NAMA SEKOLAH : SD NEGERI 2 BUDURAN KEGIATAN SCREENING : PUSKESMAS BAGOR

TANGGAL PEMERIKSAAN KELAS : I (SATU)

KELAMIN TGL LAHIR NAMA ORTU HASIL RUJUK

NO NAMA ALAMAT BB TB KET
L P TGL BULAN TAHUN BAPAK IBU MATA BT WRN GIGI TELINGA KULIT KUKU RAMBUT YA TIDAK
AKHMAD NABIL FARZANA L
1 JURIANTO SATI
ANIZWATUL NUR HANIFAH
2 P
MUH SYAFA'AT YATEMI
BENING ELVIANA DIAH AYU P
3 P
MULYONO PARTINEM
BIMA BAGUS DWI PRAYOGA L
4 SAERAH AHMAD S PURWANTI
INDRI DWI SAFITRI
5 P
DAMIN WIWIK WIDARNINGSIH
KALISTA AGUSTIN LESTARI
6 P
RAHMAD ROMADLON ROHMI PUJI LESTARI
MINA KARTIKA SARI
7 P
SUTARMIN RUMINI
MOCHAMMAD BAGUS WIJAYANTO L WIJAYANTI
8 WAWAN DWI ARIYANTO
MUHAMMAD MAULANA IBRAHIM L
9 LATIFUL CHOBIR YULIS SULISTIYAWATI
ASFA PUGUH RAMADANI L
10 MUJI
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JENIS KELAMIN DI ISI : 1

NAMA SEKOLAH : KEGIATAN SCREENING :

TANGGAL PEMERIKSAAN : KELAS :

KELAMIN TGL LAHIR NAMA ORTU HASIL RUJUK

NO NAMA BB TB
L P TANGGAL
BULAN TAHUN BAPAK IBU MATA BT WRN GIGI TELINGA KULIT YA TIDAK

10

11

12

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15

16

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22

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KUKU =SEHAT 1

KULIT 0
RAMBUT =SEHAT 1

MATA =SEHAT 0

BT WAENA =SEHAT 0

KARIES 1

TELINGA = SERUMEN 2 SEHAT 0 INFEKSI 1

NAMA SEKOLAH : SD NEGERI SELOREJO
TANGGAL PEMERIKSAAN : 10 MARET 2020

KELAMIN TGL LAHIR

NO NAMA ALAMAT
L P TGL BULAN TAHUN
1

10

11

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13

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NAMA SEKOLAH :
TANGGAL PEMERIKSAAN :

KELAMIN TGL LAHIR

NO NAMA
L P TANGGAL
BULAN TAHUN
1
2
3
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 KEGIATAN SCREENING : PUSKESMAS BAGOR
KELAS : II (DUA)

NAMA ORTU HASIL

BB TB
BAPAK IBU MATA BT WRN GIGI TELINGA KUKU KULIT RAMBUT
 KEGIATAN SCREENING :
KELAS :

NAMA ORTU HASIL

BB TB
BAPAK IBU MATA BT WRN GIGI TELINGA KULIT
 RUJUK
KET
YA TIDAK KUKU =SEHAT 1

KULIT
RAMBUT =SEHAT 1

MATA =SEHAT 0

BT WAENA =SEHAT 0

KARIES 1

TELINGA = SERUMEN 2
 RUJUK
YA TIDAK
 PENENTUAN STATUS GIZI ANAK USIA 0 - 60 BULAN DAN 5 - 18 TAHUN
BERDASARKAN NILAI Z_SCORE BAKU RUJUKAN WHO 2005

