FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : JANUARI 2023

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 SIDIK JANGKUNGAN 1-C BUNTU NO. 7-B 3578093112520001 69 ü 15.2 38.1 4.86 78.5 31.2 39.8 14.2 16.15 ü
2 FEBRIANSYAH DWI FITRIANTO SEMOLOWARU TIMUR 2/27 3578092002960004 26 ü 16.0 41.5 5.52 75.2 28.9 38.5 13.9 13.62 ü
3 KEVIN LEO SAPUTRA KOMP. MERPATI MA-8 3515171308960002 26 ü 15.1 38.9 5.24 74.4 28.8 38.8 12.4 14.20 ü
4 FELLY LAURENSIA NGINDEN INTAN TIMUR 18/A 3578094201970004 26 ü 13.5 35.2 4.53 77.9 29.8 38.3 13.6 17.20 ü
5 YANTI NGINDEN VI-G/26 3578085602700003 52 ü 12.5 33.0 4.18 79.1 29.9 37.8 14.1 18.92 ü
6 ELSA ANATASIA PUTRI NGINDEN 2/61-B 3578096512960004 26 ü 13.6 36.6 4.74 77.3 28.6 37.1 12.9 16.31 ü
7 RAGIL SETIAWAN KEDUNGGEBANG BANYUWANGI 3510042003980004 24 698092457 16.0 41.4 5.66 73.3 28.2 38.6 14.2 12.95 ü
8 IRFAN LAZAFAR IRKHAMI SEMOLOWARU UTARA 5/7 3578092808970002 25 2161050478 15.8 40.1 5.33 75.4 29.6 39.4 13.8 14.15 ü
9 YUNI YANTI SINAGA SEMOLOWARU SELATAN 9/4 3578097006900002 32 2998555312 13.3 35.1 4.70 74.7 28.2 37.8 13.2 15.89 ü
10 SHANDY PRANATA DARMAWAN KLAMPIS SEMOLO TIMUR 9/9 AB-209 3578092803950001 27 2302495749 16.3 42.3 5.66 74.8 28.7 38.5 13.2 13.22 ü
11 Dr. HARLIANTARA LASKAS REDIGEN 3273212812630001 59 2218548497 17.0 42.4 4.94 85.9 34.4 40.0 15.2 17.39 ü
12 HENY TRI PURNANINGSIH SEMOLOWARU INDAH P/8 3578094510710004 51 1742138199 13.8 36.6 4.75 77.1 28.0 37.7 13.7 16.23 ü
13 YUSRIL AGIL MAHENDRA MENUR 4/12 3578092203980002 24 1449612909 16.2 41.0 5.29 77.6 30.6 39.5 13.6 14.67 ü
14 RISA ANGGI SYAHPUTRI DSN. BANARAN 3506194905010003 21 1793270248 13.2 34.4 4.67 73.8 28.2 38.3 12.6 15.80 ü
15 DYAH AYU PRAMITA SEMOLOWARU ELOK BLOK O-16 3578095809890003 33 1278447941 13.9 36.7 4.66 78.8 29.8 37.8 14.9 16.91 ü
16 SOFIANA SEMOLOWARU SELATAN 30 3578095610020003 20 787131303 15.4 40.3 5.44 74.2 28.3 38.2 12.5 13.64 ü
17 AHMAD KHOIRUDDIN JOMBANG 3517191012960002 27 108976803 16.5 41.9 6.23 67.3 26.4 39.3 15.2 10.80 ü
18 FAKHRIYJAL RIZKI SEMOLOWARU ELOK BLOK G/15 3578090311930002 29 100194849 13.9 36.0 5.22 69.0 26.6 38.6 14.1 13.22 ü
19 RIZKY PUTRA SUBAKTIAN JL. TEGAL MULYOREJO BARU 133 3578261208990001 23 ü 14.7 37.9 5.19 78.1 28.3 38.7 14.3 15.05 ü
20 NINA EMITA SARI NGINDEN 5/12 3578094805020001 20 2156126602 13.1 34.8 4.42 78.9 29.6 37.6 13.4 17.85 ü
21 DIAN ARI PRASETYO MENUR 2-B/3 3578091404950002 27 2378516354 15.4 40.4 5.23 77.3 29.4 38.1 14.4 14.78 ü
22 JIMMY PRANOTO NGINDEN INTAN TIMUR 1/16 3578091703940002 28 2998073676 15.3 40.0 4.88 82.0 31.3 38.2 14.5 16.80 ü
23
24
ANDRIA PRIMA DITAGO
FARIS ANSAR PRATAMA
SEMOLOWARU ELOK BLOK AF/4
TAMBAK ADI 52
3578091309900001
3578172205960001 26
32 ü
ü
14.6
18.0
37.9
43.0
4.31
5.77
67.7
74.6
26.0
31.1
38.5
41.8
15.1
15.5
15.71
12.93
ü
ü
N N
25
26
ADINDA WAHYU RESTY AMARILIS
DELFIA ARDHIANTI MASQORI
JANGKUNGAN 1-A/34
MENUR 3/1
3578096008970001
3578094606900001
25
32
ü 11.6
10.2
30.9
27.5
4.84
3.64
63.9
75.7
23.9
28.0
37.5
37.0
16.7
15.3
13.20
20.80
ü
ü
I I
H H
116793595
27 PADMO PRIADI, SH SEMOLOWRU ELOK BLOK AL-11 3578090203520001 70 193329674 12.9 33.6 4.45 75.7 28.9 38.3 13.8 17.01 ü

I I
28 RAUDHATUL FITRIANA JANGKUNGAN 1-C/3 3578095703950003 27 2355774748 14.7 38.7 5.31 73.0 27.6 37.9 14.3 13.75 ü
29 CYNTHIA RIZKI PRATIWI MENUR 1/49 3578095307980003 24 1830673473 12.9 34.5 4.29 80.5 30.0 37.3 13.9 18.76 ü
30
31
FANDY AHMAD SULAIMAN
DIKI AHMAD YASIN
SEMAMPIR BARAT 6/28
DSN. KRAJAN JEMBER
3578091911990001
3509260312010003
23
21
1819820373
690722673
16.5
15.8
42.6
40.8
5.85
5.42
72.9
75.3
28.2
29.1
38.7
38.7
15.1
13.8
12.46
13.89
ü
ü L L
32 NABILLAH FARRAS LUTHFI JL. JAMBU BLOK V3 10 BTN PKT 6474035011970003 25 1849851371 12.8 34.8 4.48 77.8 28.5 36.7 13.6 17.37 ü
33 ANANDA CA MENUR 3/71 3278025705970007 25 2683090991 12.6 33.9 4.59 73.9 27.4 37.1 12.5 16.10 ü
34 MAULANA AMRI ROSADA GRIYO WAGE ASRI B-19 SIDOARJO 3578261802970001 25 1821202953 16.7 40.7 5.63 72.4 29.6 41.0 14.4 12.86 ü
35 DENI IRAWAN SEMOLOWARU ELOK BLOK B NO.24 3518050507880005 34 1635522579 14.8 38.9 4.92 79.1 30.0 38.0 14.9 16.08 ü
36 LIE ELISSABETH MANYAR JAYA 13/B-174 6310026506970001 25 2908263396 12.3 34.8 4.51 77.3 27.2 35.3 12.9 17.14 ü
37 MOCH. AMIK NGINDEN 5-D/2 3578092205750001 47 2517116343 12.9 38.8 4.93 78.7 26.2 33.2 12.8 15.96 ü
38 FITANUL KHURNAENI SEMOLOWARU UTARA 1/16 3578094912870001 35 ü 14.1 39.1 4.54 86.1 31.1 36.1 13.7 18.96 ü
39 DEWI FIRDA JANGKUNGAN 2-A/15.-C 3578095701010003 22 2971682212 13.1 34.1 4.15 82.2 31.5 38.4 13.8 19.81 ü
40 BUDI SETIANTO JL. KEDONDONG DALAM 2/80 3374072005970002 25 ü 14.3 37.2 4.79 77.7 29.8 38.4 13.6 16.22 ü
41 JESSY THERINDA MANYAR JAYA 13/B-184 3578095412930001 29 ü 11.8 30.6 4.12 74.4 28.6 38.5 12.5 18.06 ü
42 DAVID SASMITA JL. NIAS III/N-309 PCI SIDOARJO 3515181504940001 28 2441212514 13.3 35.9 4.94 72.8 26.9 37.0 13.5 14.74 ü
43 RR. INDAH NUR RAHMAWATI SEMOLOWARU INDAH H/20 3578095701970001 26 1844473691 12.6 32.5 4.44 73.4 28.3 38.7 13.4 16.53 ü
44 ANDREAS FISHERSIA M.R DUKUH MENANGGAL 5-A/21 3578041203950010 27 193747509 14.7 38.9 5.17 75.4 28.4 37.7 13.8 14.58 ü
45 PANDU DEWATA TEGJA BUANA MANYAR JAYA 8/51 3578263012910001 31 2997307271 15.5 41.2 5.34 77.2 29.0 37.6 14.5 14.46 ü
46 HUANG SHIH CHIEH MANYAR JAYA 8/51 0000000361311087 34 ü 12.1 31.8 3.86 82.5 31.3 38.0 14.4 21.37 ü
47 ACHMAD JULIADI PUMPUNGAN 4/79 3578092507970001 25 ü 15.2 38.6 5.31 72.8 28.6 39.3 13.5 13.71 ü
48 SURYANI SEMOLOWARU SELATAN 1/49 3578095606650001 57 1904190052 14.3 45.1 6.10 74.0 23.4 31.7 12.5 12.13 ü
49 DZUL FIKRI RASYIDI SEMOLOWARU UTARA 1/133 3578090101900002 33 ü 16.0 41.2 5.44 75.8 29.4 38.8 14.5 13.93 ü
50 SALSA DINDA SABILA SEMOLOWARU ELOK BLOK C-8 BLKG 3578095002010003 21 ü 11.8 31.1 4.50 69.3 26.2 37.9 14.8 15.40 ü
51 MOCH. AMIN SIDOSERMO DALAM 22 3578040306710005 51 ü 13.3 33.4 4.50 74.4 29.5 39.8 12.4 16.53 ü
52 MASLIKHAH TEMBELENG KASIMAN BOJONEGORO 3524035507780004 44 2518107827 13.1 34.2 4.43 77.3 29.5 38.3 14.4 17.45 ü
53 LABIB SARWODHITO GAYUNG KEBONSARI 4/21 3578201011980001 24 ü 16.2 41.7 5.53 75.5 29.2 38.8 13.8 13.65 ü

JUMLAH TOTAL : 53 28 25 16 16 2 0 0 0 19

HASIL SUSPEK POSITIP : Kepala Puskesmas Menur

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : JANUARI 2023

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL 0 0
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
0 0 0 0 0 0

