PUSKESMAS MALO

KARTU SKRINING KESEHATAN

1. Tanggal Pemeriksaan : .............................................................................................

2. NIK : .............................................................................................
3. Nama/Tanggal Lahir
: .............................................................................................
4. Jenis Kelamin :L / P
5. Riwayat Penyakit Tidak Menular : .............................................................................................
6. Faktor Resiko asap rokok : YA / TIDAK
7. Aktifitas fisik 150 menit/minggu : YA / TIDAK
8. Konsumsi sayur dan buah 5 porsi/hari : YA / TIDAK
9. BB/TB : ..............................KG / .......................... CM, IMT..............
10. Lingkar perut : ......................................................( P < 80 CM, L < 90
CM)
11. Tensi Darah : ........................................mmHg (<140 / 90 mmHg)
12. Pemeriksaan Mata : KANAN ...................................KIRI.......................................
13. Pemeriksaan Telinga
: .............................................................................................
14. Pemeriksaan GDA : ............................................................mg / dl (<200 mg/dl)
15. Pemeriksaan Asam Urat : .................................. mg / dl (P = < 5,7 mg/dl, L = < 7

PUSKESMAS MALO

KARTU SKRINING KESEHATAN

1. Tanggal Pemeriksaan : .............................................................................................

2. NIK : .............................................................................................
3. Nama/Tanggal Lahir
: .............................................................................................
4. Jenis Kelamin :L / P
5. Riwayat Penyakit Tidak Menular : .............................................................................................
6. Faktor Resiko asap rokok : YA / TIDAK
7. Aktifitas fisik 150 menit/minggu : YA / TIDAK
8. Konsumsi sayur dan buah 5 porsi/hari : YA / TIDAK
9. BB/TB : ..............................KG / .......................... CM, IMT..............
10. Lingkar perut : ......................................................( P < 80 CM, L < 90
CM)
11. Tensi Darah : ........................................mmHg (<140 / 90 mmHg)
12. Pemeriksaan Mata : KANAN ...................................KIRI.......................................
13. Pemeriksaan Telinga
: .............................................................................................
14. Pemeriksaan GDA : ............................................................mg / dl (<200 mg/dl)
15. Pemeriksaan Asam Urat : .................................. mg / dl (P = < 5,7 mg/dl, L = < 7
JAGA KESEHATAN YAA.. JAGA KESEHATAN YAA.. JAGA KESEHATAN YAA..

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Puskesmas Malo Puskesmas Malo Puskesmas Malo

Puskesmas Malo Puskesmas Malo Puskesmas Malo

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Puskesmas Malo Puskesmas Malo Puskesmas Malo

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 Puskesmas Malo Puskesmas Malo Puskesmas Malo
UNTUK PESERTA SKRINING UNTUK PESERTA SKRINING UNTUK PESERTA SKRINING
NAMA : ............................................... NAMA : ............................................... NAMA : ...............................................

UMUR : ...........................................TH UMUR : ...........................................TH UMUR : ...........................................TH

TENSI DARAH : ............................................... TENSI DARAH : ............................................... TENSI DARAH : ...............................................

GDA : ........................ mg / dl (<200 mg/dl) GDA : ........................ mg / dl (<200 mg/dl) GDA : ........................ mg / dl (<200 mg/dl)

ASAM URAT : ................. mg / dl (P = < 5,7 L = < 7) ASAM URAT : ................. mg / dl (P = < 5,7 L = < 7) ASAM URAT : ................. mg / dl (P = < 5,7 L = < 7)

KOLESTEROL : ....................... mg / dl (< 150 mg/dl) KOLESTEROL : ....................... mg / dl (< 150 mg/dl) KOLESTEROL : ....................... mg / dl (< 150 mg/dl)

KETERANGAN KETERANGAN KETERANGAN

............................................................................................. ............................................................................................. .............................................................................................
............................................................................................ ............................................................................................ ............................................................................................

Puskesmas Malo Puskesmas Malo Puskesmas Malo

UNTUK PESERTA SKRINING UNTUK PESERTA SKRINING UNTUK PESERTA SKRINING
NAMA : ............................................... NAMA : ............................................... NAMA : ...............................................

UMUR : ...........................................TH UMUR : ...........................................TH UMUR : ...........................................TH

TENSI DARAH : ............................................... TENSI DARAH : ............................................... TENSI DARAH : ...............................................

GDA : ........................ mg / dl (<200 mg/dl) GDA : ........................ mg / dl (<200 mg/dl) GDA : ........................ mg / dl (<200 mg/dl)

ASAM URAT : ................. mg / dl (P = < 5,7 L = < 7) ASAM URAT : ................. mg / dl (P = < 5,7 L = < 7) ASAM URAT : ................. mg / dl (P = < 5,7 L = < 7)

KOLESTEROL : ....................... mg / dl (< 150 mg/dl) KOLESTEROL : ....................... mg / dl (< 150 mg/dl) KOLESTEROL : ....................... mg / dl (< 150 mg/dl)

KETERANGAN KETERANGAN KETERANGAN

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