Sex Tg.Timbang Tgl.Lahir Umur BB TB IMT 5 - 18 TH

NO NAMA
L=1,P=2 Tg Bln Thn Tg Bln Thn ( Bln ) ( Kg ) ( Cm ) Nilai Status
1 AKBAR NURDAFFA 2 10 3 2020 28 03 2013 83 35 123 23.1 Obes
2 ALEXA PINKA ANA 2 10 3 2020 02 08 2012 91 35 127 21.7 Obes
3 AMANDA LAYYIN I 2 10 3 2020 18 12 2012 87 24 119 16.9 Normal
4 AMIIROTUL BAHII 2 10 3 2020 28 11 2012 87 16 116.5 11.8 S. Kurus
5 BIMA PRASETYA D 2 10 3 2020 29 12 2012 86 20 114 15.4 Normal
6 BINTANG VIRGO I 2 10 3 2020 04 09 2012 90 15 109 12.6 Kurus
7 CAMEELA AZZAHR 2 10 3 2020 24 12 2012 87 15 111 12.2 Kurus
8 DHANESWARA SUT 2 10 3 2020 04 04 2012 95 22 130 13.0 Normal
9 Dimas arya qoirul m 2 10 3 2020 06 09 2012 90 17 112 13.6 Normal
10 DINDA AYU CHANT 2 10 3 2020 02 06 2011 105 0 0 FALSE Obes
11 DION DIKI SETIYA 2 10 3 2020 24 10 2012 89 16 112 12.8 Kurus
12 DWI SETYOWATI 2 10 3 2020 02 07 2012 92 15 112 12.0 Kurus
13 FARENDRAYANUAR 2 10 3 2020 30 01 2012 97 22 121 15.0 Normal
14 JIHAN HUSNA SAL 2 10 3 2020 02 07 2012 92 15 107 13.1 Normal
15 KEVIN DAFFA ADY 2 10 3 2020 18 06 2012 93 20 121 13.7 Normal
16 LUCKY CATUR PR 2 10 3 2020 16 09 2012 90 20 115 15.1 Normal
17 MOCH. YUSUF BAS 2 10 3 2020 30 09 2012 89 16 116 11.9 Kurus
18 MOCH.DAVA FADIL 2 10 3 2020 21 10 2012 89 21 114 16.2 Normal
19 MUHAMAD RIFQI S 2 10 3 2020 23 10 2012 89 15 109 12.6 Kurus
20 NABILA DWI NURAI 2 10 3 2020 20 11 2012 88 26 119 18.4 Gemuk
21 NAURA NADA LAN 2 10 3 2020 07 12 2012 87 18 113 14.1 Normal
22 RAFAEL AHMAD FA 2 10 3 2020 29 05 2012 93 16 114 12.3 Kurus
23 REVITA VERONICA 2 10 3 2020 03 02 2012 97 19 116 14.1 Normal
24 ZIDAN WAHYU YUD 2 10 3 2020 30 01 2013 85 20 118 14.4 Normal
25 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
26 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
27 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
28 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
29 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
30 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
31 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
32 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
33 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
34 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
35 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
36 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
37 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
38 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
39 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
40 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
41 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
42 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
43 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
44 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
45 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
46 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
47 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
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49 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
50 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
51 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
52 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
53 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
54 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
55 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
56 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
57 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
58 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
59 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
60 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
61 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
62 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
63 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
64 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
65 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
66 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
67 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
68 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
69 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
70 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
71 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
72 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
73 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
74 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
75 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
76 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
77 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
78 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
79 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
80 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
81 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
82 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
83 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
84 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
85 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
86 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
87 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
88 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
89 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
90 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
91 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
92 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
93 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
94 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
95 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
96 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
97 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
98 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
99 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
100 0 2 10 3 2020 0 0 0 0 0 #N/A #N/A
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#N/A #N/A #N/A #N/A 2237 2460.1 #REF! #REF!

#N/A #N/A #N/A #N/A ### #REF! #REF! #REF!