Kepala Puskesmas
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
0 0 0 0

Kepala Puskesmas Menur

KET

0
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : FEBRUARI 2023

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 PUTRA BAYU WICAKSONO MENUR 1/74-C 3578091602890001 33 2874985108 14.4 38.0 5.18 73.5 27.7 37.8 14.2 14.19 ü
2 NATASYA SAVIRA NUR HABIBAH NGINDEN PERMATA 3/37 3578095008000002 22 1542231595 ü 14.6 37.6 4.67 80.6 31.2 38.8 13.8 17.26 ü
3 SELVIANA MAULIDYA PERMATASARI NGINDEN PERMATA 1/1 3578095707970003 25 2295032095 14.3 38.2 5.23 73.1 27.3 37.4 14.2 13.98 ü
4 MOCH. DJAELANI KARANGMENJANGAN 76 3506032107950002 27 672898667 13.5 35.3 4.91 71.9 27.4 38.2 14.5 14.64 ü
5 RAHMAD ADI KUSMAN SEMOLOWARU 143 3578092903930002 29 ü 15.8 38.5 4.88 78.9 32.3 41.0 14.9 16.17 ü
6 SITI ALIFAH DUKUH PAKIS 6-A.2/120 3578216605990001 23 ü 12.5 33.5 4.26 78.7 29.3 37.3 13.4 18.47 ü
7 NUR NAVISAH MENUR 1/63 3578097107770002 45 788719432 12.7 38.2 5.04 75.9 25.1 33.2 13.7 15.06 ü
8 INTANIA HADIANI NGINDEN MAKAM 3/23 3578095605950003 27 ü 12.3 32.9 4.37 75.5 28.1 37.3 13.8 17.28 ü
9 M. YASIR ABDULAZIS SEMOLOWARU BUNTU 15-A 3578091411930002 29 2224149131 13.8 36.7 5.91 62.2 23.3 37.6 16.2 10.52 ü
10 I.G. AGUNG SETIAWAN, SE NGINDEN JAYA 2/4 3578090508820002 40 1701073348 14.6 38.7 4.85 79.9 30.1 37.7 14.7 16.47 ü
11 MUCHLIS PRATAMA HAYU MALANG 3507140604950002 27 ü 14.8 40.4 5.55 72.8 26.6 36.6 14.3 13.12 ü
12 FEBRIANA RAHMA HAPSARI, SE SEMOLOWARU ELOK BLOK AE/21 3578096602830001 39 1818935368 14.4 39.2 4.92 79.8 29.2 36.7 14.7 16.22 ü
13 LIVIA NUR KUMALA SARI PUMPUNGAN 3/30-C 3524257108040001 18 759030107 13.9 33.2 4.58 72.5 30.3 41.8 15.2 15.83 ü
14 SELAMET SIGIT HIDAYAT NGINDEN GG. VI-H/21-C 3578092205950002 27 2998208913 17.7 47.1 5.84 80.8 30.3 37.5 15.3 13.84 ü
15 FADILLAH AZIZAH AZIZ NGINDEN GG. VI-H/21-C 3515175206960002 26 1520985194 9.8 26.8 4.69 57.3 20.8 36.5 17.5 12.22 ü ü SUSPECT THALASEMIA
16 ISMA HANDAYATI SEMOLOWARU ELOK K/20 3578095212820001 40 2261811813 9.8 27.0 4.48 60.3 21.8 36.2 16.6 13.46 ü
17 ALVIRA SYAHFITRI ISPRIADI JL. SELAT BADUNG NO. 34 3578096301990001 24 1227494755 12.5 34.4 4.36 78.9 28.6 36.3 13.4 18.10 ü
18 NANIK PRASETYANINGSIH SAN DIEGO M-9 NO. 2 PAKUWON CITY 3578105202770001 46 2876010186 14.3 37.6 4.96 75.9 28.8 38.0 13.7 15.30 ü
19 BISRI MUSTHOFA SEMOLOWARU 127 3578092110830001 39 1701141063 18.0 45.6 6.18 73.9 29.1 39.4 14.1 11.96 ü
20 AMANDA AURELIA RIZKIYANTI GALAXY BUMI PERMAI H1/1-A 3578204607980003 24 2998748261 13.6 36.0 4.82 74.7 28.2 37.7 13.2 15.50 ü
21 M. SYAFIQ JANGKUNGAN 2/6 3578090311910001 31 1138403463 16.5 43.7 6.28 69.7 26.2 37.7 15.5 11.10 ü

N
22 NOPITA SARI SEMOLOWARU RAYA 55 3517154411930001 29 2471241519 13.5 36.7 4.70 78.2 28.7 36.7 14.3 16.64 ü
23 CHRISTABEL JOSEPHINE KURNIAWAN DONOKERTO 8/8 3578117006950001 27 1729212164 12.6 33.9 4.60 73.9 27.3 37.1 13.3 16.07 ü
24
25
STEVEN WUISAN
MOCH. TAUFIQ AZIZ
MENUR PUMPUNGAN 74
SEMOLOWARU UTARA 8/18
3578092302930002
3578091802970001
29
26
2425625256
1703120815
14.5
17.1
37.5
43.9
5.06
5.84
74.2
75.2
28.6
29.2
38.6
38.9
12.5
13.8
14.66
12.88
ü
ü I
26
27
NAUVIN WAHIDATIN NADZIROH
AMALIA ROSYADA GUNAWAN
DUSUN JATIDUWUR RT.06/RW.07
MENUR 1/16-A
3517125403970003
3578095006960002
25
26 1701066699
1703516139 12.5
14.3
34.3
36.7
4.37
5.29
78.7
69.5
28.6
27.0
36.4
38.9
14.2
13.9
18.01
13.14
ü
ü
H
28
29
MUCHAMMAD CHASAN BASORI
MIFTAKHUL ROMADHON
SEMOLOWARU NO. 22
NGINDEN 3/17
3578091412940001
3578092702950002
28
27
2998547943
2998187662
14.6
16.5
37.8
43.5
5.73
5.82
66.0
74.9
25.4
28.3
38.6
37.9
14.6
13.1
11.52
12.87
ü
ü
I
30
31
BAGIO ARIYANTO
RITA SUGIARTI
MANYAR KARTIKA TIMUR 4/1
SEMOLOWARU SELATAN X/17
3578091702780001
3522265909980001
45
24
ü
ü
13.7
12.5
35.4
32.0
4.76
4.87
74.5
65.8
28.7
25.6
38.7
39.0
13.2
15.6
15.65
13.51
ü
ü
L
32 DAVID BUDIONO PUMPUNGAN 1/25-B 3578093101880002 35 1049870351 15.6 39.9 5.52 72.4 28.2 39.0 15.2 13.12 ü
33 MOCHAMAD NASRULLOH JANGKUNGAN 2 TEMBUSAN NO. 3 3578091010770001 45 1049856366 18.1 45.1 5.78 79.9 31.3 39.2 15.4 13.82 ü
34 LAURENSIUS YURIWIDAYANTO SEMOLOWARU SELATAN 12/15 3578091108830003 39 1175689798 14.8 39.9 5.77 69.2 25.6 37.0 15.7 11.99 ü
35 LARASWATI TANAH MERAH SAYUR 3/36 3578174304970002 25 2921675027 11.6 31.3 4.66 67.2 24.8 37.0 19.5 14.42 ü
36 MISTIYAH SEMOLOWARU SELATAN 1/7 3508064101850012 37 3000237658 14.3 42.2 5.84 72.4 24.4 33.8 14.4 12.40 ü
37 FIDI FARDIANSYAH NGINDEN BARU 5/74 3175072207800014 42 2342302885 15.8 40.0 5.06 79.2 31.2 39.5 14.8 15.65 ü
38 ANOEGRAH MARTINO MULTATULI SEMOLOWARU INDAH S/22 3578090503840002 38 1630181507 13.3 33.9 5.11 65.5 26.0 39.2 20.6 12.82 ü
39 CHOLIFATUL CHUSNA NGINDEN 6-A/26 3578095105010002 21 2158843072 13.8 36.9 4.76 77.7 28.9 37.3 13.6 16.32 ü
40 SUPRAYITNO MEDAYU UTARA XXXI/7 3578032207600001 62 1103177889 15.2 38.8 4.63 84.0 32.8 39.1 14.2 18.14 ü
41 SITI ROMLAH NGINDEN JAYA 1/53 3578096207750002 47 2770159072 13.8 35.6 4.74 75.3 29.1 37.7 13.9 15.89 ü
42 TRI ANGGA YULIAN PUTRA KEDUNG TOMAS 4/5 3515080807920003 30 ü 16.0 39.9 4.98 80.2 32.1 40.1 14.7 16.10 ü
43 IIS FITRIA MARDANI KEDUNG TOMAS 4/51 3578094807990004 23 788028129 12.4 32.4 4.83 67.1 25.6 38.2 13.6 13.89 ü
44 ACH. FATONI NGINDEN 2/25 3529022905950001 27 779350893 15.8 41.1 5.32 77.4 29.6 38.4 14.4 14.55 ü
45 INTAN MAULIDA FITRAH NGINDEN 4-C/1 3217095603980012 24 ü 9.6 25.0 4.70 53.3 20.4 38.4 14.3 11.34 ü ü SUSPECT THALASEMIA
46 ALMAHTIAR LUMONGGA LUBIS NGINDEN BARU 3/1-B 3578095411980001 24 1481775524 13.9 43.2 5.77 75.0 24.0 32.1 13.1 13.00 ü
47 ICHSAN SALMAN NGINDEN BARU 3 1371110912960002 26 1303660888 15.2 38.7 5.96 65.1 25.5 39.2 14.8 10.92 ü
48 HARI SUSENO KLAMPIS SEMOLO BARAT 9 3501031511860001 36 ü 16.0 40.7 5.46 74.6 29.3 39.3 13.2 13.66 ü
49 ROSTIANI GALAXY BUMI PERMAI J-6/16 7373095702920003 31 1730299645 13.0 34.8 4.73 73.6 27.4 37.3 12.6 15.56 ü
50 PRITA KLAMPIS SEMOLO BARAT 9/L-35 3578095201900004 33 1958677659 13.8 35.8 4.84 74.0 28.5 38.5 12.5 15.29 ü

JUMLAH TOTAL 51 23 28 4 9 0 0 0 0 10 0 0

HASIL SUSPEK POSITIP : Kepala Puskesmas Menur

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : FEBRUARI 2023

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesmas
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas Menur
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : MARET 2023

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 RIKY TRI SETIAWAN NGINDEN 5-A/12 3578090905990001 23 2998195198 15.1 41.0 5.43 75.6 75.6 36.8 13.8 13.92 ü
2 ERIC TASYANA SETIAWAN WONOSARI KIDUL 135 3578042103960001 26 2313409836 15.7 40.9 5.67 72.3 27.6 38.3 14.4 12.75 ü
3 CHYESLER EMA MARIA BUDIMAN SEMOLOWARU TENGAH 13/M-17 3578094204960001 26 1792236543 11.8 32.8 4.50 72.9 26.2 35.9 13.5 16.20 ü
4 DEWI MACHFIRO KLAMPIS NGASEM BUNTU NO. 3 3578094405910001 31 ü 13.5 45.0 6.53 69.0 20.6 30.0 14.9 10.57 ü
5 JESSICA AGNES SOESILO GALAXY BUMI PERMAI F-1/11 3578094205940002 28 ü 14.7 39.1 5.02 77.9 29.2 37.5 13.6 15.52 ü
6 FADILLAH AKBAR MENUR 1/59 3578092101900002 33 1405951738 16.2 41.9 5.22 80.4 31.0 38.6 14.6 15.40 ü
7 CATUR ADI NUGROHO SEMOLOWARU UTARA 3-C/7 3578083007960005 26 ü 17.2 44.7 6.22 72.0 27.6 38.4 15.3 11.58 ü
8 YUNITA BELLA A.P MENUR 4/47 3578094206020001 20 ü 11.1 30.7 5.33 57.6 20.8 36.1 17.4 10.81 ü
9 NANDA TEJANINGRUM JL. SUDIRMAN GG. JAWA NO. 2 5271054804960001 26 1660573585 14.5 37.5 4.88 77.0 29.7 28.6 13.0 15.78 ü
10 MUHAMMAD ANISUDDIN NAJWAN SEMOLOWARU TENGAH 6/28 3578090403940001 29 ü 15.3 40.5 5.26 77.1 29.0 37.7 12.9 14.66 ü
11 FIRMAN KASIH SUDARSONO NGINDEN 3-C/52 3578090312960002 26 1723857041 16.0 42.9 5.71 75.3 28.0 37.2 13.1 13.19 ü
12 DIAH NUR AMALIA SEMOLOWARU UTARA 8/22-A 3578096507990001 23 2683076062 13.7 41.1 5.69 72.4 24.0 33.3 14.4 12.72 ü
13 IRRFAN ARDIAN AHMAD SEMOLOWARU UTARA 8/22-A 3672081808980001 24 49517807 15.2 39.3 5.27 74.7 28.8 38.6 13.2 14.17 ü
14 RIDHA AYUNINGSIH NGINDEN 3/30 3524056109000002 22 ü 12.9 34.9 4.72 74.1 27.3 36.9 12.5 15.70 ü
15 HANNY SAVITRI RAMADHANI NGINDEN 2-B/9 3578095801980001 25 1810214458 13.9 37.3 5.21 71.6 26.6 37.2 14.5 13.74 ü
16 OGGY TWOENTA PUTRA SEMOLOWARU UTARA 3-A/2-B 3578091403040005 18 1395333145 13.9 37.6 5.16 73.0 26.9 36.9 14.3 14.15 ü
17 MEILITA TANTOROPUTRI JL. RAJAWALI NO. 22 3310254605960001 26 ü 12.5 34.3 4.61 74.5 27.1 36.4 12.4 16.16 ü
18 JEFFREY HARTO MUNTJANG D MANYAR TIRTOMOYO 4/18 3578090102940001 29 2195593918 16.2 42.9 5.79 74.2 27.9 37.7 12.5 12.82 ü
19 NINA MARDIYANAH MENUR 5/45-A 3578095910020002 20 787005213 10.6 29.8 4.51 66.1 23.5 35.5 16.4 14.66 ü
20
21
DEBORAH YUWONO
CHRISTIAN JANITRA RUSTANDI
Jalan Karya Timur Wonosari D1
NGAGEL MADYA 37
3573015211950001
3578082712940003 28
27 2730124304
2997746752
14.0
15.1
37.1
40.1
4.98
5.43
74.6
73.9
28.1
27.8
37.7
37.6
12.4
13.3
14.98
13.61
ü
ü
N
22
23
ICHSAN BUDIARTO
WAHYU SAIFUDDIN
NGINDEN 2/79
SEMOLOWARU NO. 79.B
3578092711930001
3578092511930001
29
29
100668014 15.6
16.0
40.1
42.7
5.40
5.13
74.4
83.3
28.8
31.1
38.9
37.4
12.5
15.0
13.78
16.24
ü
ü
I
H
2158283801
24 LILI SURYANI NGINDEN 3/46 3578096505940002 20 2998205515 15.0 39.8 5.31 75.1 28.2 37.6 12.3 14.14 ü

