INTERVENSI PIS-PK

Persalinan di
faskes
Pasangan ( Rumah Imunisasi Balita di TB Berobat Hipertensi Sarana Air Penderita Gula darah Kolesterol/
Suami/Istri sakit, dasar ASI Ekslusif timbang sesuai berobat Bersih Jamban Sehat Jiwa Merokok JKN Periksa IVA Stunting sesuai Asam urat
NAMA ANGGOTA Ber KB puskesmas,b lengkap standart teratur standar sesuai standar
No. NAMA KK UMUR KELUARGA UMUR NIK
idan
praktek, dll)

ASAM
Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak sudah belum Ya Tidak Ya Tidak CHOL URAT
1 Sakaro 27 th Sakaro 27 th 1607030703930000 1 1 1 1 1 N 120/70 1 1 N 1 1 N 1 155 3.1
Shintah widya 25 th 1971125412950005 1 1 1 1 1 N 110/80 1 1 N 1 1 1 N 1 148 3.7
2 Mulyadi 34 th Mulyadi 34 th 1671122908860000 1 1 1 1 1 N 100/70 1 1 N 1 0 N 1 156 4
Irna Fitriana 31 th 1605174101890002 1 1 1 1 1 N N 1 1 N 1 N 150 4.1
Slamet Harzi 12 th 1971122811080002 1 1 1 1 1 N N 1 1 N N
Radit Ra 7 th 1971120707130003 1 1 1 1 1 N N 1 1 N N
Irsyah Maulana 3 th 1971120704170004 1 1 1 1 1 N N 1 1 N N

3 Abdul Afid 37 th Abdul Afid 37 th 1971010803830000 0 1 1 1 1 N 120/60 1 1 N 0 1 N 169 3.6

Masmeli 33 th 1671046310870007 0 1 1 1 1 N 110/60 1 1 N 1 1 1 N 176 3.3
Afiza Utami 8 th 1971017111120003 0 1 1 1 1 N N 1 1 N 1 N
M. Fauzan 4 th 1971120808160001 0 1 1 1 1 N N 1 1 N 1 N

4 Kasmadi 41 th Kasmadi 41 th 1671120601790000 1 1 1 1 1 N 130/70 1 1 N 0 1 1 N 1 155 4.1

Yeny Kemalasari 30 th 1671127107900001 1 1 1 1 1 N 100/60 1 1 N 1 1 1 N 1 159 3.8
Ayunda Argareta 10 th 1971126803100000 1 1 1 1 1 N N 1 1 N 1 1 N
Carissa Olivia 8 th 1971125611120004 1 1 1 1 1 N N 1 1 N 1 1 N

5 Irwansyah 37 th Irwansyah 37 thn 1671121212830010 N 1 1 1 1 N 122/60 1 1 N 1 1 1 133 4.3

Satika Rani 29 thn 1607174202910003 1 1 1 1 N 120/60 1 1 N 1 1 N 1 170 3.8
M. Arsyil Malik 7 thn 1971120211130002 1 1 1 1 N N 1 1 N

6 Tarzoli 49 th Tarzoli 49 th 1671120107710080 1 1 1 1 1 N 140/90 1 1 N 1 1 N 1 165 4.4

Patmawati 46 th 1671124105740004 1 1 1 1 1 N 130/70 1 1 N 1 1 1 N 1 140 3.7
Toni Parzreko 23 th 1671122102970007 1 1 1 1 1 N N 1 1 N 1 1 N
Mudea Kartika 13 th 1671126212070002 1 1 1 1 1 N N 1 1 N 1
Fahmimakarya 4 th 1671121006160002 1 1 1 1 1 N N 1 1 N 1

7 Mahpudin 49 th Mahpudin 49 th 1671060412710001 1 1 1 1 1 N 150/90 1 1 N 1 0 N 1 144 4.1

Zuryati 41 th 1671047010790007 1 1 1 1 1 N 130/60 1 1 N 1 1 1 N 1 160 4.2
M. Saiful Zulfakor 18 th 1671041904020003 1 1 1 1 1 N N 1 1 N 1 N 1
Cyntya devi les 14 th 1971044308060003 1 1 1 1 1 N N 1 1 N 1 N 1
M. ridwan Nurroh 5 th 1671041005150008 1 1 1 1 1 N N 1 1 N 1 N 1

8 Yayan Budiansyah 27 th Yayan Budiansyah 27 th 1671122601930007 N N N N N N 130/80 1 1 N 1 0 N 1 133 3.5

Tina Mustika 26 th 1601095601940002 N N N N N N 120/70 1 1 N 1 1 1 N 1 137 4

9 Mardot 53 th Mardot 53 th 1671120107670040 0 1 1 1 1 N 150/90 1 1 N 1 0 N 1 156 4.1

Maryati 51 th 1671124507690004 0 1 1 1 1 N 155/90 1 1 N 1 1 N 1 167 4.8
Mirna wati 21 th 1671124494990011 0 1 1 1 1 N N 1 1 N 1 N 1
Marisa anggraini 10 th 1671125811100004 0 1 1 1 1 N N 1 1 N 1 N 1
 aminah 5 th 1671124507150001 0 1 1 1 1 N N 1 1 N 1 N 1

10 Supriadi 51 th Supriadi 51 th 1671120105690007 0 1 1 1 1 N 140/80 1 1 N 0 1 N 1 139 4.1

Suyatmi 48 th 1671125507720001 0 1 1 1 1 N 122/80 1 1 N 0 1 N 1 144 3.4
Puji Ardianti 27 th 1671124709930004 0 1 1 1 1 N N 1 1 N 0
Yayan Apriadi 19 th 1671122604010001 0 1 1 1 1 N N 1 1 N 0 0

