REGISTER KOHORT PELAYANAN KESEHATAN LANJUT USIA TAHUN 2021

DESA / KELURAHAN : MEKARSARI

PUSKESMAS :JAMBE
KECAMATAN :JAMBE
KABUPATEN / KOTA :TANGERANG
PROVINSI :BANTEN

P3G
Tgl Pemeriksaan Gangguan
Umur* Penilaian Risiko
Status Fungsional dan Lab Tingkat Kemandirian Gangguan Gangguan Penilaian Ginjal
No Nama Alamat TGL LAHIR (AKS/ADL)* Mental Emosional Kognitif MAL NUTRISI Risiko Jatuh
Malnutrisi (MNA)
L/P 45-59 60-69 1 2
≥ 70 tahun 1 2 1 2 1 2 1 2 1 2 1
tahun tahun A B C A B C
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

02\01\2021 N
1 S.ASBARI KP.JANTUNGEUN RT 01/01 L 12-4-1944 77 √ X X X X X X X X

02\01\2021 N
2 RANTI KP.JANTUNGEUN RT 01/01 P 7-12-1956 65 √ X X X X X X X X

02\01\2021 N
3 MARWATA KP.JANTUNGEUN RT 01/01 P 09-05-1945 76 √ X X X X X X X X

02\01\2021 N
4 EPON KP.JANTUNGEUN RT 01/01 P 13-10-1961 60 √ X X X X X X X X

02\01\2021 N
5 H.HANAWI KP.JANTUNGEUN RT 01/01 L 17-04-1961 60 √ X X X X X X X X

02\01\2021 N
6 RAHI KP.JANTUNGEUN RT 01/01 L 15-06-1950 71 √ X X X X X X X X

02\01\2021 N
7 JAMSIKAH KP.JANTUNGEUN RT 01/01 P 21-11-1958 68 √ X X X X X X X X

02\01\2021 N
8 ARNIMAN KP.JANTUNGEUN RT 01/01 P 07-03-1953 68 √ X X X X X X X X

02\01\2021 N
9 SUKRIAH KP.JANTUNGEUN RT 01/01 P 08-05-1955 66 √ X X X X X X X X

02\01\2021 N
10 SUDIN KP.JANTUNGEUN RT 01/01 L 07-06-1954 67 √ X X X X X X X X

02\01\2021 N
11 MARYUNAH KP.JANTUNGEUN RT 01/01 P 05-07-1955 66 √ X X X X X X X X

02\01\2021 N
12 MUHAMAD KP.JANTUNGEUN RT 01/01 L 06-06-1954 67 √ X X X X X X X X

02\01\2021 N
13 HJ NURISAH KP.JANTUNGEUN RT 02/01 P 10-05-1935 86 √ X X X X X X X X

1/5/2021 N
14 KHAYROJI KP.JANTUNGEUN RT 02/01 L 17-09-1955 44 √ X X X X X X X X

1/5/2021 N
15 SENAH KP.JANTUNGEUN RT 02/01 P 21-08-1942 79 √ X X X X X X X X

1/5/2021 N
16 SUAYA KP.JANTUNGEUN RT 02/01 L 10-07-1935 86 √ X X X X X X X X
 1/5/2021 N
17 RUSNI KP.JANTUNGEUN RT 02/01 P 02-03-1962 59 √ X X X X X X X X