I
25 REVANA ARYANI KLAMPIS SEMOLO TIMUR 25/AB-53 3578095603890002 34 ü 12.7 34.9 4.51 77.6 28.1 36.3 13.6 17.21 ü
26 JESISCA SUBYANTO MANYAR JAYA PRAJA 5/39 5312154204890003 33 2998231312 15.1 40.9 5.10 80.3 29.6 36.9 14.6 15.75 ü

L
27 YOHAN PRASETYO SIMOLAWANG BARU 1/32 3578111710870001 35 1721240728 15.1 42.8 5.81 73.7 25.9 35.2 14.1 12.69 ü
28 MARIA NATALIA RASMIANTO MANYAR JAYA 11/4 3578106412910004 31 2693665247 13.7 38.4 5.20 74.0 26.3 35.6 12.5 14.23 ü
29 WAHYU ANGGRAINI JANGKUNGAN 2-A/16 3578086706830004 39 1705393506 12.3 33.3 5.22 63.3 23.5 36.9 15.8 12.13 ü
30 AHMAD FAHIM ZAKARIA MENUR 3/63 3578092511950002 27 ü 15.0 38.3 5.16 74.3 29.0 39.1 12.5 14.40 ü
31 DWI PUTRO SEPTIANTO NGINDEN 2/59 3578092009980001 24 2433057491 17.3 44.5 5.77 77.2 29.9 38.8 14.4 13.38 ü
32 ATTIN GALIH MENUR 3/87 3578096505980001 24 2998195301 12.4 37.8 4.85 77.9 25.6 32.8 13.2 16.06 ü
33 KISMOYO SEMOLOWARU SELATAN 1/72 3578090110920004 30 1395328331 13.8 44.0 7.04 62.5 19.6 31.4 15.1 8.88 ü ü
34 SYAHRUL MUHARRAM NGINDEN 4-A/4 3578090206970002 25 2158535362 14.5 42.2 5.05 83.6 28.7 34.4 12.4 16.55 ü
35 MOCH. MUNIF JANGKUNGAN 1-B/19 3578092511830001 40 2814719128 16.0 47.5 5.70 83.3 28.1 33.7 13.5 14.61 ü
36 DIANA PUTRI WIDIANTI DSN. CURAH KEMBANG MALANG 3507236412980001 24 683590555 13.1 40.8 5.19 78.6 25.2 32.1 12.9 15.14 ü
37 FERAWATI FAJRIN JL. JOYO SUKO 24 3573055612950006 27 1541273995 14.2 43.9 5.40 81.3 26.3 32.3 14.1 15.06 ü
38 CARLYN SOESANTO GALAXY BUMI PERMAI H-5/25 3578094405960001 26 2517477849 13.3 33.2 3.97 83.7 33.5 40.0 13.5 21.08 ü
39 AILSA NABILAH TSANY MASUD MENUR 2/2-C 3578094404980002 24 1176721334 13.6 33.1 4.47 74.1 30.4 41.0 12.5 16.58 ü
40 DITA ANIFATUL AULIA NGINDEN 5-A/7 3578094812970001 25 1725127863 13.2 33.7 4.37 77.3 30.2 39.1 12.9 17.69 ü
41 M. ISKANDAR NURMANSYAH. P NGINDEN INTAN RAYA 16 3578090907950001 27 ü 14.5 37.0 4.81 77.0 30.1 39.1 14.5 16.01 ü
42 ALETHEIA THRESKEIA SEMOLOWARU TENGAH 3/16 3578097112920001 30 100499466 9.2 24.1 3.84 62.8 23.9 38.1 16.0 16.35 ü
43 SAMUDERA WICAKSONO MANYAR TIRTOMOYO 2/52-A 3578081001960003 27 102407556 17.4 43.3 5.51 78.7 31.5 40.1 14.2 14.28 ü
44 KURNIA SARI JANGKUNGAN 2 TEMBUSAN NO. 1 3578095008970001 25 2297197506 13.5 34.9 4.53 77.2 29.8 38.6 12.9 17.04 ü
45 ERA ARINDA PURNAMA MENUR 3/29-C 3578094804970004 25 100667507 14.3 36.6 5.49 66.7 26.0 39.0 14.5 12.15 ü
46 TRI ERIANTO DUKUH DASUN PONOROGO 3502151912970001 25 1036691673 15.6 39.6 5.25 75.6 29.7 39.3 13.8 14.40 ü
47 NARENDRA DWI SATRIA PUTRA TANDES LOR 3/19 3578142604950001 27 ü 13.3 39.9 4.98 80.1 26.7 33.3 13.1 16.08 ü
48 AYU LESTARI GALAXY KLAMPIS ASRI BARAT NO. 5-6 1901024701940001 29 ü 12.5 31.0 4.57 67.9 27.3 40.3 14.3 14.86 ü
49 EVELYN KLAMPIS SEMOLO BARAT 9/54 L-27 3578095111970005 25 2475036178 13.1 32.1 4.31 74.6 30.3 40.8 12.4 17.31 ü
50 ICHDA ILFIKROTUL ALIYAH NGINDEN 5-A/14 3578095308980005 24 1404475424 11.2 28.1 4.11 68.6 27.2 39.8 17.5 16.69 ü
51 BINTANG ARAAFI MUHARRAM SEMOLOWARU INDAH BLOK M/21 3578090305990002 23 172568474 15.3 38.5 5.19 74.3 29.4 39.7 13.3 14.32 ü
52 RHENZIE NADA PRATIWI NGINDEN INTAN TIMUR XVII A7-29 3578086303930004 30 ü 13.7 35.0 4.74 74.0 28.9 39.1 12.5 15.61 ü
53 ROBIN ANDEAS HARIYANTO GALAXI KLAMPIS ASRI BARAT BLOK F2/5-6 3510091001920001 31 ü 17.8 44.7 5.58 80.2 31.8 38.8 14.6 14.37 ü

JUMLAH TOTAL : 53 24 29 15 23 1 0 0 0 26

HASIL SUSPEK POSITIP : Kepala Puskesmas Menur

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : MARET 2023

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesmas
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas Menur
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : APRIL 2023

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 AYU NADYA FIRDAUSI MENUR 1/22-B 3525015712970002 25 11.8 30.1 4.35 69.2 27.1 39.2 15.7 15.91 ü
2 MAHARANI MITA DAMAYANTI MENUR 4/33-A 3578096610960005 26 12.4 31.2 4.20 74.5 29.5 39.7 12.4 17.74 ü
3 YOGA ASPARELLA GRIYO SAMUDRA ASRI B-11/22 SDA 3515131104950008 28 ü 14.0 35.4 5.25 67.5 26.6 39.5 15.2 12.86 ü
4 MUSYAYADAH SEMOLOWARU 135-B 3578096704950002 27 2913647174 12.6 32.0 4.12 77.7 30.5 39.3 14.4 18.86 ü
5 NIMAS MUSTIKA RINI SEMOLOWRU ELOK BLOK B/15 3578096310930002 29 1702739981 11.8 30.2 4.11 73.6 28.7 39.0 14.2 17.91 ü
6 FEBRIS ZIANDA BAYU PRATAMA SEMOLOWARU SELATAN I/53 3578093101960003 27 1395333303 15.6 39.2 5.51 71.3 28.3 39.7 15.4 12.94 ü
7 KHUSAINA SEMOLOWARU SELATAN 1/30 3578097004830003 40 787105899 13.1 34.0 4.42 77.1 29.6 38.5 12.9 17.44 ü
8 HERTANTIO MANYAR KARTIKA 2/8 3578091509890004 33 ü 17.1 43.4 5.46 79.5 31.3 39.4 15.6 14.56 ü
9 MOCH. FAJAR ISWANTO JANGKUNGAN 1-B/23-A 3578092405960001 26 1467211217 16.0 40.3 5.00 80.7 32.0 39.7 13.8 16.14 ü
10 AMINATUR ROCHMAH JANGKUNGAN GG.II-A/14 3505116507970006 25 ü 12.5 31.9 4.27 74.8 29.2 39.1 12.4 17.52 ü
11 SENITZA ANISA SALSABILLA KLAMPIS SEMOLO TIM.4/11 AB-93 3578096411960001 26 ü 12.3 31.2 4.71 66.3 26.1 39.4 15.5 14.08 ü
12 EVI DWI RATNA SARI URANG AGUNG SIDOARJO 3515085605940004 26 ü 13.7 37.7 5.09 74.2 26.9 36.3 14.8 14.58 ü
13 BRIAN DELTAMA FANI SEMOLOWARU ELOK K-16 3515082610950001 27 100583807 15.3 39.1 5.38 72.9 28.4 39.1 15.1 13.55 ü
14 ELOK TUTIE KIRANA SEMOLOWARU UTARA I/126 H 3578096305890002 33 1809089728 14.2 36.2 5.27 68.7 26.9 39.2 14.1 13.04 ü
15
16
CATRA ADHYATMAKA DUTONO
ARI SUGIARTO
SEMOLOWARU INDAH BLOK N/30
NGINDEN PERMATA 3/6
3578090806920001
3516182209890002
30
33
101396226
2683101857
15.3
15.1
40.4
39.6
5.66
5.37
71.5
73.9
27.0
28.1
37.8
38.1
15.4
14.1
12.63
13.76
ü
ü
N
17
18
AGRISTA PRIMA ADITIA HADI
SUGIANTO
SEMOLOWARU UTARA 1/126H
NGINDEN GANG V-E/4-A
3505060311940007
3578090205820002
28
38
671394475
ü
14.4
16.2
37.3
40.8
4.99
5.53
74.9
73.8
28.8
29.2
38.6
39.7
13.1
14.1
15.01
13.35
ü
ü
I
19
20
DWI YOLANDA PUTRI
OKTAVIANTO PUTRA PRATAMA
SEMOLOWARU UTARA 1/141
ASRAMA BRIMOB NGINDEN JKN
3578096107980002
3578092110000002 22
24 787036228