11 Ali Ahmad 32 th Ali Ahmad 32 th 1671120109880006 1 1 1 1 1 N 110/60 1 1 N 0 N 1 120 4.3

Rojia Mardani 27 th 1671120203910002 1 1 1 1 1 N 120/80 1 1 N 1 1 N 1 144 3.7
Meli Apriza 9 th 1671126804110001 1 1 1 1 1 N N 1 1 N
Fikri Hamdza 5 th 16711202010150001 1 1 1 1 1 N N 1 1 N

12 Sanusi 74 th Sanusi 74 th 1671121110460001 N N N N 0 N 160/70 1 1 N 1 N 1 157 5.3

Masnawati 69 th 1671125205510002 N N N N 0 N 160/90 1 1 N 1 N 1 144 3.4
Rojia Mardani 29 th 1671126203910002 N N N N 0 N N 1 1 N N 1 120 3.2

13 Karim 76 th Karim 76 th 1671120311440001 N N N N 0 N 156/72 1 1 N N 1 147 5.4

Salama 68 th 1671125103520001 N N N N 0 N 140/80 1 1 N 1 N 1 110 3.6

14 Ujang 55 th Ujang 55 th 1671120603500000 1 1 1 1 1 N 140/90 1 1 N 1 N 1 126 3.3

Elli Hikma 42 th 1671126008780000 1 1 1 1 1 N 130/60 1 1 N 1 1 N 1 133 3.4
Andri 21 th 16711201061099001 1 1 1 1 1 N N 1 1 N 1
Laila Karisa Putri 11 th 1671120201090002 1 1 1 1 1 N N 1 1 N

15 Sahnan 62 th Sahnan 62 th 1671121201580003 N N N N 0 N 150/100 1 1 N N 1 155 5.4

Kartini 59 th 1671124101610010 N N N N 0 N 110/60 1 1 N 1 N 1 125 3.6

16 Matdong 47 th Matdong 47 th 1671121907730004 N N N N N N 120/70 1 1 N 0 1 N 1

Setia Budi 46 th 1671126703740002 N N N N N N 110/80 1 1 N 1 1 1
Santodi 19 th 1671121101010005 N N N N N N 100/70 1 1 N 0 1
Fandi 8 th 1671120612120001 N N N N N N 1 1 N 1 1

17 Kasiman 39 th Kasiman 39 th 1671131012910001 N N N N N N 120/80 1 1 N 0 1

Meriyana 35 th 1671120801180001 N N N N N N 120/80 1 1 N 1 1
Fandi 2 th 1671120801120001 N N N N N N 1 1 N 1 1

18 Budin 65 th Budin 65 th 1671120108740002 N N N N N N 150/90 1 1 N 1 1

Yanti 55 th 1671125012640009 N N N N N N 150/90 1 1 N 1 1
Firmansyah 35 th 1671120812840003 N N N N N N 120/70 1 1 N 1 0
Dina Sartika 34 th 1671124110960001 N N N N N N 110/70 1 1 N 1
Almunar 34 th 1671122406960001 N N N N N N 120/70 1 1 N 1 1 0
Mujahidullah 17 th 1671123108020001 N N N N N N 1 1 N 1

19 Wandi 42 th Wandi 42 th 1671120204780004 N N N N N N 130/70 1 1 N 1 N N 1 145 4.1

Desy Rosilawati 36 th 1671066512840015 N N N N N N 120/70 1 1 N 1 1 N 1 168 3.9
Kazahtan Zayan 7 th 1671121111200001 N N N N N N 1 1 N 1 N N 1
Zahran Ukaysah 4 th 1671121108160001 N N N N N N 1 1 N 0 N N 1
1
20 Sapidin 56 th
21 Ali Usman 31 th Ali Usman 31 th 1671121708880007 1 N N N N N 120/80 1 1 N 1 N N 1 145 4.1
Napsiah 31 th 1671126008880009 1 N N N N N 100/60 1 1 N 1 1 N 1 168 3.9
M. Rifqi A 7 th 1671120511120001 N N N N N N N 1 1 N 1 N N 1
Zacky Al-Habiyah 3 th 1671122306160002 N N N N 1 N N 1 1 N 0 N N 1

22 Daman 50 th Daman 50 th 1671120607690004 N N N N N 0 1 160/100 1 1 N N N N 1 201 3.7

23 Saminah 65 th Saminah 65 th 1671120607690004 N N N N N N 1 120/60 1 1 N 0 1 N N 1 157 4.4

24 Suryadi 51 th Suryana 51 th 1671121808680005 N N N N N N 120/60 1 1 N N 1 N N 1 189 4.7

Samsiah 49 th 1671126512700005 N N N N N N 130/60 1 1 N N 1 0 N 1 202 3.8
Ayessa Julka 13 th 1671126406060001 N N N N N N N 1 1 N N 1 N N 1

25 Tarzili 47 th Tarzili 47 th 1671121502730003 N N N N N N 140/90 1 1 N N 1 N N 1 161 3.4

Sarima 36 th 1671126812820002 N N N N N N 130/80 1 1 N N 1 1 N 1 120 4.4
Edho Fitriansyah 20 th 16711208010o0003 N N N N N N N 1 1 N N 1 N N 1
Reyza Syaputra 13 th 1671122910070001 N N N N N N N 1 1 N N 1 N 1

26 Darwin 40 th Darwin 40 th 1671121005860004 N N N N N N 130/70 1 1 N N 1 N N 1 122 3.8

Marisa 32 th 1671126103880005 N N N N N N 122/68 1 1 N N 1 1 N 1 143 4.1
Febriansyah 10 th 1671120502100003 N N N N N N N 1 1 N N 1 N N 1
Siti Nur Fadila 3 th 1671124201170002 N N N N N N N 1 1 N N 1 N N 1

