Nama Sekolah (tulis

Timestamp Tingkat Pendidikan? dengan lengkap) Kelas

12/12/2020 12:23 SD/MI SLB YPLAB 1

12/12/2020 18:00 SLB SLB YPLAB 9 SMPLB
12/12/2020 19:23 SLB SLB YPLAB WARTAWAN SMPLB
12/15/2020 9:22 SMA/SMK/MA Slb yplab wartawan 10 sma
Nama Lengkap Tanggal Lahir Golongan Darah Nama Orangtua/Wali

Marcello Antonius rompas 9/17/2013 AB Dedi mulyana

M. Indrastoto S 7/13/2005 O Rofikun
ARIIQ RAKA FIKRI 1/7/2006 O DUDIN WAHYUDIN
M Fadli Wiriadinata 3/28/2003 O Eulis Maryati
Alamat tempat tinggal Jika menyandang
saat ini (tulis dengan No. HP/Whatsapp yang Apakah Anda seorang disabilitas, klik sesuai
Jl.banteng
lengkap) kecil no.26a bisa dihubungi penyandang disabilitas? ADHD
dengan(Gangguan
jenis disabilitas:
RT/RW 09/07 Pemusatan
kel.turangga
Seskoad flat D kec.lengkong
302 83822692278 Ya Perhatian/Hiperaktivitas)
Grahita (keterbelakangan
Bandung
JL CIKUTRA BLK 165 GG 81320309318 Ya mental)
Jl terusan barununggal.
NEGLASARI 1 Rt 04 Rw
Cipagalo kulon. 85659325744 Tidak Grahita (keterbelakangan
03 82119945113 Ya mental)
 A. Riwayat Kesehatan Diri
A. Riwayat Kesehatan Diri [Pernah mengalami A. Riwayat Kesehatan Diri A. Riwayat Kesehatan Diri
[Alergi] cedera] [Riwayat kejang berulang] [Riwayat pingsan]

Tidak Tidak Tidak Tidak

Tidak Tidak Ya Tidak
Tidak Tidak Tidak Ya
Tidak Ya Tidak Tidak
A. Riwayat Kesehatan Diri A. Riwayat Kesehatan Diri
[Riwayat transfusi darah [Riwayat kelainan bawaan A. Riwayat Kesehatan Diri B. Gejala kesehatan saat
berulang] yang dimiliki] [Riwayat penyakit lainnya] ini [Batuk]

Tidak Tidak Ya Tidak

Tidak Tidak Tidak Tidak
Tidak Ya Tidak Tidak
Tidak Tidak Tidak Tidak
B. Gejala kesehatan saat
ini [Demam ≥ 37.3 B. Gejala kesehatan saat B. Gejala kesehatan saat B. Gejala kesehatan saat
Celcius] ini [Nyeri tenggorokan] ini [Sesak napas] ini [Flu/pilek]

Tidak Tidak Tidak Tidak

Tidak Tidak Tidak Tidak
Tidak Tidak Tidak Tidak
Tidak Tidak Tidak Tidak
B. Gejala kesehatan saat Jika ada gejala kesehatan C. Riwayat Imunisasi C. Riwayat Imunisasi
ini [Diare] lainnya, sebutkan: [Hepatitis B (0-24 jam)] [BCG (1 bulan)]

Tidak Tidak ada Ya Ya

Tidak Kejang berulang Ya Ya
Tidak GIGI GERAHAM RUSAK Ya Ya
Tidak Tidak ada Ya Ya
 C. Riwayat Imunisasi C. Riwayat Imunisasi
C. Riwayat Imunisasi [DPT - HB - Hib1 (2 C. Riwayat Imunisasi [DPT - HB - Hib2 (3
[Polio 1 (1 bulan)] bulan)] [Polio 2 (2 bulan)] bulan)]

Ya Ya Ya Ya
Ya Ya Ya Ya
Tidak Ya Ya Tidak
Ya Ya Ya Ya
 C. Riwayat Imunisasi
C. Riwayat Imunisasi [DPT - HB - Hib3 (4 C. Riwayat Imunisasi C. Riwayat Imunisasi [IPV
[Polio 3 (3 bulan)] bulan)] [Polio 4 (4 bulan)] (4 bulan)]

Ya Ya Ya Ya
Ya Ya Ya Ya
Tidak Tidak Tidak Tidak
Ya Ya Ya Ya
 C. Riwayat Imunisasi
C. Riwayat Imunisasi [DPT - HB - Hib (18-24 C. Riwayat Imunisasi C. Riwayat Imunisasi
[Campak/MR (9 bulan)] bulan)] [Campak (18-24 bulan)] [Campak (Kelas 1 SD)]

Ya Ya Ya Ya
Ya Ya Ya Ya
Tidak Ya Tidak Ya
Ya Ya Ya Ya
 D. Riwayat Kesehatan
Keluarga. Apakah
orangtuamu atau keluarga
C. Riwayat Imunisasi [DT C. Riwayat Imunisasi [Td C. Riwayat Imunisasi [Td lain menderita:
(Kelas 1 SD)] (Kelas 2 SD)] (Kelas 5 SD)] [Tuberkulosis (TBC)]

Tidak Tidak Tidak Tidak

Ya Ya Ya Tidak
Tidak Tidak Tidak Tidak
Ya Ya Ya Tidak
D. Riwayat Kesehatan D. Riwayat Kesehatan D. Riwayat Kesehatan D. Riwayat Kesehatan
Keluarga. Apakah Keluarga. Apakah Keluarga. Apakah Keluarga. Apakah
orangtuamu atau keluarga orangtuamu atau keluarga orangtuamu atau keluarga orangtuamu atau keluarga
lain menderita: [Diabetes lain menderita: lain menderita: lain menderita: [Penyakit
Mellitus/kencing manis] [Hepatitis/sakit kuning] [Asma/bengek] lainnya]

Ya Tidak Tidak Tidak

Ya Tidak Tidak Tidak
Tidak Tidak Ya Tidak Tahu
Ya Tidak Tidak Tidak
 E. Perilaku Berisiko
E. Perilaku Berisiko [Apakah E. Perilaku Berisiko
E. Perilaku Berisiko [Apakah kamu suka jajan orangtua/keluarga ada [Apakah kamu pernah
[Apakah kamu sarapan?] di sekolah?] yang merokok?] merokok?]

Selalu Kadang Selalu Kadang

Selalu Kadang Tidak Pernah Tidak Pernah
Selalu Kadang Kadang Kadang
Selalu Kadang Tidak Pernah Tidak Pernah
E. Perilaku Berisiko
[Apakah
orangtua/keluarga ada
yang minum minuman Berapakah usiamu saat Apakah menstruasi kamu
beralkohol?] Jenis Kelamin menstruasi pertama? teratur setiap bulan?