1/5/2021 N
18 UMAR KP.JANTUNGEUN RT 02/01 L 04-03-1960 66 √ X X X X X X X X

1/5/2021 N
19 ANTIMAH KP.JANTUNGEUN RT 02/01 P 03-04-1938 83 √ X X X X X X X X

1/5/2021 N
20 SATIMAH KP.JANTUNGEUN RT 02/01 P 11-12-1940 81 √ X X X X X X X X

04\02\2021 N
21 ARSANI KP.JANTUNGEUN RT 02/01 P 17-07-1940 81 √ X X X X X X X X

04\02\2021 N
22 UJANG.R KP.JANTUNGEUN RT 02/01 L 14-12-1956 65 √ X X X X X X X X

04\02\2021 N
23 UMET KP.JANTUNGEUN RT 02/01 L 06-04-1958 63 √ X X X X X X X X

04\02\2021 N
24 MURHANI KP.JANTUNGEUN RT 02/01 P 06-02-1953 68 √ X X X X X X X X

04\02\2021 N
25 MISTUTI.N KP.JANTUNGEUN RT 02/01 P 28-06-1962 59 √ X X X X X X X X

04\02\2021 N
26 LEMUT KP.JANTUNGEUN RT 02/01 L 10-10-1940 81 √ X X X X X X X X

04\02\2021 N
27 H.RANIM KP.JANTUNGEUN RT 02/01 L 15-08-1935 68 √ X X X X X X X X

04\02\2021 N
28 SAMIAH KP.JANTUNGEUN RT 02/01 P 13-04-1940 61 √ X X X X X X X X

07\02\2021 N
29 MASASIH KP.JANTUNGEUN RT 02/01 P 20-01-1955 53 √ X X X X X X X X

07\02\2021 N
30 NAWAWI KP.JANTUNGEUN RT 02/01 L 10-12-1958 58 √ X X X X X X X X

07\02\2021 N
31 SAPIAT KP.JANTUNGEUN RT 02/01 P 07-10-1951 61 √ X X X X X X X X

07\02\2021 N
32 ASNAH KP.JANTUNGEUN RT 02/01 P 10-11-1952 48 √ X X X X X X X X

07\02\2021 N
33 USMU KP.JANTUNGEUN RT 02/01 L 11-11-1952 47 √ X X X X X X X X

07\02\2021 N
34 MURSIH KP.JANTUNGEUN RT 02/01 P 10-03-1956 46 √ X X X X X X X X

07\02\2021 N
35 DADI KP.JANTUNGEUN RT 02/01 L 10-10-1957 52 √ X X X X X X X X

07\02\2021 N
36 ASTA KP.JANTUNGEUN RT 02/01 L 06-04-1962 46 √ X X X X X X X X

07\02\2021 N
37 H.TAYA KP.JANTUNGEUN RT 02/01 L 10-12-1955 45 √ X X X X X X X X
 07\02\2021 N
38 H.YATI KP.JANTUNGEUN RT 02/01 P 05-01-1957 51 √ X X X X X X X X

03\03\2021 N
39 RAIS KP.JANTUNGEUN RT 02/01 L 07-08-1948 56 √ X X X X X X X X

03\03\2021 N
40 UNIAH KP.JANTUNGEUN RT 02/01 P 09-09-1950 57 √ X X X X X X X X

03\03\2021 N
41 KOSWARA KP.JANTUNGEUN RT 02/01 L 01-07-1940 57 √ X X X X X X X X

03\03\2021 N
42 MAEMUNAH KP.JANTUNGEUN RT 02/01 P 08-08-1958 54 √ X X X X X X X X

03\03\2021 N
43 SUBEHI KP.JANTUNGEUN RT 02/01 L 14-12-1958 60 √ X X X X X X X X

03\03\2021 N
44 JAMSIAH KP.JANTUNGEUN RT 02/01 P 01-11-1949 54 √ X X X X X X X X

03\03\2021 N
45 HERMAN KP.JANTUNGEUN RT 03/01 L 07-09-1956 60 √ X X X X X X X X

03\03\2021 N
46 SIRAT KP.JANTUNGEUN RT 03/01 P 02-05-1951 70 √ X X X X X X X X

03\03\2021 N
47 YADI KP.JANTUNGEUN RT 03/01 L 09-05-1962 59 √ X X X X X X X X

03\03\2021 N
48 SADNAH KP.JANTUNGEUN RT 03/01 P 11-11-1960 61 √ X X X X X X X X

03\03\2021 N
49 UJANG KP.JANTUNGEUN RT 03/01 L 06-02-1960 61 √ X X X X X X X X

03\03\2021 N
50 SANUSI KP.JANTUNGEUN RT 03/01 L 11-07-1953 68 √ X X X X X X X X

10\03\2021 N
51 RUMSINAH KP.JANTUNGEUN RT 03/01 P 11-10-1960 68 √ X X X X X X X X

10\03\2021 N
52 RAYA KP.JANTUNGEUN RT 03/01 L 11-11-1954 67 √ X X X X X X X X

10\03\2021 N
53 MADSAMAN KP.JANTUNGEUN RT 03/01 L 12-12-1942 79 √ X X X X X X X X

10\03\2021 N
54 MARIAM KP.JANTUNGEUN RT 03/01 P 06-03-1960 68 √ X X X X X X X X

10\03\2021 N
55 SUMARTA KP.JANTUNGEUN RT 03/01 L 24-05-1935 86 √ X X X X X X X X

10\03\2021 N
56 EEM KP.JANTUNGEUN RT 03/01 P 21-05-1943 76 √ X X X X X X X X

10\03\2021 N
57 SARTAYA KP.JANTUNGEUN RT 03/01 L 05-05-1958 63 √ X X X X X X X X

10\03\2021 N
59 KETI KP.JANTUNGEUN RT 03/01 L 21-01-1958 63 √ X X X X X X X X
 02\04\2021 N
59 JOHANAH KP.JANTUNGEUN RT 03/01 P 27-07-1961 60 √ X X X X X X X X