27 Karsun 47 th Karsun 47 th 1671120209730009 1 1 1 1 1 N 150/100 1 1 N 1 0 N 1 122 3.7

Suswati 36 th 1671124307820005 1 1 1 1 1 N 120/70 1 1 N 1 1 1 N 1 143 4
Gustu Agung 18 th 1671120700020002 1 1 1 1 1 N N 1 1 N 1 N 1
Galang 12 th 1671120301080003 1 1 1 1 1 N N 1 1 N 1 N 1
Suseno 8 th 1671122101200003 1 1 1 1 1 N N 1 1 N 1 N 1

28 Sugiono 52 th Sugiono 52 th 1671122104680005 N N N N N N 150/100 1 1 N N 1 N N 1 132 4.2

Nasibah 46 th 16711255504740003 N N N N N N 155/70 1 1 N N 1 1 N 1 144 3.1
Shinta Widya 25 th 1671125412950005 N N N N N N 110/60 1 1 N N 1 N N 1
Bagus S 18 th 1671122508020004 N N N N N N N 1 1 N N 1 N N 1

29 Farul Rozi 48 th Farul Rozi 48 th 1671121203720004 0 1 1 1 1 N 140/90 1 1 N 1 0 N 1 122 4.3

Sumarni 34 th 1671128012770002 0 1 1 1 1 N 120/60 1 1 N 1 1 N 1 135 4.1
Davit saputra 18 th 1671121102020003 0 1 1 1 1 N N 1 1 N 1 N 1
Nayla Rahma 14 th 1671126210060003 0 1 1 1 1 N N 1 1 N 1 N 1
Muhammat Helmi 5 th 1671121202160001 0 1 1 1 1 N N 1 1 N 1 N 1

30 Yasmin 30 th Yasmin 30 th 1671121212900009 N N N N 0 N 140/90 1 1 N 1 N 1 144 2.3

Yunita sari 19 th 1671125007020001 N N N N 0 N 120/70 1 1 N 1 N 1

31 Supandi 55 th Supandi 55 th 1671123112650049 1 1 1 1 1 N 155/70 1 1 N 1 0 N 1 144 4.4

Yana 50 th 1671127101700001 1 1 1 1 1 N 130/80 1 1 N 1 1 1 N 1 145 3.1
Yasmin 30 th 1671121212900009 1 1 1 1 1 N 110/80 1 1 N 1 N 1
Suherman 27 th 1671120404930004 1 1 1 1 1 N 130/80 1 1 N 1 N 1
 Susela Ayu 22 th 1671124211980002 1 1 1 1 1 N 110/70 1 1 N 1 N 1

32 Rosid 64 th Rosid 64 th 1671122106600000 N N N N N N 120/80 1 1 N 0 1 N 1 130 4.2

Zainur 52 th 1671124708680001 N N N N N N 120/80 1 1 N 1 1 N 1 118 3.7
M. Aprizal 17 th 1671122604030002 N N N N N N 1 1 N 1 1 N 1

33 Samidi 42 th Samidi 42 th 16711208077600001 N N N N N N 120/80 1 1 N 0 1 N 1 133 4.4

Mardiana 43 th 16711203116770904 N N N N N N 120/80 1 1 N 1 1 1 N 1 154 3.2
Andika 26 th 1671121602060001 N N N N N N 110/80 1 1 N 1 1 N 1
Okta Beriansyah 19 th 1671122010910001 N N N N N N 110/80 1 1 N 1 1 N 1
Marpin 11 th 1671122005090001 N N N N N N 110/80 1 1 N 1 1 N 1

34 Nurhasanah 51 th Nurhasanah 51 th 1671126909690001 N N N N 0 N 130/80 1 1 N 1 N 1 141 4.2

Aris Munandar 25 th 1671121920950001 N N N N 0 N 110/70 1 1 N 1 N 1
Jokosuryanto 20 th 1671121006000008 N N N N 0 N N 1 1 N 1 N 1
Pery 9 th 1671122911010006 N N N N 0 N N 1 1 N 1 N 1

35 A. Rohman 73 th A. Rohman 73 th 1671123112470026 N N N N N N 120/80 1 1 N 0 1 N 1 151 4.2

Hodija 71 th 1671127112490023 N N N N N N 120/80 1 1 N 1 1 N 1 144 3.7
Said 54 th 1671123112660030 N N N N N N 1 1 N 1 1 N 1 128 3.3

36 Rudi Hartono 34 th Rudi Hartono 34 th 1671042007860010 1 N N N N N 130/70 1 1 N 1 N N 1 122 3

Frisca ayu dwi 33 th 1671146608870008 1 N N N N N 130/70 1 1 N 1 1 N 1 140 3.2
M. Rayhan Alfatih 8 th 1671142206120004 N N N N N N N 1 1 N 1 N N 1
M. Fawwaz Maulana6 th 1671122908140001 N N N N 1 N N 1 1 N 0 N N 1
Noureen Mikayka 3 th 1671126712170003 N N N N 1 N N 1 1 N 0 N N 1

37 Darlis 41 th Darlis 41 th 1671120305790011 1 N N N N N 144/72 1 1 N 1 N N 1 155 3.4

Leni Arika 36 th 1671125904820008 1 N N N N N 110/70 1 1 N 1 1 N 1 121 2.7
Deni Charlis 18 th 1671122506020005 N N N N N N N 1 1 N 1 N N 1
Rata Andini 16 th 1671120504040005 N N N N N N N 1 1 N 1 N N 1