ü
12.8
17.3
34.1
44.1
4.59
5.69
74.4
77.6
27.8
30.4
37.5
39.2
12.5
14.4
16.21
13.64
ü
ü
H
21
22
WIDYA ASMARA
GERALDO ARISSAPUTRA KUNTANI
PUMPUNGAN I-B/15
APT. GUNAWANGSA B.0707 MENUR
3578097107960004
3578090104150001 26
26 2275062715
2041602186
12.0
15.1
30.8
39.5
5.73
4.76
53.8
83.1
20.9
31.7
38.9
38.2
15.2
13.6
9.39
17.46
ü
ü
ü
I
23
24
RIZKI MUKSONI
WENDIK ADIANTO
SEMOLOWARU UTARA 3/14-D
NGINDEN GG II/115-B
3578090807930001
3578090906900001
29
32
2641246716
3061769084
15.6
15.1
41.1
38.8
5.42
5.05
75.9
77.0
28.7
29.9
37.9
38.9
13.7
14.5
14.00
15.25
ü
ü
L
25 DEWANA REYHAN NARADIPTA MANYAR REJO 4/17 3578093103960004 27 1162319455 13.1 35.6 5.39 66.1 24.3 36.7 14.6 12.26 ü
26 KATARINA CHERYL SETYANI PUMPUNGAN 4/71-B 3578096209990003 23 1727084272 13.6 35.4 4.73 75.0 28.7 38.4 13.1 15.86 ü
27 MELLING PRASETYA MANYAR JAYA 11/9 6473026406950002 27 2261527964 11.5 30.2 5.19 58.2 22.1 38.0 14.3 11.21 ü
28 DANANTA PUTRA TEJA MANYAR JAYA 11/9 3578092410940003 28 1372555361 15.8 42.8 5.56 77.0 28.4 36.9 13.7 13.85 ü
29 AMIRUL CHOIR MENUR 4/35A 3578092409960002 26 1256353435 15.8 41.4 5.54 74.8 28.5 38.1 12.4 13.50 ü
30 MOHAMMAD KURNIAWAN JL.SEMOLOWARU UTARA I NO.126A 3578092708960003 26 1395286885 15.4 39.5 5.44 72.7 28.3 38.9 13.5 13.36 ü
31 A. ABRORI NGINDEN PERMATA 2/18 3578091107930002 29 1859992672 15.6 43.9 5.47 80.3 28.5 35.5 12.9 14.68 ü
32 MUH. SYAIFUDDIN ZUHRI MENUR 5/17B 3523140304980005 25 3280937308 14.5 38.3 4.86 79.0 29.8 37.8 14.1 16.26 ü
33 ADINDA SEKAR SARI MANYAR KARTIKA BARAT 17C 3578096910010003 21 788101593 13.2 34.0 4.49 75.8 29.3 38.8 13.8 16.88 ü
34 RISKA ARINTA PRATISTARI,S.KOM SEMOLOWARU 142 3578096609880001 34 ü 13.9 35.8 4.98 72.0 27.9 38.8 16.1 14.46 ü
35 INARA PUTRI PRAHANDITA MANYAR INDAH 1/55 3578096611960001 26 1888142321 13.3 34.0 4.60 74.1 28.9 39.1 12.5 16.11 ü
36 PUJI SRI LESTARI NGINDEN PERMATA IV/14 3578094207970001 25 2998217542 13.1 33.2 4.79 69.5 27.3 39.4 14.8 14.51 ü
37 M. KHOIRUL ALIM NGINDEN 2/25-D 3578091912830003 38 1642832572 14.1 36.7 4.71 78.1 29.9 38.4 14.3 16.58 ü

JUMLAH TOTAL : 37 20 17 14 12 1 0 0 0 8 0 37

HASIL SUSPEK POSITIP : Kepala Puskesmas

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : APRIL 2023

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : MEI 2022

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 DYANA MADYARATRI TEMPUREJO RT. OO1/RW.007 NGAWI 3521105612970001 24 1080741576 13.2 37.4 4.86 77.2 27.2 35.2 13.7 15.88
2 AISYAH FAADHILAH MANYAR TIRTOMOYO 57 3578096552950001 26 ü 13.3 37.5 5.01 74.9 26.5 35.4 13.2 14.95
3 ANTON DJUNAIDI PUMPUNGAN 1/21 3578093006790005 42 ü 13.7 38.8 5.75 67.6 23.8 35.3 14.3 11.76
4 DIA WAHYU ANJARWATI NGINDEN JAYA 1/48 3578096412960005 25 ü 13.3 36.9 4.89 75.5 27.1 36.0 13.8 15.44
5 NATASHA ELVINA RASUBALA SEMOLOWARU TENGAH 9/39 3578096910900001 31 ü 11.8 33.5 4.16 80.6 28.3 35.2 15.3 19.38
6 CIPTA WIJAYA JL. SOMBO 1/8 SIDOTOPO 3578163005910002 30 ü 15.0 42.5 5.64 75.4 26.5 35.2 13.8 13.37
7 IDZA NUR ISTIKHOMAH NGINDEN 3-B/5 3578096605980005 23 786919735 10.7 29.0 4.23 68.6 25.2 36.8 14.1 16.22
8 AYU FIRNANDA ANGGRAENI SEMOLOWARU TENGAH 1/27 3578096305040003 17 ü 13.0 35.1 5.19 67.7 25.0 37.0 15.1 13.04
9 AL FAJAR DSN. BRAYU KULON 3516171501990004 23 ü 14.3 37.9 4.78 79.3 29.9 37.7 14.8 16.59
10 NANDA ZULKARNAIN SEMOLOWARU 143 3578091111970005 24 1542729701 15.5 42.3 5.11 82.8 30.3 36.6 14.4 16.20
11 ALFIATUS SHOLEHA KREMBANGAN JAYA UTARA 6/51 3526146812010002 21 ü 12.4 34.2 4.71 72.7 26.3 36.2 14.3 15.44
12 MUHAMMAD SHOLEHUDDIN SEMOLOWARU 122-D 3578090503970003 25 ü 13.8 37.5 4.71 79.7 29.2 36.8 14.0 16.92
13 WAHYU NOR HAMZAH NGINDEN 2/53-E 3578090805980005 23 ü 15.3 40.3 5.40 74.7 28.3 37.9 13.2 13.83
14 TAUFIK AJI WICAKSONO DSN. BOTO 3322031510950005 25 ü 16.2 43.4 5.61 77.5 28.8 37.3 14.4 13.81
15 ERLYN PUSPASARI SEMOLOWARU UTARA 1/116-A 3578094804970005 25 ü 14.5 39.9 5.47 73.1 26.5 36.3 14.3 13.36
16 ARISTA ALIFIANTI MENUR 3/1 3578097001940004 28 ü 14.6 39.6 5.56 71.4 26.2 36.8 14.6 12.84
17 ONGKI PRATAMA SIWALANKERTO 90 3578040612960010 25 ü 14.1 38.1 5.68 67.2 24.8 37.0 14.4 11.83
18 RENGGANIS NGINDEN 4-C/9 3578094203980001 24 ü 13.3 36.7 4.75 77.4 28.0 36.2 13.7 16.29
19 ARFIN KURNIYANTO NGINDEN PERMATA 1/9 3578092103970001 25 1161647752 17.5 47.4 6.25 75.9 28.0 36.9 14.5 12.14
20 MOCHAMMAD FIRMAN SEMOLOWARU UTARA 3-A/2-A 3578092912920001 29 ü 15.5 43.9 5.64 78.0 27.4 35.3 13.6 13.83
21 DANNY ENGGAR HENDROPRIYATNO SEMOLOWARU ELOK AD/4 3578091707930003 28 ü 15.6 45.3 6.15 73.7 25.3 34.4 14.1 11.98
22 KRISTIAN ZILIWU MENUR PUMPUNGAN NO. 62 3510162809870003 34 2218118916 16.0 45.6 5.84 78.1 27.3 35.0 13.5 13.37
23 RAMADHAN ALI SAPUTRA NGINDEN JAYA 1/43 3578090701960002 25 ü 13.1 36.6 4.99 73.5 26.2 35.7 14.2 14.73
24 AFIFATUL MACHMUDAH NGINDEN 5-A/7 3578096811920001 29 1434423699 13.1 36.5 4.96 73.6 26.4 35.8 13.4 14.84
25 SUKMAWATI DIANA ANGGRAINI JANGKUNGAN 2-C/8 3578096108990004 22 ü 12.1 34.0 5.44 62.5 22.2 35.5 15.2 11.49
26 MUCH. RISKY ADE PRAYOGO PUMPUNGAN 5/6 3578091807000003 21 2275057967 12.1 32.8 6.17 53.2 19.6 36.8 15.3 8.62
27 HANGGARA NANDIWARDHANA SEMOLOWARU ELOK BLOK A1/20 3525100811940001 27 ü 14.0 39.5 5.70 69.4 24.5 35.4 15.6 12.18
28 FRENDY GALLA NOVANDA GUBENG KERTAJAYA 5-F/6 3578081411990003 22 ü 14.5 43.1 5.69 75.9 25.4 33.6 13.7 13.34
29 FAUZI AL AMIN MENUR 2/53 3578092608950001 26 ü 14.7 40.8 5.28 77.4 27.8 36.0 14.4 14.66
30 SITI OKTAVIA MENUR 2/53 3517125510030002 18 ü 12.4 36.7 4.58 80.3 27.0 33.7 14.6 17.53
31 MOCH. RISAL ROHMI FATAHILLAH NGINDEN VI-E/12 3578090206980002 23 ü 14.3 41.0 5.20 79.0 27.5 34.8 14.9 15.19
32 FRANS SETYADI TWEE DYANTO P SEMAMPIR GG. KELURAHAN 120 3578091304770003 45 100843907 14.8 41.4 5.37 77.1 27.5 35.7 13.7 14.36
33 ANNISA JL. KALONGAN KIDUL 1/55 3578154809830003 39 ü 12.4 35.5 4.58 77.7 27.0 34.9 14.4 16.97
34 UMMI RAHMA MAULIDIYAH MANYAR SABRANGAN 5/38-A 3578266105020001 20 ü 10.3 29.0 5.00 58.0 20.5 35.5 16.3 11.60
35 MOCHAMMAD ADI ISWANTO SEMOLOWARU UTARA 1/32 3578091012970002 24 ü 14.6 39.4 5.38 61.8 22.8 37.0 15.4 11.49
36 FARIDA NUR MALA SARI SEMOLOWARU NO. 161-A 3578095007950001 26 1462488344 12.0 33.3 4.59 72.7 26.1 36.0 14.3 15.84
37 MUHAMMAD ASRO ROFI'I NGINDEN 6/17-A 3578090609970001 25 ü 14.4 39.9 5.07 78.8 28.4 36.0 14.9 15.54
38 RAUDLATUL JANNAH DSN. TUMPANGREJO MALANG 3507326805000003 20 ü 12.4 35.6 5.02 71.1 24.7 34.8 14.7 14.16
39 NURRACHMAYANTI SEMOLOWARU UTARA 8/5-E 3578096410990002 22 786852909 11.1 75.7 4.15 75.7 26.7 35.3 13.8 18.24
40 MOCHAMAD ALIF ALAMIN SEMOLOWARU UTARA 4/30-B 3578092807970003 24 2423632307 13.1 36.8 4.90 75.3 26.7 35.5 13.9 15.37
41 EDO HALIM PERDANA MENUR 1/37-C 3578092903960005 26 ü 16.0 44.3 5.56 79.8 28.7 36.1 14.7 14.35
42 CAHYO WAHYU ANGGORO RUNGKUT MAPAN TENGAH 3/DB-19 3578252005810001 41 ü 14.7 41.8 5.10 82.1 28.8 35.1 15.2 16.10
43 AINUL ROFIQ NGINDEN 4/7 3578092510890001 31 ü 15.3 42.5 5.36 79.4 28.5 36.0 14.8 14.81
44 APRILIYA ANANDA PUTRI DUSUN TENGAH PROBOLINGGO 3513084404030002 19 ü 13.5 37.5 4.70 79.9 28.7 36.0 14.0 17.00
45 MUHAMMAD BARON MENUR 2/5 3578090601870001 35 ü 12.7 35.4 5.15 68.9 24.6 35.8 14.9 13.38
46 WIDI ASTITI SOPYANI NGAGEL DADI 1/33 3578046110770006 44 ü 10.1 31.8 4.41 72.2 22.9 31.7 15.2 16.37
47 ALIFAH RAHMI NGINDEN INTAN TIMUR 3/16 F4/18 3578096101960004 26 ü 12.5 34.7 4.99 69.6 25.0 36.0 13.9 13.95
48 REZKY IRAWAN SEMOLOWRU TIMUR 5/AE-3 3578091411860001 35 ü 13.7 39.1 5.16 75.9 26.5 35.0 13.7 14.71
49 PRAMANA RIZKY FERNANDA T.P SEMOLOWARU ELOK E-4 3578082309960003 25 ü 14.0 39.5 5.45 72.5 25.6 35.4 14.4 13.30
50 WILLIAM ADI PUTRA NGINDEN INTAN TIMUR XVII/25 3578090302880001 34 ü 16.1 42.3 7.10 59.6 22.6 38.0 15.0 8.39
51 SIAU RAN NGINDEN INTAN TIMUR XVII/25 3511116202880003 34 2680679518 13.2 36.3 4.30 84.5 30.6 36.3 14.1 19.65
52 RONI WIJAYA BOJONEGORO 3522162502960005 26 BPJS 14.8 40.5 5.56 73.0 26.6 35.5 15.1 13.13
53 EKA NANDA AGNESIA SEMOLOWARU UTARA 3-A/2-B 3578096110980003 23 1395333156 12.0 37.6 5.20 72.4 23.0 31.9 14.4 13.92
54 MONICA TANTRIYUSWIDYA W. TYAS SEMOLOWARU SELATAN 4/10 3578094405830004 39 ü 10.9 30.8 4.22 73.1 25.8 35.3 14.3 17.32
55 JAROT SETYAJI MENUR 2-A/18-A 3578092412980002 23 1395310645 14.8 41.0 5.46 75.1 27.1 36.0 13.1 13.75
56 GRYSDA REVINGGA PRIYONO MENUR 1/22-A 3576016007920001 29 ü 12.5 37.5 5.71 65.7 21.8 33.3 15.6 11.51
57 EDI NUGROHO DS. SELOREJO RT. 07/RW. 05 3518142109950002 26 2710674077 15.0 39.3 5.47 72.0 27.4 38.1 14.5 13.16
58 ISMI JULAIKA PUMPUNGAN 3/15 3578094707990002 22 786865149 12.2 32.7 5.80 56.5 21.0 37.3 15.7 9.74
59 GHEANITHA MUTIARA SJACHNIAR P NGINDEN 6-C/10 3578094809960002 25 1622088797 14.7 40.7 5.16 78.9 28.4 36.1 14.9 15.29
60 PRITA ANDRIASIH SEMOLOWARU UTARA 1/119 3578095903960003 26 ü 13.2 36.8 4.69 78.6 28.1 35.8 14.2 16.76
61 DIANI ANUGRAH WICAKSONO PUMPUNGAN 4/17 3578092107990002 26 ü 15.3 42.9 5.44 78.9 28.1 35.6 14.9 14.50
62 QURROTA A'YUN THOYYIBAH NGINDEN 5-E/10 3578094504930003 29 1701069884 11.4 32.6 4.85 66.0 23.0 34.9 14.7 13.61
63 SUTJIPTO NGINDEN 5-B/12 3578092306550002 66 ü 12.1 34.5 4.39 78.8 27.5 35.0 14.9 17.95
64 TUKIYEM MENUR1/86 3578094506630011 55 ü 12.5 36.1 4.51 80.2 27.7 34.6 14.6 17.78
65 BAYU WILIS DSN. KETAPANG MADURA 3527122306970006 25 ü 14.8 41.2 5.21 79.2 28.4 35.9 14.8 15.20
66 RANI DWI KURNIA PUTRI NGINDEN 4/33-A 3578097112020003 19 2459460969 12.1 34.9 4.78 73.1 25.3 34.6 14.2 15.29
67 DESSY ARYANTI NINGSIH NGINDEN 2/81 3578096312960001 25 1465209628 10.9 31.7 4.32 73.5 25.2 34.3 14.2 17.01
68 AKBAR NURRAZAQ KREMBANGAN BARU 02/01 3578152909970004 24 ü 12.8 36.3 5.36 67.9 23.8 35.2 15.1 12.67
69 AA. ISTRI AGUNG PARWITRI KOMP. SERENITY KAV. NO. 33 3578095810810001 40 ü 12.5 35.2 4.69 75.2 26.6 35.5 13.9 16.03
70 DESI FITRIAWATI SEMOLOWARU UTARA 4/10 3578096812000002 21 787136117 12.7 36.9 4.79 77.1 26.5 34.4 14.5 16.10