02\04\2021 N
60 AGUS SALIM KP.JANTUNGEUN RT 03/01 L 05-08-1957 64 √ X X X X X X X X

02\04\2021 N
61 JAHARA KP.JANTUNGEUN RT 03/01 P 09-08-1939 82 √ X X X X X X X X

02\04\2021 N
62 JAYA KP.JANTUNGEUN RT 03/01 L 28-09-1953 68 √ X X X X X X X X

02\04\2021 N
63 SARWIS KP.JANTUNGEUN RT 03/01 P 11-11-1957 64 √ X X X X X X X X

02\04\2021 N
64 SUKARTI KP.JANTUNGEUN RT03/01 L 17-06-1960 61 √ X X X X X X X X

02\04\2021 N
65 MELAH KP.JANTUNGEUN RT04/02 P 04-05-1960 61 √ X X X X X X X X

02\04\2021 N
66 MARNI KP.JANTUNGEUN RT04/02 P 02-11-1960 61 √ X X X X X X X X

02\04\2021 N
67 UTI KP.JANTUNGEUN RT04/02 P 11-02-1960 61 √ X X X X X X X X

02\04\2021 N
68 MARHANAH KP.JANTUNGEUN RT04/02 P 13-10-1958 63 √ X X X X X X X X

07\04\2021 N
69 ANTANI KP.JANTUNGEUN RT04/02 L 14-03-1950 61 √ X X X X X X X X

07\04\2021 N
70 SANIAH KP.JANTUNGEUN RT04/02 P 11-11-1940 81 √ X X X X X X X X

07\04\2021 +
71 SARAH KP.JANTUNGEUN RT04/02 P 28-04-1944 77 √ X X X X X X X X

07\04\2021 N
72 MAMAT KP.JANTUNGEUN RT04/02 L 19-07-1934 87 √ X X X X X X X X

07\04\2021 N
73 ICHSANUDIN KP.JANTUNGEUN RT04/02 L 06-03-1950 61 √ X X X X X X X X

07\04\2021 N
74 RASIH KP.JANTUNGEUN RT04/02 P 18-06-1960 61 √ X X X X X X X X

07\04\2021 N
75 ODIH KP.JANTUNGEUN RT04/02 L 07-06-1960 61 √ X X X X X X X X

07\04\2021 N
76 SARHILI KP.JANTUNGEUN RT04/02 L 03-05-1960 61 √ X X X X X X X X

07\04\2021 N
77 JONO KP.JANTUNGEUN RT04/02 L 14-03-1952 69 √ X X X X X X X X

07\04\2021 N
78 SAUD KP.JANTUNGEUN RT04/02 L 17-11-1961 60 √ X X X X X X X X

07\05\2021 N
79 AMAN KP.JANTUNGEUN RT04/02 L 08-12-1942 79 √ X X X X X X X X
 07\05\2021 N
80 KOMAR KP.JANTUNGEUN RT04/02 L 10-09-1959 62 √ X X X X X X X X