38 Sopudin 57 th Sopudin 57 th 1671121220300006 N N N N N N 140/90 1 1 N 0 1 N 1 125 3.5

Jamilah 62 th 1671125418600004 N N N N N N 130/80 1 1 N 1 1 N 1 133 4.1
Riskendi 25 th 1671120203880003 N N N N N N 1 1 N 1 1 N 1
Fitri yani 18 th 1671126885020002 N N N N N N 1 1 N 1 1 N 1
Cindi Hanifah 15 th 16711249090050006 N N N N N N 1 1 N 1 1 N 1
Sina 72 th 1671127914600002 N N N N N N 190/100 1 1 N 0 1 N 1 155 5.1

39 Baslim 51 th Baslim 51 th 1671120111690002 N N N N N N 120/80 1 1 N 0 1 N 1 141 4.2

Salma 51 th 1671125709690004 N N N N N N 120/80 1 1 N 1 1 N 1 133 3.2
Suhendar 33 th 1671122710870004 N N N N N N 1 1 N 1 1 N 1
Baria 28 th 2171104509929005 N N N N N N 150/90 1 1 N 0 1 N 1 125 4.4

40 Sarkowi 47 th Sarkowi 47 th 1671121307730002 N N N N N N 130/70 1 1 N N 1 N N 1 122 3.2

Mahuna 44 th 1671124405760005 N N N N N N 120/60 1 1 N N 1 1 N 1 142 4.2
Winda Rianna 22 th 1671125990198003 N N N N N N N 1 1 N N 1 N N 1
Wahyuni 17 th 1671126805030005 N N N N N N N 1 1 N N 1 N N 1
Rahma Nadia 14 th 1671124208050003 N N N N N N N 1 1 N N 1 N N 1

41 Sarpan 50 th Sarpan 50 th 1671120505700003 N N N N N N 130/70 1 1 N N 1 N N 1 145 3.6

 Fatmawati 43 th 1671124705880003 N N N N N N 122/73 1 1 N N 1 1 N 1 144 3.6
Jauhari 18 th 1671120208020003 N N N N N N N 1 1 N N 1 N N 1
Anggun dwi 13 th 1671126103070002 N N N N N N N 1 1 N N 1 N N 1
M. AdFahri 10 th 1671126103070002 N N N N N N N 1 1 N N 1 N N 1
Saffa Arsyila 15 th 1671125302160002 N N N N N N N 1 1 N N 1 N N 1

42 Yemmi 67th Yemmi 67th 1671114405530004 N N N N 0 N 150/100 1 1 N N 1 157 5.4

43 Firman Gunandi 43 th Firman Gunandi 43 th 1671041302770006 N N N N N N 120/70 1 1 N N 1 N N 1 143 3.4

Misnawati 37 th 1671046611830011 N N N N N N 130/70 1 1 N N 1 1 N 1 120 4.7
Aulia Karima 15 th 1671046210060002 N N N N N N N 1 1 N N 1 N N 1
Rizki Baidilah 10 th 1671122809100001 N N N N N N N 1 1 N N 1 N N 1

44 Mulyadi 41 th Mulyadi 41 th 1671040510700014 N N N N N N 120/70 1 1 N N 1 N N 1 133 4.3

Meri yanti 39 th 1671045198810014 N N N N N N 100/60 1 1 N N 1 1 N 1 151 3.3
Rara Agustin 20 th 1671045708000011 N N N N N N N 1 1 N N 1 N N 1
Syairul Ramah 18 th 1671040011020005 N N N N N N N 1 1 N N 1 N N 1
Merdi Gumanti 15 th 1671041205050004 N N N N N N N 1 1 N N 1 N N 1
Desvita Muya 10 th 1671045912100001 N N N N N N N 1 1 N N 1 N N 1
M. Ali Kaffi 28th 1671041096920013 N N N N N N N 1 1 N N 1 N N 1

43 Masisa 48 th Masisa 48 th 1671126704720008 N N N N 0 N 120/70 1 1 N N 1 N N 1 124 4.2

Muzakar 21 th 1671122812990004 N N N N 0 N 130/70 1 1 N N 1 N N 1

44 Sahlan 67 th Sahlan 67 th 16711209904530001 N N N N 0 N 122/72 1 1 N N 1 N N 1 124 4.2

Mina 65 th 16711247995500001 N N N N 0 N 130/80 1 1 N N 1 N N 1

45 Antoni 40 th Antoni 40 th 1610050211800003 N N N N N N 130/80 1 1 N N 1 N N 1 122 128

Santi 35 th 1672530785000005 N N N N N N 110/60 1 1 N N 1 1 N 1 4.1 3.8
Natasyah 8 th 1671125211120002 N N N N N N N 1 1 N N 1 N N 1
Plo Albyan 4 th 1671122008160002 N N N N N N N 1 1 N N 1 N N 1

46 Husaini 51 th Husaini 51 th 1671121506690005 0 1 1 1 1 N 130/80 1 1 N 1 0 N 1 133 3.6

Sarina 44 th 1671125906760007 0 1 1 1 1 N 120/70 1 1 N 1 1 N 1 124 3.4
Junaidi 23 th 1671120310970002 0 1 1 1 1 N N 1 1 N 1 N 1
Faisal Arifah 18 th 1671122301030004 0 1 1 1 1 N N 1 1 N 1 N 1
Elhsa Tia Andini 12 th 1671124807080001 0 1 1 1 1 N N 1 1 N 1 N 1

47 M. Yusuf 51 th M. Yusuf 51 th 1671121904590001 N N N N N N 120/70 1 1 N N 1 N N 1 122 143

Hudariah 47 th 1671124912730003 N N N N N N 100/60 1 1 N N 1 1 N 1 3.8 4.2
Rahmat Riyadi 17 th 1671120803030002 N N N N N N N 1 1 N N 1 N N 1
yudah afriza 12 th 1671121704080004 N N N N N N N 1 1 N N 1 N N 1
Hahmud 5 th 1671122704150001 N N N N N N N 1 1 N N 1 N N 1