Kadang Laki-Laki
Tidak Pernah Laki-Laki
Tidak Pernah Laki-Laki
Tidak Pernah Laki-Laki
 Apakah kamu Apakah kamu pernah
mengonsumsi Tablet Darimana kamu mengalami keputihan
Apakah pada saat Tambah Darah (TTD) mendapatkan Tablet (keluarnya cairan/lendir
menstruasi disertai nyeri sebanyak 1 tablet setiap Tambah Darah (TTD) yang keluar dari
perut hebat? minggu? tersebut? kemaluan)?
 Apakah kamu pernah
disentuh secara paksa
pada bagian vital
Apakah kamu pernah tubuhmu (alat Apakah kamu pernah
mengalami gatal-gatal di kelamin/payudara/bokong Apakah kamu pernah mengalami kencing
sekitar kemaluan? )? mimpi basah? kuning kental?

Tidak Tidak
Ya Tidak
Ya Tidak
 Apakah kamu pernah Kuesioner Kekuatan dan
disentuh secara paksa Kesulitan pada Anak Usia
Apakah kamu pernah pada bagian vital 6 - 10 Tahun [Dapat
mengalami gatal-gatal di tubuhmu (alat memperdulikan perasaan
sekitar kemaluan? kelamin/bokong)? Umur (tahun) orang lain.]

7 Tidak Benar
Tidak Tidak 15
Ya Tidak 14
Ya Tidak 17
 Kuesioner Kekuatan dan
Kuesioner Kekuatan dan Kesulitan pada Anak Usia
Kuesioner Kekuatan dan Kesulitan pada Anak Usia 6 - 10 Tahun [Jika Kuesioner Kekuatan dan
Kesulitan pada Anak Usia 6 - 10 Tahun [Sering mempunyai mainan, Kesulitan pada Anak Usia
6 - 10 Tahun [Gelisah, mengeluh sakit kepala, kesenangan atau pensil, 6 - 10 Tahun [Sering sulit
terlalu aktif, tidak dapat sakit perut atau sakit-sakit anak bersedia berbagi mengendalikan
diam untuk waktu lama.] lainnya.] dengan anak-anak lain.] kemarahan.]

Agak Benar Tidak Benar Agak Benar Agak Benar

 Kuesioner Kekuatan dan
Kesulitan pada Anak Usia Kuesioner Kekuatan dan
Kuesioner Kekuatan dan 6 - 10 Tahun [Umumnya Kuesioner Kekuatan dan Kesulitan pada Anak Usia
Kesulitan pada Anak Usia bertingkah laku baik, Kesulitan pada Anak Usia 6 - 10 Tahun [Suka
6 - 10 Tahun [Cenderung biasanya melakukan apa 6 - 10 Tahun [Banyak menolong jika seseorang
menyendiri, lebih suka yang disuruh oleh orang kekhawatiran atau sering terluka, kecewa atau
bermain seorang diri.] dewasa.] tampak khawatir.] merasa sakit.]

Tidak Benar Agak Benar Tidak Benar Agak Benar

Kuesioner Kekuatan dan Kuesioner Kekuatan dan
Kesulitan pada Anak Usia Kuesioner Kekuatan dan Kesulitan pada Anak Usia Kuesioner Kekuatan dan
6 - 10 Tahun [Terus Kesulitan pada Anak Usia 6 - 10 Tahun [Sering Kesulitan pada Anak Usia
menerus bergerak dengan 6 - 10 Tahun [Mempunyai berkelahi dengan anak- 6 - 10 Tahun [Sering
resah atau menggeliat- satu atau lebih teman anak lain atau merasa tidak bahagia,
geliat.] baik.] mengintimidasi mereka.] sedih atau menangis.]

Tidak Benar Agak Benar Tidak Benar Tidak Benar

 Kuesioner Kekuatan dan
Kesulitan pada Anak Usia
6 - 10 Tahun [Gugup atau
Kuesioner Kekuatan dan Kuesioner Kekuatan dan sulit berpisah dengan Kuesioner Kekuatan dan
Kesulitan pada Anak Usia Kesulitan pada Anak Usia orangtua/pengasuhnya Kesulitan pada Anak Usia
6 - 10 Tahun [Pada 6 - 10 Tahun [Mudah pada situasi baru, mudah 6 - 10 Tahun [Bersikap
umumnya disukai oleh teralih perhatiannya, tidak kehilangan rasa percaya baik terhadap anak-anak
anak-anak lain.] dapat berkonsentrasi.] diri.] yang lebih muda.]

Agak Benar Agak Benar Agak Benar Tidak Benar

 Kuesioner Kekuatan dan
Kuesioner Kekuatan dan Kesulitan pada Anak Usia Kuesioner Kekuatan dan
Kuesioner Kekuatan dan Kesulitan pada Anak Usia 6 - 10 Tahun [Sering Kesulitan pada Anak Usia
Kesulitan pada Anak Usia 6 - 10 Tahun [Diganggu, menawarkan diri untuk 6 - 10 Tahun [Sebelum
6 - 10 Tahun [Sering dipermainkan, diintimidasi membantu orang lain melakukan sesuatu, ia
berbohong atau berbuat atau diancam oleh anak- (orangtua, guru, anak- berpikir dulu tentang
curang.] anak lain.] anak lain).] akibatnya.]

Tidak Benar Tidak Benar Agak Benar Agak Benar

 Kuesioner Kekuatan dan
Kesulitan pada Anak Usia
Kuesioner Kekuatan dan 6 - 10 Tahun [Memiliki
Kuesioner Kekuatan dan Kesulitan pada Anak Usia Kuesioner Kekuatan dan perhatian yang baik
Kesulitan pada Anak Usia 6 - 10 Tahun [Lebih Kesulitan pada Anak Usia terhadap apapun, mampu
6 - 10 Tahun [Mencuri dari mudah berteman dengan 6 - 10 Tahun [Banyak menyelesaikan tugas atau
rumah, sekolah atau orang dewasa daripada yang ditakuti, mudah pekerjaan rumah sampai
tempat lain.] dengan anak-anak lain.] menjadi takut.] selesai.]

Tidak Benar Agak Benar Agak Benar Tidak Benar

Kuesioner Kekuatan dan Kuesioner Kekuatan dan
Kesulitan pada Anak Usia Kuesioner Kekuatan dan Kesulitan pada Anak Usia
11-18 Tahun [Saya Kuesioner Kekuatan dan Kesulitan pada Anak Usia 11-18 Tahun [Kalau saya
berusaha bersikap baik Kesulitan pada Anak Usia 11-18 Tahun [Saya sering memiliki mainan CD atau
kepada orang lain. Saya 11-18 Tahun [Saya sakit kepala, sakit perut makanan, saya biasanya
peduli dengan perasaan gelisah, saya tidak dapat atau macam-macam sakit berbagi dengan orang
mereka.] diam untuk waktu lama.] lain.] lain. ]

Benar Tidak Benar Tidak Benar Agak Benar

Benar Benar Tidak Benar Tidak Benar
Benar Benar Tidak Benar Benar
Kuesioner Kekuatan dan
Kesulitan pada Anak Usia Kuesioner Kekuatan dan Kuesioner Kekuatan dan Kuesioner Kekuatan dan
11-18 Tahun [Saya Kesulitan pada Anak Usia Kesulitan pada Anak Usia Kesulitan pada Anak Usia
menjadi sangat marah 11-18 Tahun [Saya lebih 11-18 Tahun [Saya 11-18 Tahun [Saya
dan sering tidak bisa suka sendirian daripada biasanya melakukan apa banyak merasa cemas
mengendalikan bersama dengan orang- yang diperintahkan oleh atau khawatir terhadap
kemarahan saya.] orang seumur saya.] orang lain.] apapun.]

