Puskesmas :
Kabupaten :
Tanggal Penyelidikan :
A. IDENTITAS PENDERITA
1. NAMA :
2. Umur (tahun + bulan) :
3. Status dalam keluarga :
4. Alamat
RT/RW :
Kelurahan/Desa :
Kecamatan :
Kab/Kota :
Provinsi :
5. Pekerjaan Utama :
Alamat tempat kerja :
6. Pekerjaan sampingan :
Alamat tempat kerja :
B. RIWAYAT PENYAKIT
1. Sakit yang sekarang sudah berapa lama ? hari
2. Antara 2-4 minggu sebelum sakit yang sekarang, apakah pergi bermalam ke luar
daerah/desa ? Ya/Tidak
RT/RW/Dusun :...................................
Desa/Kelurahan :...................................
Kecamatan :...................................
Kabupaten :...................................
Provinsi :....................................
a. Demam
b. Pusing
c. Mual
d. Muntah
e. Menggigil
f. Pegal-pegal
g. Diare
a. Indigenous
b. Relaps
c. Import
20.00-22.00
22.00-24.00
00.00-02.00
02.00-04.00
04.00-06.00
Hasil Pemetaan
Lokasi
Penularan/Rumah
Penderita
Lokasi Habitat 1.
Vektor 2
3.
4.
5.
1.
2.
Lokasi Vektor 3.
Malaria 4.
5.
a. .........................................................................................................................................
b. .........................................................................................................................................
c.....................................................................................................................................
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Kesimpulan :
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Pewawancara :
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