48 Harnalis 27 th Harnalis 27 th 1671120707930003 N N N N N N 130/80 1 1 N N 1 N N 1 155 4.3

Juriyah 25 th 1671125005950012 N N N N N N 110/60 1 1 N N 1 1 N 1 125 3
Ahaqirah Aurelia 1 th 1671126204190001 N N N N N N N 1 1 N N 1 N N 1

49 Bariah 32 th Bariah 32 th 1671044111880008 N N N N 0 N 120/80 1 1 N 1 N 1 133 4.1

Farhan Arafah 9 th 1671020411110001 N N N N 0 N N 1 1 N 1 N 1
Sakinah Amalia 5 th 1671126207150001
50 Eakkeri 88 th Eakkeri 88 th 1671040203320002 N N N N N N 150/100 1 1 N N 1 N N 1 155 4.7
Erna 64 th 1671045110560002 N N N N N N 180/100 1 1 N N 1 N 1 140 4.4
Anisa Mawarni 37 th 1671044612830008 N N N N N N N 1 1 N N 1 N N 1
Bariah 32 th 1671044111880008 N N N N N N N 1 1 N N 1 N N 1

51 Muslimin 33 th Muslimin 33 th 1671040707870018 N N N N N N 120/80 1 1 N N 1 N N 1 156 4.4

Misnawati 30 th 1671036702900007 N N N N N N 110/70 1 1 N N 1 1 N 1 148 3.8
Nazirin 10 th 1671042912100002 N N N N N N N 1 1 N N 1 N N 1
Marwatillah 4 th 1671044805160002 N N N N N N N 1 1 N N 1 N N 1

52 Iqbal Parlianta 31 th Iqbal Parlianta 31 th 1604246078900004 N N N N N N 110/70 1 1 N N 1 N N 1 155 3.1

Helly Widiyawati 28 th 1604244101920001 N N N N N N 130/70 1 1 N N 1 1 N 1 112 2.5
M.Khiar Alkhafi 4 th 1671121403160006 N N N N N N N 1 1 N N 1 N N 1

53 Amri 47 th Amri 47 th 1671120912730002 N N N N N N 150/100 1 1 N N 1 N N 1 148 3.2

Neti 40 th 1671125708800007 N N N N N N 120/70 1 1 N N 1 1 N 1 133 4.1
Nasri 16 th 1671126712040003 N N N N N N N 1 1 N N 1 N N 1
M. Nepri 10 th 1671122804100004 N N N N N N N 1 1 N N 1 N N 1
Wegi 6 th 1671122710140001 N N N N N N N 1 1 N N 1 N N 1
Musdalifah 6 th 1671126710140001 N N N N N N N 1 1 N N 1 N N 1

54 Paeran 64 th Paeran 64 th 1671061504560006 N N N N N N 150/90 1 1 N N 1 N N 1 151 4.8

Sulastri 61 th 1671045308590005 N N N N N N 120/70 1 1 N N 1 1 N 1 144 3
Ferianto 41 th 1671041010790024 N N N N N N N 1 1 N N 1 N N 1 157 2.1
Noprianto 29 th 1671040111910006 N N N N N N N 1 1 N N 1 N N 1
Dessy Purnama 26 th 1671064112940018 N N N N N N N 1 1 N N 1 N N 1

55 Iwan Gunandi 45 th Iwan Gunandi 45 th 1671122808750002 N N N N N N 130/90 1 1 N N 1 N N 1 130 4.9

Hikmah 38 th 1671125511820008 N N N N N N 100/60 1 1 N N 1 1 N 1 147 2.6
DwiAndhini 12 th 1671126210080006 N N N N N N N 1 1 N N 1 N N 1
Wais Gunandi 4 th 1671121510160001 N N N N N N N 1 1 N N 1 N N 1

56 Sahlan 67 th Sahlan 67 th 1671126994530001 N N N N N N 130/70 1 1 N N 1 N N 1 144 3.1

Mina 65 th 1671124799550001 N N N N N N 150/90 1 1 N N 1 N 1 139 4.4

57 Imron 53 th Imron 53 th 1671120212670002 N N N N N N 100/70 1 1 N N 1 N N 1 159 4.3

Yati 49 th 1671126111710001 N N N N N N 130/80 1 1 N N 1 1 N 1 122 2.1
Taufik 33 th 1671121109870003 N N N N N N N 1 1 N N 1 N N 1
Aripin 26 th 1671120202940008 N N N N N N N 1 1 N N 1 N N 1

58 Sunadi 39 th Sunadi 39 th 1671121401810002 1 N N N N N 120/70 1 1 N 1 N N 1 161 2.5

yulianti 37 th 1671124510830003 1 N N N N N 120/70 1 1 N 1 1 N 1 124 3.4
Yuke wulandari 12 th 1671120101080002 N N N N N N N 1 1 N 1 N N 1
Kurnia mutiara 8 th 1671124511120002 N N N N N N N 1 1 N 1 N N 1

59 M. Sarif 53 th M. Sarif 53 th 1671120510670004 N N N N N N 110/70 1 1 N N 1 N N 1 155 3.4

Rohimah 48 th 1671124206720003 N N N N N N 130/70 1 1 N N 1 1 N 1 143 3.2
Jepriadi 27 th 6711202029300007 N N N N N N 120/70 1 1 N N 1 N N 1
Medi Izwar 23 th 1671122510970001 N N N N N N N 1 1 N N 1 N N 1
Jeki Kurniawan 15 th 1671121107050001 N N N N N N N 1 1 N N 1 N N 1
60 A. Wahab HS 63 th A. Wahab HS 63 th 1671122502570001 N N N N N 0 1 1 1 N N N N 1 153 3.7
Antoni 31 th 1671121906890003 N N N N N 0 1 1 1 N N N N 1 165 3.2

