I.

Identitas Anak
1. Nama Anak
a. Nama Lengkap :.........................................................................................
b. Nama Panggilan :.........................................................................................
2. Tempat dan Tanggal Lahir :.........................................................................................
3. Jenis Kelamin :.........................................................................................
4. Agama :.........................................................................................
5. Jumlah Saudara :.........................................................................................
6. Anak ke- :.........................................................................................
7. Kewarganegaraan :.........................................................................................
II. Riwayat Perkembangan Anak
Riwayat Kelahiran
1. Perkembangan masa kehamilan :.............................................................................
2. Penyakit pada masa kehamilan :.............................................................................
3. Usia kehamilan :.............................................................................
4. Proses kelahiran :.............................................................................
5. Tempat kelahiran :.............................................................................
6. Gangguan saat kelahiran :.............................................................................
7. Berat badan bayi :........................................................................cm
8. Panjang badan bayi :.........................................................................kg
9. Tanda-tanda kelahiran :.............................................................................
Perkembangan Masa Balita
1. Menyusu pada ibu hingga umur :.............................................................................
2. Minum susu formula dari umur :.............................................................................
3. Imunisasi dari umur, hingga : Dari umur......................,hingga umur................
4. Pemeriksaan rutin : (Ya/Tidak)
5. Anak mengalami kesulitan makan : (Ya/Tidak)
Perkembangan Fisik
1. Dapat berdiri pada umur :.............................................................................
2. Dapat berjalam pada umur :.............................................................................
3. Mengucapkan sesuatu pada umur :.............................................................................
4. Bicara dengan lancar pada umur :.............................................................................
5. Kesulitan gerakan yang dialami :.............................................................................
6. Status gizi balita : (Baik / Kurang Baik)
7. Riwayat kesehatan balita : (Baik / Kurang Baik)
III. Data Orang Tua
1. Nama Orang Tua
a. Ayah :.............................................................................
b. Ibu :.............................................................................
2. Pekerjaan
a. Ayah :.............................................................................
b. Ibu :.............................................................................
3. Agama
a. Ayah :.............................................................................
b. Ibu :.............................................................................
4. Pendidikan Terakhir
a. Ayah :.............................................................................
b. Ibu :.............................................................................
5. Nomor Telephone
a. Ayah :.............................................................................
b. Ibu :.............................................................................
6. Alamat Orang Tua :.............................................................................

:.............................................................................
IV. Informasi Profil Kondisi Anak
1. Golongan darah :.................................................................
2. TB/BB :..........................cm..............................kg
3. Penyakit khusus yang pernah diderita :.................................................................
4. Kelainan khusus pada anak :.................................................................
5. Imunisasi yang pernah diterima :.................................................................
6. Kondisi anak ketika dalam kandungan :.................................................................
7. Kondisi anak pada waktu kelahiran :.................................................................
8. Kebiasaan anak :.................................................................