Tidak Benar Tidak Benar Tidak Benar Tidak Benar

Tidak Benar Tidak Benar Agak Benar Tidak Benar
Benar Agak Benar Agak Benar Tidak Benar
 Kuesioner Kekuatan dan
Kuesioner Kekuatan dan Kesulitan pada Anak Usia
Kuesioner Kekuatan dan Kesulitan pada Anak Usia 11-18 Tahun [Saya sering
Kesulitan pada Anak Usia 11-18 Tahun [Bila sedang Kuesioner Kekuatan dan bertengkar dengan orang
11-18 Tahun [Saya selalu gelisah atau cemas, Kesulitan pada Anak Usia lain. Saya dapat
siap menolong jika ada badan saya sering 11-18 Tahun [Saya memaksa orang lain
orang terluka, kecewa bergerak-gerak tanpa mempunyai satu teman melakukan apa yang saya
atau merasa sakit.] saya sadari.] baik atau lebih.] inginkan.]

Agak Benar Tidak Benar Benar Tidak Benar

Tidak Benar Agak Benar Agak Benar Tidak Benar
Tidak Benar Benar Agak Benar Benar
 Kuesioner Kekuatan dan
Kuesioner Kekuatan dan Kuesioner Kekuatan dan Kesulitan pada Anak Usia
Kuesioner Kekuatan dan Kesulitan pada Anak Usia Kesulitan pada Anak Usia 11-18 Tahun [Saya
Kesulitan pada Anak Usia 11-18 Tahun [Orang lain 11-18 Tahun [Perhatian merasa gugup dalam
11-18 Tahun [Saya sering seumur saya pada saya mudah teralihkan. situasi baru. Saya mudah
merasa tidak bahagia, umumnya menyukai Saya sulit memusatkan kehilangan rasa percaya
sedih atau menangis.] saya.] perhatian pada apapun.] diri. ]

Tidak Benar Benar Agak Benar Tidak Benar

Tidak Benar Tidak Benar Benar Agak Benar
Agak Benar Tidak Benar Benar Tidak Benar
 Kuesioner Kekuatan dan
Kuesioner Kekuatan dan Kuesioner Kekuatan dan Kesulitan pada Anak Usia
Kesulitan pada Anak Usia Kuesioner Kekuatan dan Kesulitan pada Anak Usia 11-18 Tahun [Saya sering
11-18 Tahun [Saya Kesulitan pada Anak Usia 11-18 Tahun [Saya sering menawarkan diri untuk
bersikap baik pada anak- 11-18 Tahun [Saya sering diganggu atau membantu orang lain,
anak yang lebih muda dari dituduh berbohong atau dipermainkan oleh anak- orangtua, guru atau anak-
saya.] berbuat curang.] anak atau remaja lainnya.] anak.]

Benar Tidak Benar Tidak Benar Agak Benar

Agak Benar Tidak Benar Tidak Benar Tidak Benar
Agak Benar Tidak Benar Agak Benar Agak Benar
 Kuesioner Kekuatan dan Kuesioner Kekuatan dan
Kuesioner Kekuatan dan Kesulitan pada Anak Usia Kesulitan pada Anak Usia
Kesulitan pada Anak Usia 11-18 Tahun [Saya 11-18 Tahun [Saya lebih Kuesioner Kekuatan dan
11-18 Tahun [Sebelum mengambil barang yang mudah berteman dengan Kesulitan pada Anak Usia
melakukan sesuatu, saya bukan milik saya dari orang dewasa daripada 11-18 Tahun [Banyak
berpikir dahulu tentang rumah, sekolah atau dari dengan orang-orang yang saya takuti. Saya
akibatnya.] mana saja.] seumur saya.] mudah merasa takut.]

Agak Benar Tidak Benar Benar Tidak Benar

Agak Benar Tidak Benar Tidak Benar Agak Benar
Tidak Benar Tidak Benar Benar Benar
Kuesioner Kekuatan dan
Kesulitan pada Anak Usia
11-18 Tahun [Saya
menyelesaikan pekerjaan 1. Modalitas Belajar.
yang sedang saya 1. Modalitas Belajar. [Memahami sesuatu 1. Modalitas Belajar.
lakukan. Saya mempunyai [Suka mengingat sesuatu dengan melihat [Memahami sesuatu dari
perhatian yang baik dengan grafik/bagan/skema atau mendengar/petunjuk
terhadap apapun.] membayangkannya.] membaca tulisan.] lisan.]

Tidak Pernah Kadang-Kadang Kadang-Kadang

Agak Benar Tidak Pernah Tidak Pernah Selalu
Agak Benar Kadang-Kadang Kadang-Kadang Tidak Pernah
Tidak Benar Kadang-Kadang Selalu Kadang-Kadang
 1. Modalitas Belajar. [Bisa 1. Modalitas Belajar.
1. Modalitas Belajar. mengerjakan grafik, 1. Modalitas Belajar. [Saya dapat menyusun
[Mudah mengikuti bagan/skema dan poster [Senang melakukan tugas bongkar pasang gambar
instruksi tertulis.] dengan baik.] dengan dikte.] (puzzels) dengan baik.]

Kadang-Kadang Tidak Pernah Kadang-Kadang Kadang-Kadang

Tidak Pernah Tidak Pernah Tidak Pernah Tidak Pernah
Kadang-Kadang Tidak Pernah Tidak Pernah Selalu
Tidak Pernah Tidak Pernah Tidak Pernah Kadang-Kadang
 1. Modalitas Belajar. 1. Modalitas Belajar.
[Mudah memahami [Suka mencatat dan 1. Modalitas Belajar.
1. Modalitas Belajar. penjelasan dengan alat membuat daftar apa yang [Mudah mengikuti
[Senang membaca.] peraga.] ingin saya ingat.] petunjuk di peta.]

Kadang-Kadang Kadang-Kadang Tidak Pernah Tidak Pernah

Tidak Pernah Selalu Tidak Pernah Tidak Pernah
Selalu Kadang-Kadang Kadang-Kadang Tidak Pernah
Tidak Pernah Kadang-Kadang Tidak Pernah Tidak Pernah
 1. Modalitas Belajar.
[Suka mendengar 1. Modalitas Belajar.
1. Modalitas Belajar. seseorang berbicara [Membutuhkan penjelasan 1. Modalitas Belajar.
[Suka mengikuti petunjuk dalam mendapatkan tentang suatu diagram [Senang berdiskusi
lisan.] informasi.] atau peta.] membicarakan suatu hal.]