61 Wongso suseno 28 th Wongso suseno 28 th 16071410084500003 N N N N N N 130/70 1 1 N N 1 N N 1 155 3.3

Novita Arianti 29 th 16711268119100003 N N N N N N 110/80 1 1 N N 1 1 N 1 125 2.6
Ishell Charita 2 th 16711356121800001 N N N N N N N 1 1 N N 1 N N 1

62 Wancik 41 th Wancik 41 th 1671121111790007 N N N N N N 150/90 1 1 N N 1 N N 1 161 4.4

Susilawati 36 th 1671124110820006 N N N N N N 140/70 1 1 N N 1 1 N 1 122 4.1
Rangga Radita 15 th 1671121308050004 N N N N N N N 1 1 N N 1 N N 1
Raffi dewi aulia 8 th 1671125001120001 N N N N N N N 1 1 N N 1 N N 1
M. Rafif rajendra 4 th 1671120912160002 N N N N N N N 1 1 N N 1 N N 1

63 Husin Mersi 35 th Husin Mersi 35 th 1671050204850016 N N N N N N 120/70 1 1 N N 1 N N 1 143 3.2

Aiunun lestari 40 th 1671125512800004 N N N N N N 130/70 1 1 N N 1 1 N 1 136 2.6
Mona ratu Liyu 15 th 1671124209050001 N N N N N N N 1 1 N N 1 N N 1
Zuliansyah 10 th 1671120807100002 N N N N N N N 1 1 N N 1 N N 1
Melisa Wulandari 5 th 1671126003150001 N N N N N N N 1 1 N N 1 N N 1
Geisyah 1 th 1671125006190003 N N N N N N N 1 1 N N 1 N N 1

64 Yanto 43 th Yanto 43 th 1671122011770003 N N N N N N 155/80 1 1 N N 1 N N 1 155 4.3

Suna 33 th 1671125603870004 N N N N N N 120/70 1 1 N N 1 1 N 1 120 2.5
Ariyah 15 th 1671124818050001 N N N N N N N 1 1 N N 1 N N 1
Raffi Iqbal 10 th 1671122109100001 N N N N N N N 1 1 N N 1 N N 1

65 Lukman Lukman 1671123003580002 N N N N N N 110/60 1 1 N N 1 N N 1 155 5.2

Ratna dewi 1671126410980005 N N N N N N N 1 1 N N 1 N 1 124 2.1
Mat. Amin 1671123112300016 N N N N N N N 1 1 N N 1 N N 1 158 4.5

66 Nanang 39 th Nanang 39 th 1671122312910001 1 N N N N N 130/80 1 1 N 1 N N 1 140 3.3

Rusdah 35 th 1671124307650011 1 N N N N N 120/70 1 1 N 1 1 N 1 122 3.4
M.Ardas 7 th 1671121708130004 N N N N N N N 1 1 N 1 N N 1
Carista azzura 3 th 1671126505170004 N N N N N N N 1 1 N 1 N N 1

67 Idris 46 th Idris 46 th 1671041112750018 N N N N N N 150/90 1 1 N N 1 N N 1 136 4.4

Teni susanti 36 th 1671046910840009 N N N N N N 120/70 1 1 N N 1 1 N 1 124 3.2
Siti Nurcahaya 15 th 1671045005060003 N N N N N N N 1 1 N N 1 N N 1
Siti Rahayu 12 th 1671047103080004 N N N N N N N 1 1 N N 1 N N 1
M. Reihan 5 th 1671042502150004 N N N N N N N 1 1 N N 1 N N 1

68 Darmanto Jumandi30 th Darmanto Jumandi 30 th 1671122303900001 1 N N N N N 130/70 1 1 N 1 N N 1 154 3.2

Tri Wahyuni 24 th 1671126402960001 1 N N N N N 120/70 1 1 N 1 1 N 1 122 3
Manda Cahya 2 th 1671126505190001 N N N N N N N 1 1 N 1 N N 1

69 Sajuda 65 th Sajuda 65 th 1671126402550001 N N N N N N 160/100 1 1 N N 1 N N 1 140 3.4

Muslimin 42 th 1671121407750005 N N N N N N 140/70 1 1 N N 1 N N 1 123 3.2

70 Sarkomi 49 th Sarkomi 49 th 1671120503710004 N N N N N N 130/80 1 1 N N 1 N N 1 155 4.1

Saripah 47 th 1671125405730002 N N N N N N 122/70 1 1 N N 1 1 N 1 134 4.4
Saripudin 28 th 1671122209920002 N N N N N N 120/70 1 1 N N 1 N N 1
 Edi Saputra 25 th 1671123004960001 N N N N N N 100/60 1 1 N N 1 N N 1
Mita Sari 23 th 1671124706970002 N N N N N N N 1 1 N N 1 N N 1
Miza Setiani 15 th 1671120110050001 N N N N N N N 1 1 N N 1 N N 1

71 M. Hatami 46 th M. Hatami 46 th 1671120508740006 N N N N N N 140/90 1 1 N N 1 N N 1 120 2.1

Masyiana 43th 1671125206770004 N N N N N N 120/60 1 1 N N 1 1 N 1 133 2.7
Hartina 18 th 1671124808020002 N N N N N N 90/60 1 1 N N 1 N N 1
M. Farij 7 th 1671120306130003 N N N N N N N 1 1 N N 1 N N 1

72 M. Ali 43 th M. Ali 43 th 1671121802770006 1 N N N N N 150/90 1 1 N 1 N N 1 140 4.4

Diana Ariyanti 33 th 1671126601870002 1 N N N N N 120/60 1 1 N 1 1 N 1 144 2.8
Dahri Dahlan 6 th 1671122604140003 N N N N N N N 1 1 N 1 N N 1
Amna wati 35 th 1671127105650001 N N N N N N 122/63 1 1 N 1 N N 1 128 3.1