JUMLAH TOTAL : 70 37 33 13 8 1 48

HASIL SUSPEK POSITIP : Kepala Puskesmas

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : MEI 2022

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : JUNI 2022

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 NUR HARIROH NGINDEN RAYA BUNTU 14 3578094503690004 53 ü #DIV/0! ü
2 AUDREY GABRIELE ISKANDAR MANYARV JAYA 2/A-57 3578094807950001 26 2360962967 #DIV/0! ü
3 RESKY DWI KURNIAWAN JL. WR. SUPRATMAN 67 TUBAN 3523162810970001 24 103208422 #DIV/0! ü
4 MUHAMMAD AGUS SETIAWAN SEMOLOWARU SELATAN 1/37-B 3578091208940001 28 787923415 #DIV/0! ü
5 DENI NURIANTO MENUR 4/47 3578091412870002 34 ü #DIV/0! ü
6 LUTHFANSYAH MOHAMMAD SUKO SEMOLO VII/G-14 3578121309960001 25 ü #DIV/0! ü
7 HARI SANTOSO SEMOLOWARU SELATAN 9/11 3578252307890001 32 ü #DIV/0! ü
8 MOCH. ALFARISYI MANYAR KARTIKA BARAT 21 3578092608910001 30 1538819166 #DIV/0! ü
9 RAHMAT AGATHA PUMPUNGAN 3/2-A 3578092208010001 20 ü #DIV/0! ü
10 PRILIYANTI ROSITA MENUR PUMPUNGAN KOMP. PLN -10 3578094404910002 31 ü #DIV/0! ü
11 KOMARIYAH SEMOLOWARU SELATAN 1/16-D 3578094101590004 63 2744764075 #DIV/0! ü
12 TRISAH ESTININGRUM MENUR 2-B/11 3578096106990002 22 2480906171 #DIV/0! ü
13 MARSHANDA ANANTA PUTRI NGINDEN 4-D/2 3578095904030003 19 2416682147 #DIV/0! ü
14 GABRIELA WUISAN MENUR PUMPUNGAN 74 3578094608950002 26 2425626101 #DIV/0! ü
15 KENNETH MARTINO DJAJAPRANATA JL. EMBONG TANJUNG NO. 18 3578072603950001 27 2880004285 #DIV/0! ü
16 TANIA ARYANDNA PRASETYA KLAMPIS SEMOLO TIMUR D/12-A 3578094609960003 25 1853643126 #DIV/0! ü
17 ACHMAD ROBBY RAMADHAN JL. RAJAWALI UTARA 3/I-150 3515182001960001 26 ü #DIV/0! ü
18 NURMAULIA TRI ASTUTIK BULAK BANTENG LOR BHINEKA 4/18 3578175706010014 21 3000046331 #DIV/0! ü
19 MOCH. RIKGON ALHIDAYAH NGINDEN JAYA 1/25-C 3578081908980002 24 1049840842 #DIV/0! ü
20 NURUL ADINIYA HALIMATUS S KEDUNG TOMAS 4/41-C 3578096107020003 20 1821018317 #DIV/0! ü
21 NANANG JULIANTO BAKALAN RT.002/RW.001 MOJOKERTO 3516151507970005 25 ü #DIV/0! ü
22 TAQBIRULLOH AZIZ PUTRA PERDANA SEMOLOWARU UTARA 1/72 3578092306910001 30 ü #DIV/0! ü
23 TRIYANTO SUKARNO MANYAR SABRANGAN 3/27 3578061804750002 47 ü #DIV/0! ü
24 NUNUK HARYATI NGINDEN 6-C/10 3578096011750002 46 2684291253 #DIV/0! ü
25 ERDIANTO WIDOGO MENUR 4/20 3578090304950001 27 ü #DIV/0! ü
26 RUMIATI PURWOSARI PASURUAN 3514085012940004 27 BPJS #DIV/0! ü
27 MOCH. MUNIF JANGKUNGAN 1-B/19 3578092511830004 39 ü #DIV/0! ü
28 SRI RUSMIYATI BRATANG GEDE 3-I/30 3578095611800006 42 1705401652 #DIV/0! ü
29 DEFI RATNAWATI NGINDEN 6-B/15 3578094812820003 40 ü #DIV/0! ü
30 M. HARIS AFFANDIK DSN. HULAAN GRESIK 3523170511800001 41 ü #DIV/0! ü
31 MOH. SUGIANTO DSN. PANGJAJAR PAMEKASAN 3528011911920001 29 773649303 #DIV/0! ü
32 SITI MUNAWAROH JANGKUNGAN 1-D/12 3578094903980001 24 2158535643 #DIV/0! ü
33 SYAIFUL RIJAL SEMOLOWARU UTARA 1/122-A 3511031003720005 50 ü #DIV/0! ü
34 LELY HIDAYAH KEDUNG TOMAS 3/6 3578096503900001 32 788501261 #DIV/0! ü
35 YOGI SANJAYA GUBENG KERTAJAYA 10-A/14 3578080603950001 27 ü #DIV/0! ü
36 AININ JARIYAH NGINDEN SEMOLO NO. 12 3578097105750003 47 2998549383 #DIV/0! ü
37 BENDI WIDIYOBANDONO PLOSO TIMUR 5-A DALAM NO. 6-B 3515070111750001 47 1772789646 #DIV/0! ü
38 SUPRIADI KEDUNG TOMAS 3/19-A 3578090911800003 42 ü #DIV/0! ü
39 IBNU MAS'UD NGINDEN 2/53-C 3578091803010001 21 ü #DIV/0! ü
40 RENALDO MAXILLION PARINUSSA NGINDEN BARU 8 BLOK B-46 3578091705950004 27 ü #DIV/0! ü
41 SUKARNO BIMA HARYUNDA SEMOLOWARU UTARA 4/30-C 3578091506930002 29 ü #DIV/0! ü
42 NOVITA EKA RAHMAWATI PUMPUNGAN MASJID 1-B 3578094911990001 22 2459912725 #DIV/0! ü
43 MIRA SAFITA MENUR 4/16-A 3578065402750007 47 ü #DIV/0! ü
44 ERNEST YOWONO ABADI MANYAR KARTIKA 5/23 3578090310930001 28 ü #DIV/0! ü
45 JESSICA ANGELINA JL.BENDULMERISI AURI KAV 11-D 3578026507960002 25 ü #DIV/0! ü
46 EVI DIAS DWI LESTARI MENUR 1/104 3578094607960002 25 1083661795 #DIV/0! ü
47 MUHAMMAD RIFA'I NGINDEN 3/40 3578092609920001 29 ü #DIV/0! ü
48 ABDUL. ROCHIM KALISARI DAMEN 85 3578262401970001 25 ü #DIV/0! ü
49 NOVI KURNIA PUMPUNGAN MASJID 1-B 3578096911930003 28 787430722 #DIV/0! ü
50 DESY NUR CAHYANI MENUR 164 3578096007920002 29 ü #DIV/0! ü
51 NIZAR AL RHAAZI MANYAR INDAH 10/19 3578093004970001 25 2064489142 #DIV/0! ü
52 AHMAD RIZKI KURNIAWAN NGINDEN JAYA 1/41-A 3578092706960005 25 ü #DIV/0! ü
53 ALMIRA AMANTA CHRISANDI KEPUTRAN KEJAMBON 2/55 3578076606960001 25 ü #DIV/0! ü
54 GUSTINHALIM GUNTARANO SULAWESI TENGAH 7203190808880003 35 ü #DIV/0! ü
55 WAHYU MUSTIKA WARDHANI MANYAR SABRANGAN 9-I/94 3519045805960001 26 2377885825 #DIV/0! ü