Kadang-Kadang Kadang-Kadang Tidak Pernah Tidak Pernah

Selalu Selalu Selalu Kadang-Kadang
Tidak Pernah Selalu Selalu Kadang-Kadang
Tidak Pernah Selalu Selalu Tidak Pernah
 1. Modalitas Belajar.
[Suka melakukan
gerakan-gerakan untuk 1. Modalitas Belajar.
1. Modalitas Belajar. mengingat sesuatu [Suka bekerja dengan
[Suka mendengarkan 1. Modalitas Belajar. (mengetuk-ngetuk pena, tangan saya dalam
irama musik untuk [Suka mendengarkan menggoyang-goyang membuat atau
mempelajari sesuatu.] musik.] tungkai).] memperbaiki sesuatu.]

Kadang-Kadang Kadang-Kadang Kadang-Kadang Kadang-Kadang

Selalu Selalu Selalu Kadang-Kadang
Kadang-Kadang Selalu Selalu Kadang-Kadang
Kadang-Kadang Selalu Kadang-Kadang Tidak Pernah
 1. Modalitas Belajar.
1. Modalitas Belajar. 1. Modalitas Belajar. [Suka melihat gerakan
[Suka berdiri atau [Suka menggunakan tubuh seseorang untuk
berjalan-jalan saat gerakan tangan saat 1. Modalitas Belajar. memahami maksud
belajar.] berbicara.] [Terampil berolah raga.] pikirannya.]

Tidak Pernah Kadang-Kadang Kadang-Kadang Kadang-Kadang

Tidak Pernah Kadang-Kadang Kadang-Kadang Kadang-Kadang
Selalu Selalu Tidak Pernah Tidak Pernah
Kadang-Kadang Kadang-Kadang Tidak Pernah Kadang-Kadang
1. Modalitas Belajar. 2. Dominasi Otak
[Harus melakukan apa 2. Dominasi Otak [Suka [Kesulitan dalam
yang telah dipelajari agar bergerak dan banyak mewarnai gambar dan 2. Dominasi Otak [Sangat
mudah dipahami.] beraktivitas?] menulis?] peka terhadap kritikan?]

Kadang-Kadang 1 1 1
Kadang-Kadang 1 1 0
Kadang-Kadang 1 1 1
Kadang-Kadang 1 1 0

2. Dominasi Otak
[Terampil dalam 2. Dominasi Otak
menyusun mainan [Terampil dalam
(building toys), misalnya menyusun puzzles dan
lego, balok susun.] mazes?]
1 1
0 0
0 0
0 0
2. Dominasi Otak [Bila
dibacakan sebuah buku 2. Dominasi Otak [Sangat
kepada kamu sebanyak 2 penting untuk menyukai
atau 3 kali, dapatkah guru di sekolah agar
kamu mengisi kata yang dapat mengerjakan
hilang dengan ingatan pekerjaan dengan baik di
yang sangat baik?] dalam kelas?]
0 1
0 1
0 0
0 1
2. Dominasi Otak [Mudah 2. Dominasi Otak [Tidak 2. Dominasi Otak 2. Dominasi Otak [Harus
beralih perhatiannya atau dapat menyelesaikan [Cenderung berbuat dulu memotong label baju
sering melamun?] tugas secara konsisten?] baru berpikir?] sebelum dikenakan?]

0 1 0 0
0 0 1 0
1 1 1 1
1 1 1 1
 2. Dominasi Otak [Sangat
menikmati saat berolah
raga, berada di pesta 2. Dominasi Otak [Harus
2. Dominasi Otak [Hanya yang ramai dan selalu diingatkan untuk
mau memakai baju yang berekreasi di taman 2. Dominasi Otak mengerjakan sesuatu
lembut dan nyaman?] hiburan?] [Cenderung pemalu?] pekerjaan?]

0 1 0 1
1 1 0 0
1 1 1 1
1 0 1 1
 2. Dominasi Otak
[Mempunyai kemampuan
di atas rata-rata untuk 2. Dominasi Otak [Apakah
2. Dominasi Otak [Senang 2. Dominasi Otak mengerti dan selalu ingin sempurna
bersaing dan tidak mau [Memiliki rasa humor yang menciptakan permainan dalam mencoba sesuatu
kalah?] baik?] kata?] yang baru?]

1 1 1 0
0 1 0 0
0 0 0 0
0 0 0 0
2. Dominasi Otak
[Mampukah mengingat
kembali saat liburan atau
kejadian pada 1 atau 2 Hitung frekuensi nadi (kali
tahun yang lalu secara Frekuensi napas (kali / / menit), kemudian isi
gamblang detailnya?] Suhu tubuh (Celcius) menit) hasilnya dibawah ini:

1 35.6 120 60
0 36.1 17 80
0 36 30 30
0 36 12 75
 Minta bantuan orang tua
atau orang dewasa
lainnya untuk memfoto
bagian dalam kelopak
mata kanan dan kiri kamu
sesuai posisi contoh
Berat badan (kg) Tinggi badan (cm) Lingkar perut (cm) gambar dibawah ini:

37 130 80 https://drive.google.com/open?id=1PMJpp
60 165 93 https://drive.google.com/open?id=1Ic5jNR
33 155 45 https://drive.google.com/open?id=1eXZKW
45 165 50 https://drive.google.com/open?id=14fd1Ya
Bagaimanakah warna Risiko Anemia [Apakah Risiko Anemia [Apakah Risiko Anemia [Apakah
bagian dalam kedua kamu sering merasa kamu sering merasa kamu sering merasa
kelopak matamu? pusing/ingin pingsan?] mengantuk?] susah berkonsentrasi?]

Merah muda Tidak Tidak Tidak

Merah muda Tidak Tidak Tidak
Pucat Tidak Tidak Ya
Merah muda Tidak Tidak Ya

Apakah rambutmu
mengalami salah satu
atau lebih kondisi berikut?
Apakah dalam 3 (tiga) (kotor, mudah patah,
bulan terakhir kamu rontok, bercabang,
pernah periksa kadar Hasil pemeriksaan Hb kusam, berketombe, dan
Hemoglobin (Hb)? (g/dL) berkutu)
Tidak Tidak
Tidak Tidak
Tidak Tidak
Tidak Tidak
Apakah kulitmu
mengalami salah satu
atau lebih kondisi berikut?
(terdapat bercak berwarna
keputihan, kemerahan,
kehitaman, luka koreng,
bintik-bintik merah,
sayatan, atau memar)
Tidak
Ya
Tidak
Tidak
Apakah kuku tangan dan
kakimu mengalami salah
satu atau lebih kondisi
berikut? (kuku panjang,
terdapat kotoran dibawah
kuku, permukaan kuku
tidak rata, terdapat luka Keluhan kesehatan mata
pada kuku, warna tidak [Tidak dapat
bening, kulit dibawah kuku Keluhan kesehatan mata melihat/membaca dengan Keluhan kesehatan mata
terlihat pucat/kebiruan) [Mata perih dan bengkak] baik] [Menggunakan kacamata]