73 Sudirman 38 th Sudirman 38 th 1671120505820012 1 N N N N N 120/80 1 1 N 1 N N 1 144 5.7

Em Diana 25 th 1671125803850003 1 N N N N N 100/70 1 1 N 1 1 N 1 118 3.1
Andreas Pako 10 th 1671122912100001 N N N N N N N 1 1 N 1 N N 1
Naufal pako 6 th 1671122103140002 N N N N N N N 1 1 N 1 N N 1
Renzo Pako 3 th 1671122105170001 N N N N N N N 1 1 N 1 N N 1

74 Zaini bin Badarudin70 th Zaini bin Badarudin 70 th 1671120311800003 N N N N N N 150/100 1 1 N N 1 N N 1 140 4.1
Sopian 1671124707710005 N N N N N N N 1 1 N N 1 1 N 1 151 2.2
Irpandy Pratama 1671121704030002 N N N N N N N 1 1 N N 1 N N 1
Riko Prayoga 1671122008070001 N N N N N N N 1 1 N N 1 N N 1

75 Badarudin 70 th Badarudin 70 th 1671122010500002 N N N N N N 170/90 1 1 N N 1 N N 1 155 4.1

Yunani 55 th 1671126606650001 N N N N N N 130/70 1 1 N N 1 N 1 149 5.7
Pendi 42 th 1671120508870000 N N N N N N N 1 1 N N 1 N N 1 165 4

76 Fendi 42 th Fendi 42 th 16711205086700004 N N N N N N 140/90 1 1 N N 1 N N 1 155 4.4

Meli novianti 32 th 16711247058800004 N N N N N N 110/70 1 1 N N 1 1 N 1 136 2.5

77 M. Ad Khairun 51 th M. Ad Khairun 51 th 1671121707690001 N N N N N N 120/70 1 1 N N 1 N N 1 165 4.2

Mala 54 th 1671125800958002 N N N N N N 140/90 1 1 N N 1 N 1 123 4.3
Ham. Sanjaya 19 th 1671121008010002 N N N N N N N 1 1 N N 1 N N 1

78 ismail 50 th ismail 50 th 1671120611700003 N N N N N N 120/70 1 1 N N 1 N N 1 132 3.2

Siti 45 th 1671125210750002 N N N N N N 100/60 1 1 N N 1 1 N 1 144 2.2
Misnawati 25 th 1671124604950005 N N N N N N N 1 1 N N 1 N N 1
Sandiman 10 th 1671122112000004 N N N N N N N 1 1 N N 1 N N 1
Tema 82 th 1671125506380001 N N N N N N 160/90 1 1 N N 1 N N 1 155 5.1

79 Idrus 30 th Idrus 30 th 1671122111900005 N N N N N N 130/80 1 1 N N 1 N N 1 130 4.4

Rizki Amalia 29 th 1671076304910006 N N N N N N 110/80 1 1 N N 1 1 N 1 122 2.5
Saqila Quina 7 th 1671124706130002 N N N N N N N 1 1 N N 1 N N 1
Shesilia Qonita 3 th 1671124505170002 N N N N N N N 1 1 N N 1 N N 1

80 Yusron 62 th Yusron 62 th 1671120101580023 N N N N N N 120/80 1 1 N N 1 N N 1 155 4.6

Mariah 52 th 1671125401680001 N N N N N N 130/70 1 1 N N 1 1 N 1 143 3.2
Yulisman 25 th 1671121112950001 N N N N N N 110/70 1 1 N N 1 N N 1
Sopatillah 13 th 1671121202070001 N N N N N N N 1 1 N N 1 N N 1
81 iin Irawan 32 th iin Irawan 32 th 1671121203880004 N N N N N N 130/80 1 1 N N 1 N N 1 126 4.6
Rina Prihatin 29 th 1671126707910006 N N N N N N 120/70 1 1 N N 1 1 N 1 155 2.1
Ridwan Abid 5 th 1671123098160004 N N N N N N N 1 1 N N 1 N N 1

82 Ruslan 60 th Ruslan 60 th 1671120806600001 N N N N N N 140/70 1 1 N N 1 N N 1 134 3.1

Mariana 52 th 1671124401680001 N N N N N N 120/70 1 1 N N 1 1 N 1 122 3.2
Mario Febriana 12 th 1671120101080002 N N N N N N N 1 1 N N 1 N N 1

83 Nurhasanah 51 th Nurhasanah 51 th 1671126909690001 N N N N N N 140/80 1 1 N N 1 1 N 1 144 2.1

Aris munandar 25 th 1671121910980001 N N N N N N 100/60 1 1 N N 1 N N 1
JokoSuryanto 10 th 1671121006000008 N N N N N N N 1 1 N N 1 N N 1
Pery 9 th 1671122911010006 N N N N N N N 1 1 N N 1 N N 1

84 Darmadi 60 th Darmadi 60 th 1671041406600002 N N N N N N 150/100 1 1 N N 1 N N 1 155 2.6

Salamah 60 th 1671044108600008 N N N N N N 130/70 1 1 N N 1 1 N 1 127 2.2
Hardianti 24 th 1671046012968003 N N N N N N N 1 1 N N 1 N N 1

85 Rosidah 45 th Rosidah 45 th 1671045111750009 N N N N N N 130/80 1 1 N N 1 1 N 1 124 3.3

Ade kusuma 26 th 1671041218940008 N N N N N N 120/80 1 1 N N 1 N N 1
Risman 22 th 1671041707900006 N N N N N N N 1 1 N N 1 N N 1
Jeni 17 th 1671044201030011 N N N N N N N 1 1 N N 1 N N 1
Rido Anugrah 10 th 1671041707100001 N N N N N N N 1 1 N N 1 N N 1