JUMLAH TOTAL 55 30 25 12 14 0 0 0 0 29 55

HASIL SUSPEK POSITIP : Kepala Puskesmas

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : JUNI 2022

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : JULI 2021

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 SOELISTIYOWATI MANYAR SABRANGAN 9-I/92-E 3578264404860001 35 1878334299 18.4 43.1 5.6 77.1 32.8 42.6 14.5 13.77 ü
2 MUKHLISAH DUSUN SIDOWARAS KRATON KRIAN 3515115409740002 46 2749885569
3 MUHAMMAD SAIFURROZI SEMOLOWARU SELATAN 1/51 3578090504860001 35 1395333448
4 AYUKO FARAGH DAGAS TSANI SEMOLOWARU ELOK F/30 3578096308970001 23 ü
5 DEVINA MONICA PATTIWAEL MANYAR JAYA 12/4 3578096411930001 27 1964250977
6 YORDIANO SEBASTIAN HARYONO JL. NANGKA UTARA PERMATA ARSANDI 5171040701930003 28 2251651083
7 DHANY FERDIANTO NGINDEN 5/48 3508100603820001 38 2697031091
8 ANGGRAINI WIDDI PRATAMA PLOSO 8/4 TAMBAKSARI 3578086210840006 36 ü
9 BAMBANG PRABOWO SEMOLOWARU UTARA IV/36 3578092511590001 61 100500985
10 DEWI RATNA KUMALA MENUR 3/1 3578094503000005 21 ü
11 ARIF MUSTHOFA JANGKUNGAN 2/1-B 3578091305910002 30 ü
12 RIZKY PRATAMA NGINDEN JAYA 1/25 3578152206940002 27 1544672722
13 YULI EKO PRASTIWI SEMOLOWARU SELATAN 1/38-A 3578094407850002 36 1830161428
14 D. BERRILLINA SATRIA MUDA I NGINDEN 1/29 3578094112970001 23 2464843364
15 DINNA TUS SOFIYAH NGINDEN PERMATA 1/37 3526185510010004 20 ü
16 MUHAMMAD ROBBACH RAYA MENGANTI 31 3524260301930001 28 ü
17 TULUS AHMAD KHOLIQ MUHTADI SIDOMLANGEAN LAMONGAN 3524061907810002 40 1279712441
18 SHAFFIRRA RAMADHONA AMADEA SEMOLOWARU SELATAN 4/22 3578096901960002 25 1701400926
19 NENA APRILYANA MENUR 3/1 3578096604850002 36 ü
20 DARMUJI BULAK RUKEM 1/47 3578162010760003 44 ü
21 RIZCA AYU WIDYA KUSUMA NGINDEN 5/14-A 3578176802930001 28 2051968318
22 LUKITA DEWI KARMILA NGINDEN GG, VI-G/9 3578094606870003 34 ü
23 HAVID BADAARRUDIN PERUM GKGA BLOK DE-37 3525141602960002 25 1475462338
24 TIEN SILVIANI JANGKUNGAN 1/17 3578094203880002 32 1141380516
25 ANASTANIA BALQIS KEDUNG TOMAS 2/34 3578105401950003 26 ü
26 MUHAMMAD MANSHUR DUSUN KRAJAN 01 GRESIK 3525070911780001 42 764128934
27 SITI JULAIKHA SEMOLOWARU INDAH II BLOK P-20 3578096202040002 19 1294237754
28 DYAH RAHMAWATI SEMOLOWARU SELATAN 6/4 3578095910980004 22 ü
29 KEVIN TARUNADJAJA TAMAN ALFA INDAH K-I NO. 46 3174102810930001 27 BPJS
30 ELIZABETH CITRA DEWI RAHARDJO RAYA MANYAR INDAH 65 AA-15 3578095405940002 27 1481372526
31 DONI ARIF AFANDI SEMOLOWARU SELATAN 3/21 3578090401810003 40 1541279248
32 AGUNG PRIBADI KEPUTRAN PANJUNAN 2/49 3578071809950001 25 ü
33 CHAIRUDIN SEMOLOWARU UTARA 3/31 3578093005790001 42 ü
34 NUR INDAH CHAIRANI NGINDEN PERMATA 4/28 3578096712970002 23 ü
35 DAVID KADARUSMAN MENUR 3/29 3578091810850002 35 ü
36 KARINDA DYAH PUSPITASARI DUSUN KERET KREMBUNG SIDOARJO 3515034307940001 27 ü

JUMLAH TOTAL : 1 17 19 0 0 0 0 0 0 16 0 1

HASIL SUSPEK POSITIP : Kepala Puskesmas

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : JULI 2021

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : AGUSTUS 2021

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 PRAMUDIYONO, IR MANYAR INDAH 8/14 3578090812540005 66 ü #DIV/0!
2 BIANGGA ANGGI SAPUTRA MENUR 4/6 3509121206040006 17 ü #DIV/0!
3 HARRY HARIYANTO JLN. CENDRAWASIH KUPANG 5371032203830005 38 ü #DIV/0!
4 PATRICIA MONICA GOZALI, S.SOS KLAMPIS SEMOLO BARAT 2/19 (Q-18) 3578095607880001 33 ü #DIV/0!
5 PUDJIONO MENUR 1/16 3578092011670001 44 ü #DIV/0!
6 SRI MULYANI MENUR 2-B/9 3578095011760002 44 ü #DIV/0!
7 MIFTACHUL NUR JANNAH JANGKUNGAN 1/32 3578095004940002 26 1702083137 #DIV/0!
8 DANARJATI ABHIRAMA SEMOLOWARU INDAH BLOK M/32 3578092702940003 27 100225181 #DIV/0!
9 PARAMITHA SARI SEMOLOWARU ELOK BLOK W/16 3578096804860001 35 ü #DIV/0!

N N
10 GHEA CINANTYA PUSPITA SUKO SEMOLO II/23 (BLOK J-11) 3578096006950001 26 ü #DIV/0!
11 MEINARTI KURNIADIARTI PUMPUNGAN 1/15-B 3578095005840005 37 ü #DIV/0!
12
13
RAHMAD HUDOYO
IDA AYU KHOMANG
PONDOK DAMAI NO. 7-A DEPOK
SEMOLOWARU TIMUR 10/AJ-26
3276050203910009
3578204801920002
30
29
ü
ü
#DIV/0!
#DIV/0! I I
14
15
FAHMI RACHMADHANI
IKA NICKY WAHYUNINGRUM
MANYAR KARTIKA BARAT 15
NGINDEN PERMATA 3/1
3578091501990002
3578095201930002
22
28
788631579
ü
#DIV/0!
#DIV/0! H H
16
17
SALSABILLA EKA WIDYATANTI
ANGGI DANU MAULANA
SEMOLOWARU ELOK BLOK AJ/10
NGINDEN JAYA 1/9
3578096211000005
3578091307970004 24
20 ü
ü
#DIV/0!
#DIV/0!
I I
18
19
WINDA LAILA
SALMAN AL FARISY
NGINDEN 4/25
PANDEGILING TENGAH 58
3517085903000002
3578051506970001 24
21 ü
ü
#DIV/0!
#DIV/0!
L L
20 OLIVIA ANGGITA YUSUF PUTRI SEMOLOWARU ELOK E/23 3578097105940003 26 ü #DIV/0!
21 SUFIA ASTUTI SEMOLOWARU ELOK BLOK P/9 6309035103980003 23 2659878527 #DIV/0!
22 BAYU ARYA ANGGARA SEMOLOWARU ELOK BLOK P/9 3578092809930001 27 ü #DIV/0!
23 MOCHAMMAD BASHIR ZEIN SEMOLOWARU UTARA 101-B 3507142903961001 25 ü #DIV/0!
24 YAHYUN NADHIVAH NGINDEN 3-C/39 3578094304000004 21 ü #DIV/0!
25 LAILANI FAUZIYAH JANGKUNGAN 1-B/20 3578096604950001 26 1715877617 #DIV/0!
26 DONI SUSILO JL. SUKUN SIDOMULYO 20 3573040307910010 30 784150119 #DIV/0!
27 SITI INDANA JL. SEMOLOWARU UTARA 1/158 3578096103970001 24 ü #DIV/0!

JUMLAH TOTAL : 27 12 15 2 4 0 0 0 0 21

HASIL SUSPEK POSITIP :

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : AGUSTUS 2021

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : SEPTEMBER 2021

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 ARIF PRASETIYO WIBOWO SEMOLOWARU UTARA IV/36 3578091305940001 27 ü
2 INDIARSA ARIEF LESTIA, DR PUMPUNGAN 3/21 3578092108810002 40 ü
3 MOCHAMAD ARFIANSYAH SEMOLOWARU UTARA I/86-A 3578090809950003 26 ü
4 SINDY MAGDA LINA SYAH SEMOLOWARU UTARA I/86-A 3578064908970004 24 ü
5 PRIMA BERLIANTO GUNUNGANYAR JAYA IIIB/8 3578252705940002 27 1536634541
6 LAILI MAULIDAH JANGKUNGAN I-D/1 3578094109930002 28 ü
7 TRI RETNO WAHY NINGRUM TENGGILIS MULYA GG. 1-D/23-I 3578095105860004 35 ü
8 RENNY SOPHIA SEMOLOWARU ELOK B-34 3578096908710002 50 2626031226
9 ROHMAN GANDI KALITEKUK RT.034/RW.010 YOGYA 3403123012940001 26 653272885
10 RAHMAD FAUZI TAMBAK WEDI BARU 9/31-B 3578171201980001 23 ü
11 WIDYA JUNIARTI NGINDEN 2/65-I 3578096006970002 24 ü
12 MIFYACHUL OKTAVIANI MENUR 1/39-A 3578094810960004 24 1450919441
13 ROUDHATUL FITRIANI JANGKUNGAN 1-C/3 3578095203950001 26 ü
14 ABRAHAM ADITYA SEMOLOWARU UTARA 1/54 3578092803880003 33 ü
15 BILLIE TJAHJONO MANYAR JAYA XII/8 3578092505960001 25 ü
16 CLARISA SITA THEODORUS TERUSAN SRI RAHAYU 5 3573056607960002 25 1205156564
17 ANIK W NGINDEN 2/101 3578094509820006 39 ü
18 YURIKE SUTJIONO KLAMPIS SEMOLO BARAT 7/60A J-21 3578095606920003 29 ü
19 ITA WULANDARI NGINDEN 5-B/8 3510036610920003 28 2467917022
20 YASON NIELSEN ARGOSURIO KLAMPIS SEMOLO BARAT 7/60A J-21 1371030304920008 29 ü
21 RIZQI AUGUST W SEMOLOWARU TENGAH 7/20 357800218930002 27 ü
22 DINI NOVITA ANGGRAINI SEMOLOWARU BAHARI BLOK 8/28 3578097011990005 21 1337497446

N N
23 RUDIYANTO DSN. KRAJAN BANYUWANGI 3510190312990004 22 2073017428
24 ENDANG JANGKUNGAN 2-C/6 3509225809800004 40 ü

I I
25 HANIEF ANSHAR SEMOLOWARU ELOK BLOK K-22 3578092103880003 33 ü
26 AYU AJENG ANDINI SEMOLOWARU NO.87-A 3578094610980001 22 ü
27
28
MERISA LOURENTIA PURNOMO
ALI KURNIAWAN
KENJERAN NO. 158
JL. SOEKARNO HATTA 47 PASURUAN
3578106309910001
3575022906940002 27
29
2467046204
ü
H H
29
30
LANANG ALIM CHAQIQI
AMALINA ANDRIANI
SEMOLOWARU 151
MENUR 3/5
3578090408970002
3578095904930005
23
28
787063871
ü
I I
31
32
MAULINA PUTRI WULANDARI
INTAN AYU PERMATASARI
NGINDEN IV-A/5
SEMOLOWARU SELATAN I/66
3578096506980001
3578095411960001
23
24
ü
ü
L L
33 FITRI NURHANDAYANI JL. MANYAR NO. 85 3578096403990002 22 2155564528
34 MUSADIKAH MANYAR SAMBONGAN 69 3578097012810003 39 ü
35 FADLI ASGHAR JANGKUNGAN II/4 3578090202920002 29 ü
36 ROBBY SUHARTA MENUR 3/67 3578092305940001 27 1335321887
37 NUR CHOLIFAH SEMOLOWARU UTARA I/126 3578096909860003 35 2686444841
38 RACHMAD PUJIYANTO JL. JERUK VI/12 PERUMNAS KAMAL 3526041411920002 28
39 AUDIA MUMTAZ RIFASKY PUCANG SEWU 20 3578084702970001 24 102025495
40 I WAYAN DODY SEPTIANTA,A. MD SEMOLOWARU SELATAN 12/8 3578090309890004 32 ü
41 DAVID KHAN BAYU SANJAYA DUSUN GAMBIRONO KULON JEMBER 3509060508950004 25 ü
42 ITA AMELIA MENUR 4/47 3578096908010001 20 1049870068
43 SENA SEADI BRIGJEN KATAMSO I NO. 30 351518170197004 24 ü
44 KIKI SETYABUDI JANGKUNGAN 1-D/7-D 3578091509800003 41 ü
45 MELIZA W NGINDEN BARU 2/14 3578096305810002 38 ü
46 AYU GALIH FAJARSARI SEMOLOWARU TENGAH XI/16 3578095407850003 36 1319956784
47 SUTRIA PADMA SARASWATI SEPANJANG TANI RT. 02 RW. 05 3515136109950004 26 2736374444
48 ANIN CITRA YANI MENUR 2/19 3578097110980001 22 ü
49 MOCH. ICHWAN ROSYADI MEDOKAN 4/5-B 3578092107000001 21 ü
50 INTAN KARTANEGARA JANGKUNGAN I-B/23 3578094606980001 23 ü
51 ARETA GRISELDA SABELA SEMOLOWARU UTARA I/136-A 3578096906000003 21 ü
52 ALDO PRASETYA SECOWININGRAT NO. I-A 3578081510000008 21 1706908634
53 RIZKY YUDIA PRATAMA PUMPUNGAN III/47 3578091212970001 23 ü
54 LAILATUL MUKAROMAH DUSUN KARANG TENGAH LUMAJANG 3508055905020003 21 787102795