Tidak Tidak Ya Ya
Tidak Tidak Tidak Tidak
Tidak Tidak Tidak Tidak
Tidak Tidak Ya Tidak
 Berapa lama kamu Berapa jarak mata kamu
Keluhan kesehatan mata menonton TV + melihat dengan buku/bahan
[Tidak dapat layar gadget/HP/tablet + bacaan pada saat kamu
Keluhan kesehatan mata membedakan warna komputer dalam 1 hari? membaca sehari-hari?
[Mata juling] dengan baik] (jam) (cm)

Tidak Ya 1 30
Tidak Tidak 3 30
Ya Tidak 2 40
Ya Tidak 6 10
Saat kamu menonton TV, Kesehatan pendengaran
berapa meter jarak antara Tes hitung jari [Jarak 3 Tes hitung jari [Jarak 6 [Tidak merespon bila ada
kamu dan layar TV? meter] meter] suara keras]

1 Pandangan jelas Samar-samar Tidak

2 Pandangan jelas Pandangan jelas Tidak
40 Pandangan jelas Pandangan tidak jelas Ya
50 Samar-samar Samar-samar Tidak
Kesehatan pendengaran Kesehatan pendengaran Kesehatan pendengaran
[Tidak merespon bila [Tidak mendengar dengan Kesehatan pendengaran [Telinga terasa tertutup
dipanggil] jelas] [Keluar cairan dari telinga] atau tersumbat]

Tidak Tidak Tidak Tidak

Tidak Tidak Tidak Tidak
Ya Tidak Tidak Tidak
Tidak Tidak Tidak Tidak
 Kesehatan pendengaran
[Apakah orang tua kamu Volume saat Bagaimana kamu
saat berbicara atau mendengarkan menjelaskan keadaan
Kesehatan pendengaran memanggil kamu sering musik/menonton di kesehatan gigi dan gusi
[Nyeri telinga] dengan berteriak?] TV/gadget? kamu ? [Gigi]

Tidak Ya Sedang Sangat baik

Tidak Tidak Sedang Baik
Ya Tidak Sedang Baik
Tidak Tidak Sedang Baik
 https://drive.google.com/o
Minta bantuan orang
P0x_r07k6NrX-jG,
pen?
tua/orang dewasa lainnya
https://drive.google.com/o
id=1BKm4sV_eaGnMhcN
untuk memfoto kondisi
pen?
hYoESXIgNhOOMhKYq,
gigi kamu sesuai dengan
id=1dK_CNFcDpW9ejtkB
https://drive.google.com/o
posisi dibawah ini : 1.
n-5O06qjDuIz-tD1,
pen?id=1DXUxaOtqw-
tampak depan, 2. tampak
https://drive.google.com/o
Bagaimana kamu XYOXx-
samping kanan, 3. tampak
pen?id=11r- Kesehatan gigi dan mulut
menjelaskan keadaan 6_7Tn5eD5SA71WkR,
samping kiri, 4. tampak
8NK7dXwRaEY7_ekrxdk Kesehatan gigi dan mulut [Apakah gusi kamu
kesehatan gigi dan gusi https://drive.google.com/o
atas dan
VEV28F_Zon,5. tampak [Apakah ada gigi kamu bengkak dan terasa
kamu ? [Gusi] pen?
bawah
https://drive.google.com/o yang terasa sakit?] sakit?]
id=1n5PE9_qfgyfHI1Uwg
pen?id=1f--
Sangat baik qFoEE8Z9LmuJPmK
2d7NGGqZi6Do1LcIjrj_6R Tidak Tidak
Baik t4Ji1m0 Tidak Tidak
Buruk https://drive.google.com/open?id=1FN2XL2ULNkdw_cJh_RAvCFI4qyNrpj1t
Ya Ya
Baik https://drive.google.com/open?id=1_FBRpIHuagYVAGX35IxXlRxF21aEmc1a
Tidak Tidak
 Seberapa sering kamu
Kesehatan gigi dan mulut merasakan sakit gigi atau
[Apakah ada gigi kamu perasaan tidak nyaman Apa alat yang kamu
yang berlubang dan pada gigi kamu selama 12 Seberapa sering kamu gunakan untuk
terasa sakit?] bulan terakhir? membersihkan gigi kamu? menggosok gigi?
Dua kali atau lebih dalam
Tidak Jarang sehari
Dua kali atau lebih dalam Sikat gigi
Tidak Tidak Pernah sehari
Dua kali atau lebih dalam Sikat gigi
Ya Kadang-kadang sehari Sikat gigi
Tidak Tidak Pernah Sehari sekali Sikat gigi
 Apakah di rumahmu ada
orang dengan kondisi
seperti di bawah ini:
Apakah di rumahmu ada [Suspek covid-19 dan
orang dengan kondisi isolasi mandiri (memiliki
seperti di bawah ini: gejala dan 14 hari terakhir
[Kontak erat dan isolasi memmiliki riwayat
Seberapa sering kamu Apa alasan kamu saat mandiri (memiliki riwayat perjalanan/tinggal di
datang ke dokter gigi erakhir kali datang ke kontak dengan penderita daerah dengan transmisi
selama 12 bulan terakhir? dokter gigi? covid-19)] lokal)]
Tidak pernah datang ke dokter gigi
Pemeriksaan / perawatan Tidak Tidak
Sekali rutin Tidak Tidak
Tidak tahu/tidak ingat Tidak Tidak
Tidak pernah datang ke dokter gigi Tidak Tidak
Apakah di rumahmu ada Apakah di rumahmu ada Apakah di rumahmu ada
orang dengan kondisi orang dengan kondisi orang dengan kondisi
seperti di bawah ini: seperti di bawah ini: seperti di bawah ini: Keluar rumah
Apakah kamu bila betul
keluar
[Positif covid-19 namun [Positif covid-19 dan [Meninggal karena covid- betul
rumahdiperlukan (misal
selama pandemi
isolasi mandiri] dirawat di Rumah Sakit] 19] membantu
COVID-19?keluarga
membeli bahan pangan
Tidak Tidak Tidak atau obat, dan lain lain)
Tidak Tidak Tidak Selalu di rumah
Tidak Tidak Tidak Selalu di rumah
Tidak Tidak Tidak Selalu di rumah
 Apakah kamu
menerapkan protokol
Apakah kamu kesehatan di bawah ini? Apakah kamu
menerapkan protokol [Mencuci tangan menerapkan protokol
Apakah kamu kesehatan di bawah ini? menggunakan sabun dan kesehatan di bawah ini?
menerapkan protokol [Menjaga jarak atau air mengalir atau [Langsung mandi dan
kesehatan di bawah ini? menerapkan physical menggunakan cairan mengganti pakaian
[Menggunakan masker] distancing] berbasis alkohol] setelah berpergian]

Selalu Selalu Selalu Selalu

 Perilaku cuci tangan pakai Perilaku cuci tangan pakai
Perilaku cuci tangan pakai Perilaku cuci tangan pakai sabun dan air mengalir sabun dan air mengalir
sabun dan air mengalir sabun dan air mengalir [Setelah dari toilet/kamar [Setelah bermain atau
[Sebelum makan] [Setelah makan] mandi] beraktivitas]

