2
1 1
1
1 1
1 1
1 1
1 1
1 1
1 1
1 2
1 1
1 1
1 1
1 2
1 2
1 1
1 1
1 1
1 1
2 1
1 1
2 1
1 1
1 2
1 1
1 1
1 1
1 2
1 2
1 1
1 1 2 1 1 1
1 1 2 1 1 1
1 1 2 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 2 1 1 2
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 2
1 1 1 1 1 2
1 1 1 1 1 2
1 1 1 1 1 2
1 1 1 1 1 2
3 1 1 1 1 1
3 1 1 1 1 1
 Pasangan Usia
Ibu Hamil Ibu Menyusui Balita
Subur

Jenis Kontrasepsi

lama menyusui
menyusui anak
data ibu hamil

kehamilan Ke
Masalah

Penimbangan
Pemeriksaan
aksektor KB

kehamilan
Kesehata

Buteki

Balita
n Khusus

0 2 0 1 0 0 1 0 0 2
0 2 1 1 0 0 1 0 0 1
0 2 1 1 0 0 1 0 0 1
1 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
0 2 2 1 0 0 2 2 4 2
2 1 0 1 0 0 1 0 0 2
3 1 0 1 0 0 1 0 0 2
0 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
4 2 2 1 0 0 1 0 0 1
0 2 3 1 0 0 2 2 4 2
0 1 0 1 0 0 1 0 0 1
0 2 2 1 0 0 1 1 2 2
0 2 2 1 0 0 2 2 3 2
5 1 0 0 0 0 1 0 0 1
0 2 2 0 0 0 1 0 0 2
0 1 0 0 0 0 1 0 0 2
0 1 0 1 0 0 1 0 0 1
6 1 0 1 0 0 1 0 0 1
6 1 0 1 0 0 1 0 0 1
5 1 0 1 0 0 1 0 0 1
8 1 0 1 0 0 1 0 0 2
0 1 0 1 0 0 1 0 0 1
5 1 0 1 0 0 1 0 0 1
4 1 0 1 0 0 1 0 0 1
4 1 0 0 0 0 1 0 0 1
9 1 3 1 0 0 1 0 0 1
5 1 0 1 0 0 1 0 0 1
0 2 2 1 0 0 2 2 3 2
5 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
10 1 0 1 0 0 1 0 0 1
7 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
11 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
9 1 0 1 0 0 1 0 0 0
0 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
0 2 2 1 0 0 1 0 0 1
0 2 2 1 0 0 1 0 0 1
0 2 2 1 0 0 1 0 0 1
0 2 3 1 0 0 1 0 0 1
0 2 2 1 0 0 1 0 0 1
0 2 3 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 2 2 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
5 1 0 1 0 0 1 0 0 0
0 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
0 1 0 1 0 0 1 0 0 1
Balita Anak & Remaja Usia Lanjut

Upaya Pengobatan
Kepemilikan KMS

Kegiatan Lansia
Jenis Penyakit
Kondisi Anak

Data Lansia
Pendidikan
Usia Anak
Imunisasi

2 2 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 2 2 1 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
2 0 0 0 0 1 0 0 0
1 1 0 0 0 2 4 2 3
1 1 0 0 0 2 4 2 3
0 0 2 3 3 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 2 1 1 1 0 0 0
2 2 0 0 0 1 0 0 0
0 0 2 1 1 1 0 0 0
2 2 0 0 0 1 0 0 0
2 2 3 5 1 1 0 0 0
0 0 0 0 0 2 3 1 1
2 2 2 2 1 1 0 0 0
2 2 3 2 1 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 2 2 1 4
0 0 0 0 0 1 0 0 0
0 0 1 1 1 1 0 0 0
2 2 3 3 2 1 0 0 0
0 0 2 2 1 2 1 0 0
0 0 0 0 0 2 1 1 2
0 0 0 0 0 1 0 0 0
0 0 2 1 1 1 0 0 0
0 0 2 3 1 1 0 0 0
0 0 1 1 1 2 1 3 1
2 2 2 1 1 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 1 1 1 1 0 0 0
0 0 2 1 1 1 0 0 0
0 0 0 0 0 2 3 1 2
0 0 2 3 1 1 0 0 0
0 0 3 3 1 2 0 3 1
0 0 2 1 1 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 3 3 1 1 0 0 0
0 0 1 1 1 1 0 0 0
0 0 1 1 1 1 0 0 0
0 0 1 0 1 2 0 0 0
0 0 1 0 1 2 0 0 0
0 0 1 4 1 1 0 0 0
0 0 2 2 1 1 0 0 0
0 0 1 0 0 2 0 0 0
0 0 3 2 0 1 0 0 0
0O 2 3 0 0 0 0 0
0 0 2 3 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 3 3 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 2 1 2 0
0 0 1 3 1 1 0 0 0
0 0 4 3 1 1 0 0 0
0 0 3 3 1 1 0 0 0