JUMLAH TOTAL : 54 24 30 11 7 1 0 0 0 34

HASIL SUSPEK POSITIP :

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN :SEPTEMBER 2021

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : OKTOBER 2021

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 ALAN BRAMONO JANGKUNGAN I-B/16 3507272007810005 40 2998227249
2 FARISTA AULIA PULO WONOKROMO 79 3578044707960003 25 ü
3 NANIK WIDARTI NGINDEN PERMATA 3/16 3578084309890006 32 ü
4 DELILA WIDAYANTI NGINDEN JAYA I/11-A 3578095107850003 36 ü
5 AMANDA GUMELAR SEMOLOWARU ELOK BLOK AC/7 3578091008960002 25 99827234
6 YOYON CATUR RESKIANTO SEMOLOWARU UTARA GANG 1/31 3578090711840002 36 ü
7 HABIB MUSTOFA MENUR 5/45 3578090504840004 36 ü
8 SUTARNO PUMPUNGAN 3/36 3578091108620001 59 ü
9 EKO WIJANARKO PERUM CANDI MAS REGENCY B3/22 3515180811660001 54 99802607
10 NANDA YULIAWAN MANYAR REJO 8/45 3510091707960004 25 ü
11 MOCH. HANDOYO BAGUS S SEMOLOWARU UTARA 3-A/21 3578090102930002 28 ü
12 DESY NURMALA SEMAMPIR SELATAN 3-A/8 3578095512830004 37 1826102823
13 RIZKY FIRMANSYAH MANYAR INDAH 7/6 3578091804900002 31 1238251364
14 DESY ULIA ULFA JL. KAMBOJA BLIGO CANDI SIDOARJO 3578156512950001 25 ü
15 RUDI HERMAWAN SEMOLOWARU BUNTU 17 3578092309920003 29 ü
16 SILINGGA DAMAYANTI GANGGANG PANJANG SIDOARJO 3515064604970004 24 2488344524
17 BASUNDARA VITO MENUR 3/43 3328062808970002 24 1908356253
18 AARON PUTRA IMMANUEL KLAMPIS SEMOLO BARAT 7/47 BLOK I-25 3578091509960002 25 ü
19 MELYANA SUGIANTO JL. PAHLAWAN 132 PROBOLINGGO 3574036802000001 21 ü
20 HENDAR BINTANG RAHARJA SEMOLOWARU INDAH BLOK D/32 3578092811900002 30 ü
21 MARVIN MAHENDRA MANYAR REJO 10 3578092703860001 35 ü
22 MEYRIS GUNAWAN JL. NANAS IV/N-426 PCI SIDOARJO 3578015405870010 34 ü
23 NURHALIS MAJID DSN. PESISIR BARAT SAMPANG MADURA 3527040709910003 30 ü
24 FINA LUTFIANA JANGKUNGAN I-B/1-A 3578095810010003 20 ü
25 MARIATUL KHIPTIYAH SEMOLOWARU SELATAN I/43 3578096309880002 33 ü
26 SULCE RENJAAN SEMOLOWARU ELOK F/37 5304214107600040 61 2470319796
27 JUSTINUS HARTONO. SE. SH SEMOLOWARU ELOK BLOK E/14 3578090809560002 65 1295944727
28 DENY AKBAR PRAKOSO SEMOLOWARU BAHARIBLOK 12/17 3578091307950001 26 1110279341
29 CINTIA NATALIA SUCINTO KLAMPIS SEMOLO BARAT 9/31 K-48 3578095612940001 26 1609228326
30 NANANG KHOLIFI DSN. DU UMAN 3528100703980003 23 ü
31
32
DICKY SHADEWA
SITI HASANAH
NGINDEN SEMOLO NO. 12
SEMOLOWARU NO. 179
3578092302960003
3578094906920002
24
29
ü
ü
N N
33
34
YOFY LUVIANTO
PUTRI ASTUTIK
MENUR 2-C/26-D
MENUR 3/9
3578092805970002
3578095305980007
24
23
ü
ü
I I
35 SEILA MIGI APRISIA NGINDEN 2-D/12 3578094604970001 24 1161961031 H H
I I
36 LYLA NGINDEN INTAN TIMUR 18/A-5 5171035006750022 46 ü
37 IWAN PORNOMO SEMOLOWARU UTARA 3-B/42-B 3578092210820001 38 172831757

L L
38 NURUL AINI UMI KARTIKASARI PUMPUNGAN 4/17 3578096302790003 42 ü
39 CHATONI PRAYOGA SEMOLOWARU BAHARI 2/16 3578090909940002 27 ü
40 ABDUR ROCHMAN NGINDEN 5-B/2-B 3578090707010002 20 ü
41 SITI ANISAH PUMPUNGAN 4/48-E 3578094311770001 43 1049869888
42 SENADI PENGALANGAN 183 GRESIK 3525131506630004 58 ü
43 NUR SITI WAHYUNI JL. TENGKAWANG PERUM KELAPA GADING 6472066002880006 33 ü
44 POPPY INDRIANI NGINDEN JAYA 2/14 3578096403950006 26 1798893145
45 TERA SONIA PRATAMA NGINDEN JAYA I/25-C 3578156503960001 25 ü
46 RICKY HARTONO SALIM KLAMPIS SEMOLO TIMUR 10/7 (AB-229) 3578090309890003 32 ü
47 WARDAH CHOIRINA LUTFI NGINDEN BUNTU NO. 4 3578094902930002 28 1388934674
48 CHRISTIAN HUTAURUK SEMOLOWARU UTARA 6/6 3578092412900003 30 ü
49 HERI SULISTYO BUDHI SWADAYA II/59 JAKARTA 3174051811920006 28 43001662
50 HIMMATUL ALIYAH PUMPUNGAN 1-B/11 3578095009030002 18 ü
51 NABILA RIDA PUSPITASARI SEMOLOWARU TENGAH 7/7 3578095103950003 26 2737576416
52 RONY HANDOKO KLAMPIS SEMOLO TENGAH 4/21 (D-19) 3515162010860003 35 ü
53 AXZELLA RAUDHA MUKAROMAH NGINDEN SEMOLO 18-A 3578096805960003 25 1792896873
54 SATRIA ALDI PERMANA SEMOLOWARU ELOK BLOK AB/16 3578091101910001 30 1817422244
55 M. ILHAM OETOMO NGINDEN SEMOLO 18-A 3201021101960001 25 1809060276
56 ABDUL ARIEF HIDAYAT SEMOLOWARU UTARA I/30-D 3578031903820002 39 2159199731
57 MAURINE HENDRATA MANYAR JAYA 6/23 3578097105920002 29 ü
58 WAHIT SYAHIRUL NUROHMAN KEDIRI 3506241703930003 28 ü
59 ARISTA DWI HARIYANTI KEDIRI 3571015904960003 25 2814404139
60 NIKEN TRI UTAMI NGINDEN JAYA 2/21 3578096402940001 27 ü
61 FAIZ FERRIANTO SEMOLOWARU ELOK B/9 3578090802940001 27 2358181449
62 DINI FAJAR HIDAYAH JANGKUNGAN I/46 3578094209970005 24 1701120791
63 DHIMAS ANIZ SETIAPUTRA SEMOLOWARU BAHARI BLOK I/3 3578092007920002 29 1227134913
64 SOFIA TRI HABSARI MUDYANA APARTEMEN GUNAWANGSA MANYAR 3575026205950001 26 ü
65 RIZKY BUDIONO TAMAN PINANG ASRI M-5/10 SIDOARJO 3515182107960006 25 ü
66 GITA FATMALASARI KAPAS LOR WETAN 6/16 3578104806970008 24 ü
 67 ALEXANDER LUWANTO KLAMPIS SEMOLO BARAT NO. 77 3578091104880002 33 ü
68 PRAANAADIKA LEBO AGUNG 2/49 3578100209960007 25 ü
69 AGUSTIN LISANTARI NGINDEN 5-D/3 3578095208830002 38 1437537339

JUMLAH TOTAL : 69 37 32 6 19 2 0 0 0 42 0 0

Kepala Puskesmas
HASIL SUSPEK POSITIP :
- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : MENUR
BULAN : OKTOBER 2021

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : NOVEMBER 2020

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 BAGUS WIYANDIKA PERDANA MENUR 3/43 3578090904950001 26 1096978847
2 ACHMAD HABIBIE TAUFIQUR RAHMAN SEMOLOWARU TENGAH 12/15 3578090412950002 25 ü
3 PUSPITA LISTYA NURVIANI GALAXY BUMI PERMAI J-4/33-A 3578125405920004 29 2354670966
4 ALEXANDER LUWANTO KLAMPIS SEMOLO BARAT NO. 77 3578091104880002 33 ü
5 ANIS WULAN SARI LINGK. KRAJAN BANYUWANGI 3510216602960002 25 2418248766
6 CHRISTELLA AUDRIA LORENZA SEMOLOWARU TENGAH 1/58-A 3578096810950001 26 ü
7 SITI MAYANG SARI SEMOLOWARU SELATAN I/20 3578096703000004 21 ü
8 MOHAMMAD MISYONO DUSUN KRAJAN 005/002 BONDOWOSO 3511082507960001 25 ü
9 ANTHONY WIBISONO MANYAR TIRTOASRI X/45 3578092109910001 30 ü
10 QONITA RIZKY LUTFIYAH MLETO 44-D 3578096208960004 25 ü
11 YUSUF KURNIAWAN ISKASARI MANYAR REJO 1/4 3578092206950004 26 ü
12 ROFIATUL IMMAMIYAH SEMOLOWARU NO.49 3578096709900002 31 1289762627
13 DESMA ANGGARA PUTRO SEMOLOWARU UTARA I/81 3578092012940004 26 ü
14 NOVI SRI MASURAI PUTRI DS. KEMADU REMBANG JATENG 3317085511890001 32 ü
15 FATHUDDIN YUSUF NGINDEN V/16 3578092201950001 26 1264103008
16 IKE WAHYUNI MENUR 5/5 3578094307890001 32 786981756
17 NELA RACHMAN NGINDEN PERMATA 3/12 3578091208860004 35 ü
18 FITDIA PANGESTIKA PUMPUNGAN 5/76 3506154406940001 27 1402061567
19 SANTIKA PUJI AGUSTINA NGINDEN 5/11 3578094308970002 24 ü
20 RANGGA PUTRA PAMUNGKAS MENUR 3/7 3578090707990004 22 ü
21 SRI WAHYUNI SEMOLOWARU SELATAN I/70-A 3578096706890003 32 787577681
22 DYAH AYU FITRIA SUGIARTI RAYA NGINDEN 3 KAV 8 3578095512010001 19 ü
23 KHALID THOHARI DSN. SIMO 3515102404930003 28 2996253551
24 TOMY SETYAWAN SEMOLOWARU ELOK BLOK C-9 3578010906760002 45 3051711707
25 EVA FRANSISCA KEDIRI 3506105311950003 26 1842227087
26 SOFYAN CHAMMADA MENUR 2/79 3578090107940003 27 2156279837
27 DRAJAT KUSBANDONO JANGKUNGAN I-B/33 3578091002810007 40 ü
28 YOSUA ARIF TANG JAYA ADIMASTO KLAMPIS SEMOLO TIMUR AB/49 3578052610960002 25 1457071683
29
30
AYUNI SUKMAWATI
PANDU SETIAWAN
DSN. SUMBERAGUNG DESA TULUNG
MENUR 3/63-B
3519125206990002
3578091811990003 20
22
787393945
2779640651
ü
N N
31
32
TITIK DIAN ASTUTIK
FLANI ANASTASIA
DS. NGUNUT RT. 004/RW.002 MAGETAN
LARANGAN MEGA ASRI B-102 SIDOARJO
3520024409900005
3515076005960001
31
25
738123974 ü
I I
H H
1702293412
33 JAYAK UTOMO JANGKUNGAN I-B/16 3578092510940007 27 ü

I I
34 MILA SAPITRI NGINDEN 5-B/22 3578096604010003 20 2161903228
35 DEBI SINTIA DEWI SEMOLOWARU 133 3578094412950001 25 ü