Selalu Selalu Selalu Selalu

Sering Selalu Selalu Selalu
Sering Sering Sering Kadang-kadang
Kadang-kadang Selalu Sering Kadang-kadang
Perilaku cuci tangan pakai
sabun dan air mengalir
[Setelah memegang Perilaku cuci rambut /
hewan/benda lainnya] Perilaku mandi keramas Perilaku gunting kuku *
2 kali dalam sehari (misal
Selalu pagi
2 kalidan sore)
dalam atau(misal
sehari lebih Setiap hari Seminggu 1 kali
Selalu pagi dan sore) atau lebih Seminggu 2 kali atau lebih Seminggu 1 kali
Kadang-kadang 1 kali dalam sehari Seminggu 2 kali atau lebih 2 minggu 1 kali
Kadang-kadang 1 kali dalam sehari Setiap hari Seminggu 1 kali
 Makan makanan bergizi Makan makanan bergizi
[Makan makanan sumber [Makan makanan
karbohodrat setiap hari berprotein setiap hari, Makan makanan bergizi
Makan makanan bergizi seperti nasi, mie, seperti daging, ayam, [Makan sayur dan buah
[Sarapan setiap pagi] singkong, ketela, dll] ikan, telur, dll] setiap hari]

Selalu Sering Sering Sering

Selalu Selalu Selalu Selalu
Sering Selalu Sering Sering
Selalu Selalu Selalu Kadang-kadang
 Apakah kamu selalu
Makan makanan bergizi Berapa kali kamu makan melakukan olahraga atau
[Minum air putih minimal 8 Berapa kali kamu makan selingan/snack dalam aktifitas fisik minimal 30
gelas setiap hari] besar dalam sehari? sehari? menit setiap hari?

Sering 3 2 Ya
Sering 3 2 Tidak
Sering 3 3 Ya
Kadang-kadang 3 2 Tidak
Apakah mengalami Apakah saat ini Jika YA, sebutkan penyebab permasalahan kecemasan/gangguan tid
gangguan tidur selama 1 mengalami cemas terkait
minggu terakhir? COVID-19?

Tidak Tidak
Tidak Tidak Tidak ada
Tidak Tidak
Tidak Tidak Tidak
n kecemasan/gangguan tidur yang kamu rasakan saat ini.
No Kelas Nama Lengkap Tanggal Lahir

12:00 AM Marcello Antonius rompas 9/17/2013

9 SMPLB M. Indrastoto S 7/13/2005
SMPLB ARIIQ RAKA FIKRI 1/7/2006
10 sma M Fadli Wiriadinata 3/28/2003
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Golongan Darah Jenis Kelamin Umur (tahun) Nama Orangtua/Wali

AB Laki-Laki 7 Dedi mulyana

O Laki-Laki 15 Rofikun
O Laki-Laki 14 DUDIN WAHYUDIN
O Laki-Laki 17 Eulis Maryati
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 Alamat tempat tinggal
No. HP/Whatsapp yang
saat ini (tulis dengan
bisa dihubungi
lengkap)
Jl.banteng kecil no.26a
RT/RW 09/07 83822692278
Seskoad flat D
kel.turangga 302
kec.lengkong 81320309318
Bandung
JL CIKUTRA BLK 165 GG
Jl terusan barununggal. 85659325744
NEGLASARI 1
Cipagalo kulon. Rt 04 Rw 82119945113
03
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 Suhu tubuh Frekuensi napas
No Kelas Nama Lengkap
(Celcius) (kali / menit)
12:00 AM Marcello Antonius rompas 35.6 120
9 SMPLB M. Indrastoto S 36.1 17
SMPLB ARIIQ RAKA FIKRI 36 30
10 sma M Fadli Wiriadinata 36 12
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12:00 AM 0 0 0
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Frekuensi nadi (kali /
menit)
60
80
30
75
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0
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0
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0
No Kelas Nama Lengkap Berat badan (kg)

12:00 AM Marcello Antonius rompas 37

9 SMPLB M. Indrastoto S 60
SMPLB ARIIQ RAKA FIKRI 33
10 sma M Fadli Wiriadinata 45
12:00 AM 0 0
12:00 AM 0 0
12:00 AM 0 0
12:00 AM 0 0
12:00 AM 0 0
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12:00 AM 0 0
12:00 AM 0 0
12:00 AM 0 0
12:00 AM 0 0
12:00 AM 0 0
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12:00 AM 0 0
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 Bagaimanakah Risiko Anemia
Risiko Anemia
warna bagian [Apakah kamu
[Apakah kamu
Tinggi badan (cm) Lingkar perut (cm) dalam kedua sering merasa
sering merasa
kelopak pusing/ingin
mengantuk?]
matamu? pingsan?]

130 80 Merah muda Tidak Tidak

165 93 Merah muda Tidak Tidak
155 45 Pucat Tidak Tidak
165 50 Merah muda Tidak Tidak
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 Apakah dalam 3
Risiko Anemia
(tiga) bulan Hasil
[Apakah kamu
terakhir kamu pemeriks
sering merasa
pernah periksa aan Hb
susah
kadar Hemoglobin (g/dL)
berkonsentrasi?]
(Hb)?

Tidak Tidak 0
Tidak Tidak 0
Ya Tidak 0
Ya Tidak 0
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No. Kelas Nama Lengkap Jenis Kelamin

12:00 AM Marcello Antonius rompas Laki-Laki

9 SMPLB M. Indrastoto S Laki-Laki
SMPLB ARIIQ RAKA FIKRI Laki-Laki
10 sma M Fadli Wiriadinata Laki-Laki
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Apakah kamu mengonsumsi Darimana kamu
Tablet Tambah Darah (TTD) mendapatkan Tablet
sebanyak 1 tablet setiap Tambah Darah (TTD)
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 A. Riwayat
No. Kelas Nama Lengkap Kesehatan Diri
[Alergi]

12:00 AM Marcello Antonius rompas Tidak

9 SMPLB M. Indrastoto S Tidak
SMPLB ARIIQ RAKA FIKRI Tidak
10 sma M Fadli Wiriadinata Tidak
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A. Riwayat
A. Riwayat Kesehatan
Kesehatan Diri
Diri [Pernah mengalami
[Riwayat kejang
cedera]
berulang]
Tidak Tidak
Tidak Ya
Tidak Tidak
Ya Tidak
0 0
0 0
0 0
0 0
0 0
0 0
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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
Riwayat Kesehatan Diri
A. Riwayat Kesehatan
A. Riwayat Kesehatan
Diri [Riwayat transfusi
Diri [Riwayat pingsan]
darah berulang]
Tidak Tidak
Tidak Tidak
Ya Tidak
Tidak Tidak
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A. Riwayat Kesehatan A. Riwayat Kesehatan Demam ≥ Nyeri

