DATA SKRINING PENYAKIT TIDAK MENULAR PUSKESMAS PUSKESMAS KOTO PANJANG IKUA KOTO DATA SKRINING PENYAKIT TIDAK

DATA SKRINING PENYAKIT TIDAK MENULAR PUSKESMAS IKUR KOTO

HARI, TANGGAL : ............................................................................................................................................................. HARI, TANGGAL : .............................................................................................................................................................

NO KTP : ............................................................................................................................................................. NO KTP : .............................................................................................................................................................

NAMA PASIEN : ............................................................................................................................................................. NAMA PASIEN : .............................................................................................................................................................

TTL : ............................................................................................................................................................. TTL : .............................................................................................................................................................

JK : LAKI-LAKI / PEREMPUAN * AGAMA: ........................................................................ JK : LAKI-LAKI / PEREMPUAN * AGAMA: ........................................................................

ALAMAT : ............................................................................................................................................................. ALAMAT : .............................................................................................................................................................

NO TLP : ............................................................................................................................................................. NO TLP : .............................................................................................................................................................

PENDIDIKAN
TERAKHIR : ............................................................................................................................................................. PENDIDIKAN TERAKHIR : .............................................................................................................................................................

PEKERJAAN : ............................................................................................................................................................. PEKERJAAN : .............................................................................................................................................................

STATUS : MENIKAH / DUDA / JANDA / BELUM MENIKAH * STATUS : MENIKAH / DUDA / JANDA / BELUM MENIKAH *

GOLONGAN DARAH : ............................................................................................................................................................. GOLONGAN DARAH : .............................................................................................................................................................

RIW PTM PADA RIW PTM PADA

: PENYAKIT DIABETES / HIPERTENSI / JANTUNG / ASMA / KANKER / KOLESTEROL TINGGI / BENJOLAN PAYUDARA * : PENYAKIT DIABETES / HIPERTENSI / JANTUNG / ASMA / KANKER / KOLESTEROL TINGGI / BENJOLAN PAYUDARA *
KELUARGA (lingkari) KELUARGA
RIW PTM PADA DIRI RIW PTM PADA DIRI
: PENYAKIT DIABETES / HIPERTENSI / JANTUNG / ASMA / KANKER / KOLESTEROL TINGGI / BENJOLAN PAYUDARA * : PENYAKIT DIABETES / HIPERTENSI / JANTUNG / ASMA / KANKER / KOLESTEROL TINGGI / BENJOLAN PAYUDARA *
SENDIRI (lingkari) SENDIRI

MEROKOK : YA / TIDAK * MEROKOK : YA / TIDAK *

KURANG AKTIFITAS : YA / TIDAK * KURANG AKTIFITAS : YA / TIDAK *

FISIK FISIK
KURANG MAKAN KURANG MAKAN
SAYUR & BUAH : YA / TIDAK * SAYUR & BUAH : YA / TIDAK *

KONSUMSI ALKOHOL : YA / TIDAK * KONSUMSI ALKOHOL : YA / TIDAK *

TEKANAN DARAH : ............................................................................................................................................................. TEKANAN DARAH : .............................................................................................................................................................

BERAT BADAN : ............................................................................................................................................................. BERAT BADAN : .............................................................................................................................................................

TINGGI BADAN : ............................................................................................................................................................. TINGGI BADAN : .............................................................................................................................................................

LINGKAR PERUT : ............................................................................................................................................................. LINGKAR PERUT : .............................................................................................................................................................

GULA DARAH GULA DARAH

: ............................................................................................................................................................. : .............................................................................................................................................................
SEWAKTU SEWAKTU
PAKAI KACAMATA : YA / TIDAK * PAKAI KACAMATA : YA / TIDAK *

PETUGAS PEMERIKSA PETUGAS PEMERIKSA