86 Mursalin 43 th Mursalin 43 th 1671122304770001 N N N N N N 160/90 1 1 N N 1 N N 1 130 5.5

Roata 38 th 1671125502820005 N N N N N N 120/80 1 1 N N 1 1 N 1 122 3.5
Desti Eka 15 th 1671124512060002 N N N N N N N 1 1 N N 1 N N 1
Izza Syakira 7 th 1671124707130001 N N N N N N N 1 1 N N 1 N N 1
M. Fadil 5 th 1671122711150003 N N N N N N N 1 1 N N 1 N N 1

87 Mansyur 74 th Mansyur 74 th 1671120510460001 N N N N N N 170/90 1 1 N N 1 N N 1 158 5.2

Mima 68 th 1671125001520003 N N N N N N 110/60 1 1 N N 1 N 1 133 4.3

88 AndiFirmansyah 37 th AndiFirmansyah 37 th 1671041608300006 1 N N N N N 120/80 1 1 N 1 N N 1 145 2.7

Sartika 30 th 1671025501800010 1 N N N N N 100/60 1 1 N 1 1 N 1 133 2.
Anisa 10 th 1671125008100008 N N N N N N N 1 1 N 1 N N 1
M. Rafa Azka 5 th 1671122505150000 N N N N N N N 1 1 N 1 N N 1

89 Musikin 41 th Musikin 41 th 1671121502790002 N N N N N N 120/60 1 1 N N 1 N N 1 166 3.3

Fitriyanti 26 th 1671124303940003 N N N N N N 130/80 1 1 N N 1 1 N 1 124 3.2
M. Rahmadan 6 th 1671120107140004 N N N N N N N 1 1 N N 1 N N 1
M. Alfa Rizki 2 th 1671122111100001 N N N N N N N 1 1 N N 1 N N 1

90 Mansyur 60 th Mansyur 60 th 1671122307600006 N N N N N N 140/90 1 1 N N 1 N N 1 135 3.3

Robiah 55 th 1671125612650002 N N N N N N 130/70 1 1 N N 1 N 1 146 2.5
Custoni Tri putra 23 th 1671121808870002 N N N N N N 120/80 1 1 N N 1 N N 1

91 BayuPutra 24 th BayuPutra 24 th 1671010601960006 N N N N N N 130/70 1 1 N N 1 N N 1 144 3.2

Listianti 24 th 1671126606960098 N N N N N N 100/60 1 1 N N 1 1 N 1 121 2.6
Keysha Putri 4 th 1671126312160001 N N N N N N N 1 1 N N 1 N N 1
 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 16
Σ Keluarga Bernilai "Y" 17 12 13 6 29 0 52 93 93 0 122 234 71 0 2 2 2
Total Keluarga - Σ Keluarga 71 78 78 78 64 93 41 1 0 93 188 11 178 75 175 175 175
Bernilai "N"

% Cakupan RT. 018 / RW. 005 77% 80% 87% 40% 100% 100% 100% 97% 100% 100% 73% 95% 84% 100% 100% 100% 100%
KELURAHAN GANDUS
KETERANGAN
1 Pasangan Suami/Istri Ber KB N = Normal / tidak ada masalah
2 Persalinan di faskes ( Rumah sakit, puskesmas,bidan praktek, dll) 1 = Sesuai
3 Imunisasi dasar lengkap 0 = Tidak Sesuai
4 ASI Ekslusif
5 Balita di timbang
6 TB Berobat sesuai standart
7 Hipertensi berobat teratur
8 Sarana Air Bersih
9 Jamban Sehat
10 Penderita Jiwa
11 Merokok
12 JKN
13 Periksa IVA
14 Stunting
15 Gula darah sesuai standar
16 Kolesterol/Asam urat sesuai standar

Masalah Kesehatan (rt 18) :

1. Sebanyak (33%) anggota keluarga yang belum mengikuti program KB.
2. Sebanyak (60%) bayi tidak mendapatkan ASI Eksklusif
3. Sebanyak (73%) berperilaku merokok
4. Sebanyak (94,4%) penderita hipertensi tidak minum obat teratur
 INTERVENSI PIS-PK
Tanggal :
Alamat :
Persalinan
di faskes
( Rumah TB
Pasangan sakit, Imunisasi ASI Balita di Berobat Hipertensi Sarana Jamban Penderita Merokok Gula darah Kolesterol/
JMLH Suami/Ist puskesmas dasar JKN Periksa IVA Stunting
ANG NAMA ANGGOTA UMUR Ekslusif timbang sesuai berobat Air Sehat Jiwa sesuai Asam urat
No. NAMA KK NIK ri Ber KB ,bidan lengkap standart teratur Bersih standar sesuai standar
GOTA KELUARGA
KLG praktek,
dll)

Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak sudah belum Ya Tidak Ya Tidak CHOL ASAM
URAT

KETERANGAN
1 Pasangan Suami/Istri Ber KB N = Normal / tidak ada masalah Palembang ,
2 Persalinan di faskes ( Rumah sakit, puskesmas,bidan praktek, dll) 1 = Sesuai Pelaksana
3 Imunisasi dasar lengkap 0 = Tidak Sesuai
4 ASI Ekslusif
5 Balita di timbang
6 TB Berobat sesuai standart
7 Hipertensi berobat teratur
8 Sarana Air Bersih
9 Jamban Sehat
10 Penderita Jiwa
11 Merokok
12 JKN
13 Periksa IVA
14 Stunting
15 Gula darah sesuai standar
16 Kolesterol/Asam urat sesuai standar