1 2 3 4 1 2 3 4
BB / U TB / U

KETERANGAN :
1. USIA 0 - 60 BULAN BISA MENGGUNAKAN BB/U, TB/U DAN IMT/U KHUSUS 0 - 60 BULAN
2. USIA 61 BULAN (5 TAHUN 1 BULAN) S/D 228 BULAN (19 TAHUN 0 BULAN) HANYA BISA MENGGUNAKAN IMT/U UNTUK 5 - 18 TAHUN
UK 5 - 18 TAHUN
 PENENTUAN STATUS GIZI ANAK USIA 0 - 60 BULAN DAN 5 - 18 TAHUN
BERDASARKAN NILAI Z_SCORE BAKU RUJUKAN WHO 2005

Sex Tg.Timbang Tgl.Lahir Umur BB TB IMT 5 - 18 TH

NO NAMA
L=1,P=2 Tg Bln Thn Tg Bln Thn ( Bln ) ( Kg ) ( Cm ) Nilai Status
1 ADINDA RAMADHA 2 4 3 2020 23 08 2011 102 21 124 13.7 Normal
2 BAGAS DAFI ARSA 2 4 3 2020 18 06 2011 105 35 121 23.9 Obes
3 bima jaya kusuma 2 4 3 2020 22 12 2011 98 20 118 14.4 Normal
4 DWI PUTRA NURY 2 4 3 2020 11 09 2011 102 26 126 16.4 Normal
5 FATHIN ELVICKY 2 4 3 2020 08 01 2012 98 20 118 14.4 Normal
6 ILHAM NUR SYA'B 2 4 3 2020 25 07 2011 103 0 0 FALSE Obes
7 KHRISNA 2 4 3 2020 24 11 2011 99 55 139 28.5 Obes
8 MOHAMMAD AZIS 2 4 3 2020 30 09 2011 101 20 122 13.4 Normal
9 MUHAMMAD ARY 2 4 3 2020 17 08 2011 103 21 120 14.6 Normal
10 MUHAMMAD SATRI 2 4 3 2020 03 11 2011 100 0 0 FALSE Obes
11 MUHAMMAD SEPTI 2 4 3 2020 26 09 2011 101 19 118 13.6 Normal
12 NABILLAH SHERLY 2 4 3 2020 10 07 2011 104 26 127 16.1 Normal
13 najwa afriza zahra 2 4 3 2020 07 07 2011 104 43 138 22.6 Obes
14 NARINDRA DWI OK 2 4 3 2020 08 11 2011 100 24 120 16.7 Normal
15 RAISYA RAHMADIA 2 4 3 2020 10 08 2011 103 18 117 13.1 Normal
16 RANGGA AKHSANI 2 4 3 2020 19 06 2011 105 30 132 17.2 Normal
17 RETNO BUDIARTI 2 4 3 2020 11 04 2011 107 27 128 16.5 Normal
18 SHOFI ANAS TASY 2 4 3 2020 12 11 2011 100 20 119 14.1 Normal
19 VARADELLA REND 2 4 3 2020 14 03 2012 96 25 124 16.3 Normal
20 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
21 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
22 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
23 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
24 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
25 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
26 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
27 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
28 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
29 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
30 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
31 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
32 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
33 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
34 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
35 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
36 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
37 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
38 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
39 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
40 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
41 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
42 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
43 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
44 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
45 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
46 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
47 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
48 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
49 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
50 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
51 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
52 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
53 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
54 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
55 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
56 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
57 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
58 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
59 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
60 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
61 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
62 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
63 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
64 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
65 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
66 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
67 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
68 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
69 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
70 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
71 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
72 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
73 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
74 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
75 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
76 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
77 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
78 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
79 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
80 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
81 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
82 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
83 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
84 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
85 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
86 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
87 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
88 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
89 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
90 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
91 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
92 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
93 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
94 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
95 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
96 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
97 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
98 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
99 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
100 0 2 4 3 2020 0 0 0 0 0 #N/A #N/A
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1 2 3 4 1 2 3 4
BB / U TB / U

KETERANGAN :
1. USIA 0 - 60 BULAN BISA MENGGUNAKAN BB/U, TB/U DAN IMT/U KHUSUS 0 - 60 BULAN
2. USIA 61 BULAN (5 TAHUN 1 BULAN) S/D 228 BULAN (19 TAHUN 0 BULAN) HANYA BISA MENGGUNAKAN IMT/U UNTUK 5 - 18 TAHUN
UK 5 - 18 TAHUN