11-18 tahun
Data diisi secara lengkap menggunakan huruf kapital (untuk rumus)
Hati-hati saat mengisi kolom pertanyaan No. 7,11,14,21 dan 25 karena nilainya terbalik
Jumlah Skoring dan Interpretasi langsung keluar otomatis
Cenderung menyendiri
Kesimpulan Emosi ( E )
Skor Hubungan dengan
Gelis ah, terlalu aktif,
M emiliki perhatian
Bertingkah laku baik
Kesimpulan Hubungan
satu/leb ih teman
Kesulitan (E+C+H+P)
tidak d apat d iam
B erteman o rang
s ebelum tindak
berkons entras i
ber ger ak resah
B erfikir akibat
Suka menolong
Hiperaktifitas ( H)
Kesimpulan Total
Mudah takut
Sulit ken dali
Menwarkan
membantu
lebih mu da
kuran g PD
Diganggu /
or an g lain
intimidasi
d ewas a
Mencuri
Cur ang
Kesimpulan
sedih
b aik
(Pro)
No Bulan Sekolah Nama Jenis Usia Rentang
(P)
Kelamin
4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th
Jumlah Jumlah Jumlah Jumlah
L P L P L P L P L P L P L P L P L P L P L P L P L P L P L P
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 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 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 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 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 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 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 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 0 0
LAN HIPERSENSITIVTAS (H) KESIMPULAN HUBUNGAN TEMAN SEBAYA (H) K
4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th
Jumlah Jumlah Jumlah Jumlah Jumlah
L P L P L P L P L P L P L P L P L P L P L P L P L P L P
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 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 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
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 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 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
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 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
KESIMPULAN JUMLAH KESULITAN KESIMPULAN KEKUATAN (PRO-SOSIAL /Pro)
15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th 11-14 th 15-18 th 4-10 th
Jumlah Jumlah Jumlah Jumlah Jumlah
L P L P L P L P L P L P L P L P L P L P L P L P L P L P
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 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 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
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 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 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
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 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
OSIAL /Pro)
ABNORMAL
11-14 th 15-18 th
Jumlah
L P L P
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
0 0 0 0 0
0 0 0 0 0
LAPORAN HASIL SKRINING KESEHATAN JIWA MENGGUNAKAN SDQ
DAN JUMLAH PENDERITA GME YANG MENDAPAT LAYANAN
UPT PUSKESMAS . . . . . . . TAHUN 2021
JUMLAH PENDERITA G
JUMLAH SKRINING (HASIL SDQ
NO BULAN ABNORMAL/BORDERLI
4-10 11-14 15-18 15-18
Jumlah
L P L P L P L
1 JANUARI 0 0 0 0 0 0 0 0
2 FEBRUARI 0 0 0 0 0 0 0 0
3 MARET 0 0 0 0 0 0 0 0
4 APRIL 0 0 0 0 0 0 0 0
5 MEI 0 0 0 0 0 0 0 0
6 JUNI 0 0 0 0 0 0 0 0
7 JULI 0 0 0 0 0 0 0 0
8 AGUSTUS 0 0 0 0 0 0 0 0
9 SEPTEMBER 0 0 0 0 0 0 0 0
10 OKTOBER 0 0 0 0 0 0 0 0
11 NOVEMBER 0 0 0 0 0 0 0 0
12 DESEMBER 0 0 0 0 0 0 0 0
TOTAL 0 0 0 0 0 0 0 0
Bandung, . . . . . . . .
Mengetahui,
Kepala UPT Puskesmas Penanggung Jawab Program
NIP. NIP/NIPK.
DQ
g, . . . . . . . .
K.