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 Perilaku Berisiko
Apakah
Apakah orangtua/kelu
Apakah kamu Apakah kamu
Apakah kamu orangtua/kelu arga ada yang
suka jajan di pernah
sarapan? arga ada yang minum
sekolah? merokok?
merokok? minuman
beralkohol?
Selalu Kadang Selalu Kadang Kadang
Selalu Kadang Tidak Pernah Tidak Pernah Tidak Pernah
Selalu Kadang Kadang Kadang Tidak Pernah
Selalu Kadang Tidak Pernah Tidak Pernah Tidak Pernah
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 Tidak dapat
Mata perih dan Menggunakan
No Kelas Nama Lengkap melihat/memba
bengkak kacamata
ca dengan baik

12:00 AM Marcello Antonius rompas Tidak Ya Ya

9 SMPLB M. Indrastoto S Tidak Tidak Tidak
SMPLB ARIIQ RAKA FIKRI Tidak Tidak Tidak
10 sma M Fadli Wiriadinata Tidak Ya Tidak
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 Kesehatan Penglihatan

Tidak Berapa lama kamu Berapa jarak mata

Saat kamu
dapat menonton TV + kamu dengan
menonton TV,
membeda melihat layar buku/bahan bacaan Tes hitung jari [Jarak 3
Mata juling berapa meter
kan warna gadget/HP/tablet + pada saat kamu meter]
jarak antara kamu
dengan komputer dalam 1 membaca sehari-
dan layar TV?
baik hari? (jam) hari? (cm)

Tidak Ya 1 30 1 Pandangan jelas

Tidak Tidak 3 30 2 Pandangan jelas
Ya Tidak 2 40 40 Pandangan jelas
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Tidak Keluar
Tidak merespon Tidak terasa
Tes hitung jari [Jarak 6 merespon cairan Nyeri
bila ada suara mendengar tertutup
meter] bila dari telinga
keras dengan jelas atau
dipanggil telinga
tersumbat

Samar-samar Tidak Tidak Tidak Tidak Tidak Tidak

Pandangan jelas Tidak Tidak Tidak Tidak Tidak Tidak
Pandangan tidak jelas Ya Ya Tidak Tidak Tidak Ya
Samar-samar Tidak Tidak Tidak Tidak Tidak Tidak
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ngaran

Apakah orang tua

kamu saat Volume saat
berbicara atau mendengarkan
memanggil kamu musik/menonton di
sering dengan TV/gadget?
berteriak?

Ya Sedang
Tidak Sedang
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 Kondisi Anggota Keluarga di Rumah

Suspek
covid-19
dan isolasi
Kontak mandiri
erat dan (memiliki
isolasi gejala dan
Positif
mandiri 14 hari
covid-19
(memiliki terakhir
No Kelas Nama Lengkap namun
riwayat memmiliki
isolasi
kontak riwayat
mandiri
dengan perjalanan/ti
penderita nggal di
covid-19) daerah
dengan
transmisi
lokal)

12:00 AM Marcello Antonius rompas Tidak Tidak Tidak

9 SMPLB M. Indrastoto S Tidak Tidak Tidak
SMPLB ARIIQ RAKA FIKRI Tidak Tidak Tidak
10 sma M Fadli Wiriadinata Tidak Tidak Tidak
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gota Keluarga di Rumah Penerapan Protokol Kesehatan

Positif
Menjaga jarak
covid-19
Meninggal atau
dan Apakah kamu keluar rumah selama Menggunakan
karena menerapkan
dirawat di pandemi COVID-19? masker
covid-19 physical
Rumah
distancing
Sakit

Keluar rumah bila betul betul diperlukan

Tidak Tidak (misal membantu keluarga membeli bahan Selalu Selalu
Tidak Tidak pangan Selalu
atau obat, dan lain lain)
di rumah 0 0
Tidak Tidak Selalu di rumah 0 0
Tidak Tidak Selalu di rumah 0 0
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ehatan
Mencuci tangan
menggunakan
Langsung mandi
sabun dan air
dan mengganti
mengalir atau Sebelum makan
pakaian setelah
menggunakan
berpergian
cairan berbasis
alkohol
Selalu Selalu Selalu
0 0 Sering
0 0 Sering
0 0 Kadang-kadang
0 0
0 0
0 0
0 0
0 0
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0 0
0 0
0 0
0 0
0 0
0 0
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0 0
0 0
0 0
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0 0
0 0
0 0
0 0
0 0
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Perilaku Cuci Tangan
Setelah dari
Setelah makan toilet/kamar
Selalu
Selalu
Sering
Selalu
0 0
0 0
0 0
0 0
0 0
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Setelah bermain
atau beraktivitas
mandi
Selalu Selalu
Selalu Selalu
Sering Kadang-kadang
Sering Kadang-kadang
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
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0 0
0 0
0 0
0 0
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 Makan
Setelah Perilaku makanan
Perilaku
memegang cuci bergizi
Perilaku mandi gunting
hewan/benda rambut / [Sarapan
kuku *
lainnya keramas setiap
pagi]

Seminggu
Selalu 2 kali dalam sehari (misal pagi dan sore) atau lebih Setiap
Semingguhari Selalu
1 kali
Seminggu
Selalu 2 kali dalam sehari (misal pagi dan sore) atau lebih 2 kali atau
Seminggu Selalu
1 kali
2 minggu
Kadang-kadang 1 kali dalam sehari lebih
2 kali atau Sering
1 kali
Kadang-kadang 1 kali dalam sehari lebihhari Seminggu
Setiap Selalu
1 kali
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 Pola Makan

Makan Makan
Apakah
makanan makanan
kamu
bergizi bergizi Makan
Makan selalu Apakah
[Makan [Makan makanan Apakah
makanan Berapa kali Berapa kali melakuka mengalam
makanan makanan bergizi saat ini
bergizi kamu kamu n olahraga i
sumber berprotein [Minum air mengalam
[Makan makan makan atau gangguan
karbohodr setiap putih i cemas
sayur dan besar selingan/sn aktifitas tidur
at setiap hari, minimal 8 terkait
buah dalam ack dalam fisik selama 1
hari seperti gelas COVID-
setiap sehari? sehari? minimal minggu
seperti daging, setiap 19?
hari] 30 menit terakhir?
nasi, mie, ayam, hari]
setiap
singkong, ikan, telur,
hari?
ketela, dll] dll]

Sering Sering Sering Sering 3 2 Ya Tidak Tidak

Selalu Selalu Selalu Sering 3 2 Tidak Tidak Tidak
Selalu Sering Sering Sering 3 3 Ya Tidak Tidak
Kadang- Kadang-
Selalu Selalu 3 2 Tidak Tidak Tidak
kadang kadang
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 Bagaimana kamu
menjelaskan
No Kelas Nama Lengkap keadaan kesehatan
gigi dan gusi
kamu ? [Gigi]