L L
36 ACHMAD RIZKY AFANDI PUMPUNGAN I-B/19 3573030505840008 37 2038477768
37 NADHIFAH SALSABILA NGINDEN GG. II-C/1 3578095308980004 23 ü
38 JEFRY CHANDRA APARTEMEN GUNAWANGSA MANYAR 1271101407840007 37 2227952259 ü
39 HARNITA APARTEMEN GUNAWANGSA MANYAR 3515045704810002 40 2211361852
40 LILIK SUHERLINA MENUR I/46 3578095203750001 43 1259830484 ü
41 ALIF SUBEKTI WIDJOJO MUSI 16 GAJAHAN SURAKARTA 3578112407750003 46 ü
42 NINING ARI ISTININGRUM SEMAMBUNG KIDUL RT.003/RW.002 3515104512840001 36 721282206
43 BAGUS FARDIANTO ZEN JANGKUNGAN 1/11 3578092008880002 33 ü
44 YASYA GHAIDA NESTIANANTA SEMOLOWARU INDAH BLOK E/13-B 3578095809950002 26 ü
45 AMOS HAUTEAS MANYAR JAYA 14/34 5302212806750001 46 ü
46 LEILY ROCHMAWATI SEMOLOWARU PRAJA KAV 2/51 3578094510960006 25 2998073766
47 SUGIANTO DUSUN KALITALUN TULUNGAGUNG 3504192206910002 30 ü
48 PUGUH SETIAWAN, ST SEMOLOWARU UTARA VI/6-A 3578092707790002 42 ü
49 NADYA NOOR RAMADHANIA GALAXY BUMI PERMAI H-5/47 3578096301970003 24 ü
50 DWI FEBI WIDIYANTI NGINDEN I/19 3578096302990003 22 2814725496
51 AMALIA SARASWATI MENUR I/58 3578095710970003 24 ü
52 DEVI NUR ADHANIA PUMPUNGAN 4/32 3578096703990001 22 ü
53 M. AINUR ROFIK SUKODONO 1/14-A 3578161712920001 28 ü
54 SITI FATIMAH JL. SEMOLOWARU NO. 81 3578096710000001 21 ü
55 NJOO HAN LIANG GRIYO MAPAN SENTOSA BLOK BF-12 3515181010910008 30 1432842017
56 PUTRI FATIMAH RACHMAWATI MENUR 3/9 3578096401990001 22 ü
57 GRACE SUGIANTO MANYAR JAYA IV/B-24 3578096910930002 28 2452885582
58 TRESHA ASTA RUMANTI KUSUMA NGINDEN BARU 2/14 3578095506830002 38 ü
59 FENI DWI LESTARI JANGKUNGAN I-B/19 3578096402000001 21 1900915301
60 YANUAR LISTIAN SANTOSO NGINDEN BARU I/14 3578091501960001 25 ü
61 JENNIE LEVINA CHRISTIANI GRAHA CITRA RAYA BLOK E-4/8 3578306906960001 25 ü
62 YUDI EKOWANTO SEMOLOWARU TENGAH IX/19 3578090804720001 49 ü
63 ANASTANIA MARIN PURNAMA NGINDEN INTAN UTARA NO. 48 3578095706960002 25 ü
64 ALIN FITRIANI, S.SI SEMOLOWARU TENGAH III/54 3578096808880001 33 ü

JUMLAH TOTAL : 64 28 36 9 19 0 0 0 0 40 0

EVALUASI / KENDALA : TABUNG VACUMTAINER K3EDTA, HABIS PADA TANGGAL 26 APRIL- 11 MEI 2019
RTL : Petugas Laboratorium membuat permintaan tabung vacumtainer k3edta kepada dinas(gfk), unruk sementara waktu, pasein catin dilakukan pemeriksaan Hb, PITC, IMS dan HBSAG
TL : barang( tabung vacumtainer ) datang pada tanggal 13 Mei 2019, kemudian pemeriksaan catin kembali dilakukan secara lengkap
Kepala Puskesmas
HASIL SUSPEK POSITIP :
- MCV/RBC < 13
- HB < 10

dr. Medyana Puspita

NIP. 197501052007012017
 FORMAT LAP

PUSKESMAS : Menur
BULAN : November 2020

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET
 FORMAT LAPORAN PASIEN THALASEMIA

PUSKESMAS : MENUR
BULAN : DESEMBER 2020

UMUR BPJS HASIL LABORATORIUM HASIL

NO NAMA ALAMAT NIK UMUM PERHITUNGAN KONSELING RUJUK KET
L P PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA HB HCT RBC MCV MCH MCHC RDW-CV POS NEG
1 ARIS SUSANTO MENUR 2/19 3578090712770002 44 788791195
2 FELICIA CHRISTANTI WIJONO MANYAR JAYA 4/C-19 3578096801890003 32 1260452834
3 SUSAN TJAHYONO MANYAR JAYA X NO. 5 3578084702920002 29 ü
4 SUNG JAE LEE TAMANSARI SEMANGGI APT TWR A Lt. 22 3174023105905001 31 ü
5 FRANKY CHRISTYAN OELIANTO SIMO MAGEREJO TENGAH 58 3578270116840005 37 ü
6 NUR SHABRINA NOVAYANTI INESTA MANYAR JAYA XI/33 3578095311950002 26 100628381
7 DENI PRISTIAWAN JL. H. DAHLAN KEDIRI 3506171212890003 32 1438073155
8 FAKHRUDDIN ABDUL AZIS SEMOLOWARU UTARA I/121 3578090401950001 26 173595633
9 KEVIN YOHANES MENUR 2/17-B 5204082110960001 25 ü
10 MOCHAMAD YUDI PRASTIAWAN SEMOLOWARU SELATAN I/70 3578092009930002 28 ü
11 WAWAN RIYANTO MENUR 4/15 3403121411920001 29 ü
12 DARMAWAN NGINDEN TEMBUSAN 22-A 3578090212890002 32 ü
13 LAURENTIUS JOHAN ARDIAN SUKO SEMOLO TENGAH 2/R-20 3578092106900003 31 1899118225
14 MUSTIKA ALIFA JOJORAN III-A BLOK 5 NO. 18 3578086707940001 27 ü
15 NAUFAL AMMAR MENUR 2/77 3578092601950003 26 1705399918 15.5 46.1 5.82 79.3 26.6 33.6 14.8 13.63 ü
16 RIDA VIRANTI SEMOLOWARU 115 3306075201890005 32 ü
17 DENNY CATRA CHRISANDI SEMOLOWARU 115 3578092104910002 29 ü
18 SARI ZAUJAN MUTHU JL. SENOPATI DALAM II SENAYAN JAKARTA 3174075006950003 26 1266633281 14.5 40.4 5.19 78.0 27.9 35.8 13.6 15.03 ü
19 DANIEL YANUAR BUDIHARDJO SEMOLOWARU TENGAH 10/8 3578090501950002 26 ü
20 FERNANDO SEMOLOWARU ELOK BLOK D/18 3578091904860003 35 ü 15.0 43.0 5.23 82.3 28.6 34.8 15.2 15.74 ü
21 AGUS SUMANTO NGINDEN 2/61 3514091205910002 30 ü 14.0 39.2 5.42 72.5 25.8 35.7 136 13.38 ü
22
23
PUGUH WAHYUDIONO
LAILA MAULIDIA
NGINDEN II-D/10
NGINDEN 5-A/2
3578091306880004
3578096108940002
33
27
1395324303
787191682
15.2
13.0
42.7
36.2
5.34
5.26
80.1
69.0
28.4
24.7
35.5
35.9
15.4
14.9
15.00
13.12
ü
ü
N N
24
25
FITRIA MONICA FEBRIANA
ANGGA ALDY SAPUTRA
DSN. KEBANAN PLOSO MOJO KEDIRI
JANGKUNGAN GG. 1-A/17
3506025102980003
3578090404980002 23
23 1296271247
ü
12.5
15.7
35.9
43.7
4.54
5.65
79.1
77.5
27.5
27.7
34.8
35.9
14.1
12.9
17.42
13.72
ü
ü
I I
26 FATHONY ILHAM EKA PUTRA SEMOLOWARU INDAH I/C-8 3578091203970005 24 ü 14.0 39.7 6.11 65.1 22.9 35.2 15.7 10.65 ü H H
I I
27 YOHANA ANGGARA SIMOLAWANG 1/54-A 3578114606860005 35 ü 14.6 41.7 5.34 78.2 27.3 35.0 14.3 14.64 ü
28 RONY SOEBAGIA MANYAR TIRTOASRI 12/8 3578090711780001 43 ü 13.3 37.8 5.11 74.1 26.0 35.1 13.3 14.50 ü

L L
29 GIOVANNI SAMANTHA MENUR 5/35 3578092910940003 27 ü 16.6 46.6 5.93 78.6 27.9 34.5 14.5 13.25 ü
30 MACHRIDOTUL EKA S MENUR 5/14-A 3578096701990001 22 787048918 10.2 29.5 4.79 61.7 21.2 34.5 15.4 12.88 ü
31 SANTI SUMARNI SEMAMPIR MASJID 38 3578096612900003 30 ü 13.0 37.3 4.66 80.2 27.8 34.8 13.9 17.21 ü
32 USMUL YADI NGINDEN 5-D/4 3578090504900001 31 ü 16.9 48.6 6.29 77.3 26.8 34.7 13.7 12.29 ü
33 BAGUS PUTRA SEMAMPIR TENGAH 6-A/2 3578091708970003 23 ü 13.0 37.6 5.19 72.5 25.0 34.5 13.6 13.97 ü
34 TIHUB ARIFIN JANGKUNGAN 2-C//8 3578092105640001 46 1842099884 #DIV/0! ü
35 ARI HARIONO NNGINDEN VI-B/12 3578091602910002 30 2683077164 #DIV/0! ü
36 AHMAD ALFIAN DANY HUSADA MENUR 1/28-B 3578092006950004 26 1539407237 #DIV/0! ü
37 MUCHAMAD RIZKI MAULANA SEMOLOWARU NO. 133 3578091607960001 25 ü #DIV/0! ü
38 ENI SUDARSIH MENUR 3/39 3578096101820003 39 788080623 #DIV/0! ü
39 SITI MORTASIYAH SEMOLOWARU SELATAN 1/28-D 3578096608820002 39 ü #DIV/0! ü
40 ANDRIS PURNA IRAWAN SEMOLOWARU SELATAN XIII/3 3515152304700002 51 ü #DIV/0! ü
41 CINDY PARAMUDITA MENUR 2/55-B 3578094103940002 27 ü #DIV/0! ü
42 DITA AYU FEBRIATI PUMPUNGAN I/37 3578094202940003 27 ü #DIV/0! ü
43 JAENI TUMPANG PACAR KELING PASURUAN 3514060207870002 34 715125982 #DIV/0! ü
44 FRAMITA AJENG PAMBHUDI MENUR 3/47 3578095009950001 26 1080802833 #DIV/0! ü
45 DHENY DWI ENGGI SEPLIAN JL. KOBLEN NO.7 SURABAYA 3578132509950006 26 ü #DIV/0! ü
46 RIMA ZONA KHARISMA SEMOLOWARU I/116-E 3578095204870002 34 ü #DIV/0! ü
47 AGUNG SETYA BUDY KUTUNGAN GUNUNG KIDUL YOGYAKARTA 3403122907960001 25 ü #DIV/0! ü
48 SILVIA NOVITA SARI MENUR 2/42 3578094411970002 23 2432605858 #DIV/0! ü
49 ANOK WAHYU NUGROHO PUMPUNGAN 1/22 3578091204960001 25 ü #DIV/0! ü
50 OKTAVIANA VERNANDAN PUTRI NGINDEN 2/42 3578094410030001 18 1173613948 #DIV/0! ü
ü
JUMLAH TOTAL : 50 30 20 9 10 1 0 0 0 30

HASIL SUSPEK POSITIP : Kepala Puskesmas

- MCV/RBC < 13
- HB < 10
 FORMAT LAP

PUSKESMAS : Menur
BULAN : Desember 2020

UMUR
NO NAMA ALAMAT NIK
L P

N
JUMLAH TOTAL
1. HANYA YANG DITEMUKAN SUSPEK THALASEMIA

2. APABILA HASIL FEEDBACK DARI RS POSITIF THALASEMIA, DISERTAKAN NO NIK DAN BPJS NYA
FORMAT LAPORAN PENDERITA SUSPEK THALASEMIA FEEDBACK DARI RUJUKAN KE RS

BPJS
PBI MANDIRI ASKES JAMSOSTEK JAMKESDA NON KUOTA

NIHIL
Kepala Puskesm
DAN BPJS NYA
I RUJUKAN KE RS

HASIL THALASEMIA
UMUM
POS THALASEMIA A POS THALASEMIA B NEG

L
Kepala Puskesmas
KET