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NAMA MAHASISWA :

NIM :

DETEKSI DINI TUMBUH KEMBANG ANAK

A. IDENTITAS ANAK
1. NAMA : ......................................................................................................................
2. JENIS KELAMIN : ......................................................................................................................
3. TGL LAHIR : ......................................................................................................................
4. NAMA AYAH : ......................................................................................................................
5. NAMA IBU : ......................................................................................................................
6. ALAMAT : .....................................................................................................................
B. ANAMNESA
1. KELUHAN UTAMA :
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2. APAKAH ANAK PUNYA MASALAH TUMBUH KEMBANG ?
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C. PEMERIKSAAN
1. BERAT BADAN : .........................................................................................................................
2. PANJANG BADAN/ TINGGI BADAN : .........................................................................................
3. STATUS GIZI : .............................................................................................................................
4. PEMERIKSAAN KPSP :
a. MENGGUNAKAN KPSP UNTUK USIA : .........................................................................
b. HASIL INTERPRETASI :
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c. INTERVENSI
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