12:00 AM Marcello Antonius rompas Sangat baik

9 SMPLB M. Indrastoto S Baik
SMPLB ARIIQ RAKA FIKRI Baik
10 sma M Fadli Wiriadinata Baik
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 Seberapa sering kamu
Bagaimana kamu Apakah ada Apakah gusi Apakah ada gigi merasakan sakit gigi
menjelaskan keadaan gigi kamu kamu bengkak kamu yang atau perasaan tidak
kesehatan gigi dan yang terasa dan terasa berlubang dan nyaman pada gigi kamu
gusi kamu ? [Gusi] sakit? sakit? terasa sakit? selama 12 bulan
terakhir?
Sangat baik Tidak Tidak Tidak Jarang
Baik Tidak Tidak Tidak Tidak Pernah
Buruk Ya Ya Ya Kadang-kadang
Baik Tidak Tidak Tidak Tidak Pernah
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Seberapa sering kamu Apa alat yang kamu
membersihkan gigi gunakan untuk
dokter gigi selama 12 bulan terakhir?
kamu? menggosok gigi?
Dua kali atau lebih
Sikat gigi
dalam
Dua sehari
kali atau lebih
Sikat gigi
dalam sehari
Dua kali atau lebih
Sikat gigi
dalam sehari
Sehari sekali Sikat gigi
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0 0
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0 0
0 0
Apa alasan kamu
Seberapa sering kamu datang ke saat terakhir kali
datang ke dokter
gigi?
Tidak pernah datang ke dokter gigi 0
Pemeriksaan /
Sekali
perawatan rutin
Tidak tahu/tidak ingat 0
Tidak pernah datang ke dokter gigi 0
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 Apakah rambutmu
mengalami salah satu
atau lebih kondisi
No Kelas Nama Lengkap berikut?(kotor, mudah
patah, rontok, bercabang,
kusam, berketombe, dan
berkutu)

12:00 AM Marcello Antonius rompas Tidak

9 SMPLB M. Indrastoto S Tidak
SMPLB ARIIQ RAKA FIKRI Tidak
10 sma M Fadli Wiriadinata Tidak
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 Apakah kulitmu
mengalami salah satu atau Apakah kuku tangan dan kakimu mengalami
lebih kondisi berikut? salah satu atau lebih kondisi berikut? (kuku
(terdapat bercak berwarna panjang, terdapat kotoran dibawah kuku,
keputihan, kemerahan, permukaan kuku tidak rata, terdapat luka
kehitaman, luka koreng, pada kuku, warna tidak bening, kulit dibawah
bintik-bintik merah, kuku terlihat pucat/kebiruan)
sayatan, atau memar)
Tidak Tidak
Ya Tidak
Tidak Tidak
Tidak Tidak
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 Hepatitis B
No. Kelas Nama Lengkap
(0-24 jam)
12:00 AM Marcello Antonius rompas Ya
9 SMPLB M. Indrastoto S Ya
SMPLB ARIIQ RAKA FIKRI Ya
10 sma M Fadli Wiriadinata Ya
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 DPT - HB DPT - DPT -
BCG Polio 1 Polio 2 Polio 3 Polio 4 IPV
- Hib1 HB - Hib2 HB - Hib3
(1 bulan) (1 bulan) (2 bulan) (3 bulan) (4 bulan) (4 bulan)
(2 bulan) (3 bulan) (4 bulan)
Ya Ya Ya Ya Ya Ya Ya Ya Ya
Ya Ya Ya Ya Ya Ya Ya Ya Ya
Ya Tidak Ya Ya Tidak Tidak Tidak Tidak Tidak
Ya Ya Ya Ya Ya Ya Ya Ya Ya
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 DPT - HB -
Campak/MR Campak Campak DT Td Td
Hib
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(18-24 bulan)
Ya Ya Ya Ya Tidak Tidak Tidak
Ya Ya Ya Ya Ya Ya Ya
Tidak Ya Tidak Ya Tidak Tidak Tidak
Ya Ya Ya Ya Ya Ya Ya
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No. Kelas Nama Lengkap

12:00 AM Marcello Antonius rompas

9 SMPLB M. Indrastoto S
SMPLB ARIIQ RAKA FIKRI
10 sma M Fadli Wiriadinata
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 Perempuan

Apakah pada saat

Berapakah usiamu saat Apakah menstruasi kamu
Jenis Kelamin menstruasi disertai
menstruasi pertama? teratur setiap bulan?
nyeri perut hebat?

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Perempuan

Apakah kamu pernah disentuh

Apakah kamu pernah mengalami Apakah kamu pernah
secara paksa pada bagian vital
keputihan (keluarnya cairan/lendir mengalami gatal-gatal di
tubuhmu (alat
yang keluar dari kemaluan)? sekitar kemaluan?
kelamin/payudara/bokong)?

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 Laki-laki
Apakah kamu pernah
Apakah kamu
Apakah kamu pernah disentuh secara paksa
Apakah kamu pernah pernah mengalami
mengalami kencing pada bagian vital
mimpi basah? gatal-gatal di
kuning kental? tubuhmu (alat
sekitar kemaluan?
kelamin/bokong)?

0 0 0 0
Tidak Tidak Tidak Tidak
Ya Tidak Ya Tidak
Ya Tidak Ya Tidak
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 Suka bergerak
No. Kelas Nama Lengkap dan banyak
beraktivitas?

12:00 AM Marcello Antonius rompas 1

9 SMPLB M. Indrastoto S 1
SMPLB ARIIQ RAKA FIKRI 1
10 sma M Fadli Wiriadinata 1
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 Kesulitan Terampil dalam Terampil Bila dibacakan sebuah buku
Sangat
dalam menyusun mainan dalam kepada kamu sebanyak 2 atau 3
peka
mewarnai (building toys), menyusun kali, dapatkah kamu mengisi kata
terhadap
gambar dan misalnya lego, balok puzzles dan yang hilang dengan ingatan
kritikan?
menulis? susun. mazes? yang sangat baik?

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 Sangat penting untuk Harus
Mudah beralih Tidak dapat
menyukai guru di sekolah Cenderung memotong
perhatiannya menyelesaikan
agar dapat mengerjakan berbuat dulu baru label baju
atau sering tugas secara
pekerjaan dengan baik di berpikir? sebelum
melamun? konsisten?
dalam kelas? dikenakan?

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 Harus selalu
Hanya mau Sangat menikmati saat Senang
diingatkan untuk
memakai baju berolah raga, berada di pesta Cenderung bersaing dan
mengerjakan
yang lembut dan yang ramai dan berekreasi di pemalu? tidak mau
sesuatu
nyaman? taman hiburan? kalah?
pekerjaan?

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 Mempunyai
kemampuan di atas
Memiliki rasa rata-rata untuk
humor yang baik? mengerti dan
menciptakan
permainan kata?
1 1
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 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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0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Apakah selalu ingin Mampukah mengingat kembali
sempurna dalam saat liburan atau kejadian pada 1
mencoba sesuatu atau 2 tahun yang lalu secara
yang baru? gamblang detailnya?
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Skor Dominasi Hasil Dominasi
Otak Otak

13 Lebih Otak Kanan

7 Lebih Otak Kiri
Seimbang Otak Kiri
11
Kanan
Seimbang Otak Kiri
10
Kanan
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
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0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
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0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
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0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
0 Sangat Otak Kiri
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