FORMAT PENDAFTARAN BUMIL BARU

NO DATA BUMIL IBU SUAMI

1 Tanggal ......................... ................................

2 Nama ibu ......................... ................................

Ttgl Lahir/umur
3 ......................... ...............................
Agama
4 Pendidikan ......................... ..............................
Golongan darah
5 .......................... ...............................
Pekerjaan
6 No JKN .......................... ..............................
Alamat
7 No Telp .......................... ..............................

8 No.KTP .......................... ..............................

Nama Ibu kandung
9 ........................... ..............................

10 ........................... ..............................

11 .......................... .............................

12 .......................... ............................

NO INDIKATOR CATATAN KESEHATAN BUMIL

1 HPHT ........................................................... KELUHAN ..........................................................

2 TP ........................................................... TD ...........................................................
3 TB ........................................................... BB ...........................................................
4 LILA / IMT ............................/............................. UK ...........................................................
5 KB sebelum hamil ........................................................... TFU ...........................................................
6 Riwayat Penyakit ........................................................... LET.JANIN ...........................................................
7 Riwayat Alergi ........................................................... DJJ ..........................................................
8 Paritas ........................................................... OEDEMA ..........................................................
9 Anak Hidup ........................................................... Tablet FE ..........................................................
10 Anak lahir Kurang Bulan ........................................................... TT ..........................................................
11 Jarak persalinan terakhir ........................................................... Rujukan ..........................................................
12 Status imunisasi ........................................................... LABORATORIUM :
13 Penolong persalinan terakhir ........................................................... PPT .........................................................
14 Cara persalinan terakhir ........................................................... HB .........................................................
15 RESIKO BUMIL 1. ........................................... HBSag .........................................................
2. ........................................... HIV .........................................................
Tanda Tangan
3. ........................................... SIFILIS ..........................................................
4. ........................................... GD ..........................................................
------------------ P.URINE .........................................................