07\06\2021 N
81 AMSARI KP.JANTUNGEUN RT04/02 L 05-06-1951 70 √ X X X X X X X X

07\06\2021 N
82 SANUNG KP.JANTUNGEUN RT04/02 P 11/11/1942 79 √ X X X X X X X X

07\06\2021 N
83 YANAH KP.JANTUNGEUN RT04/02 P 03-04-1958 63 √ X X X X X X X X

07\06\2021 N
84 SAINAH KP.JANTUNGEUN RT04/02 P 12-10-1946 75 √ X X X X X X X X

07\06\2021 N
85 INAS KP.JANTUNGEUN RT 04/02 P 03-06-1959 62 √ X X X X X X X X

07\06\2021 N
86 SUKANTA KP.JANTUNGEUN RT 05/02 L 11-11-1945 76 √ X X X X X X X X

09\06\2021 N
87 AMITI KP.JANTUNGEUN RT 05/02 P 10-03-1950 71 √ X X X X X X X X

09\06\2021 N
88 RANI KP.JANTUNGEUN RT 05/02 P 01-07-1950 71 √ X X X X X X X X

09\06\2021 N
89 SA'AD KP.JANTUNGEUN RT 05/02 L 02-08-1960 61 √ X X X X X X X X

09\06\2021 N
90 ONIH KP.JANTUNGEUN RT 05/02 P 21-04-1955 66 √ X X X X X X X X

09\06\2021 N
91 ARYADI KP.JANTUNGEUN RT 05/02 L 01-07-1945 76 √ X X X X X X X X

09\07\2021 N
92 RAFIAH KP.JANTUNGEUN RT 05/02 P 01-07-1960 61 √ X X X X X X X X

09\07\2021 N
93 OJAH KP.JANTUNGEUN RT 05/02 P 12-10-1955 66 √ X X X X X X X X

09\07\2021 N
94 JUHANA KP.JANTUNGEUN RT 05/02 P 01-07-1940 81 √ X X X X X X X X

09\07\2021 N
95 FATONAH KP.JANTUNGEUN RT 05/02 P 01-07-1960 61 √ X X X X X X X X

09\07\2021 N
96 SAHARI KP.JANTUNGEUN RT 05/02 L 11-02-1952 69 √ X X X X X X X X

04\07\2021 N
97 LATIF KP.JANTUNGEUN RT 05/02 P 1-7-1956 65 √ X X X X X X X X

04\07\2021 N
98 JUHALI KP.JANTUNGEUN RT 05/02 L 05-02-1956 65 √ X X X X X X X X

04\07\2021 N
99 SAKKI KP.JANTUNGEUN RT 05/02 P 07-10-1952 69 √ X X X X X X X X

04\07\2021 N
100 RUFI KP.JANTUNGEUN RT 05/02 L 06-12-1950 71 √ X X X X X X X X
 p 02\08\2021 N
101 SA'AH KP.JANTUNGEUN RT 05/02 03-06-1955 86 √ X X X X X X X X

L 02\08\2022 N
102 H.RAHIM KP.JANTUNGEUN RT 05/02 02-03-1951 59 √ X X X X X X X X

p 02\08\2023 N
103 SANIMAH KP.JANTUNGEUN RT 05/02 12-10-1960 66 √ X X X X X X X X

L 02\08\2024 N
104 SARMINAH KP.JANTUNGEUN RT 05/02 09-07-1962 83 √ X X X X X X X X

P 04\08\2021 N
105 FATIMAH KP.JANTUNGEUN RT 05/02 26-08-1953 81 √ X X X X X X X X

P 04\08\2022 N
106 RUMSAH KP.JANTUNGEUN RT 05/02 12-06-1962 81 √ X X X X X X X X

L 04\08\2023 N
107 UMIN KP.JANTUNGEUN RT 05/02 07-09-1959 65 √ X X X X X X X X

L 04\08\2024 N
108 JUNEDI KP.JANTUNGEUN RT 05/02 01-07-1954 63 √ X X X X X X X X

P 04\08\2025 N
109 RASMINI KP.JANTUNGEUN RT 05/02 13-04-1962 68 √ X X X X X X X X

P 04\08\2026 N
110 SAMI KP.JANTUNGEUN RT 05/02 01-07-1955 59 √ X X X X X X X X

P 04\08\2027 N
111 SAMSAH KP.JANTUNGEUN RT 05/02 01-07-1958 81 √ X X X X X X X X

P 02\08\2021 N
112 SUANAH KP.JANTUNGEUN RT 06/03 22-06-1951 68 √ X X X X X X X X

P 02\08\2022 N
113 MAENI KP.JANTUNGEUN RT 06/03 14-07-1961 61 √ X X X X X X X X

P 02\08\2021 N
114 MARIAH KP.JANTUNGEUN RT 06/03 02-07-1960 53 √ X X X X X X X X

L 02\08\2021 N
115 NURSAH KP.JANTUNGEUN RT 06/03 10-11-1950 58 √ X X X X X X X X

P 02\08\2021 N
116 RASIPOL KP.JANTUNGEUN RT 06/03 03-02-1950 61 √ X X X X X X X X

P 02\08\2021 N
117 SARI KP.JANTUNGEUN RT 06/03 08-04-1952 48 √ X X X X X X X X

P 02\08\2021 N
118 BONAH KP.JANTUNGEUN RT 06/03 11-11-1957 47 √ X X X X X X X X

P 02\08\2021 N
119 ARSAH KP.JANTUNGEUN RT 06/03 06-05-1956 46 √ X X X X X X X X

P 02\08\2021 N
120 AYUNAH KP.JANTUNGEUN RT 06/03 05-04-1942 52 √ X X X X X X X X

P 02\08\2021 N
121 WASILAH KP.JANTUNGEUN RT 06/03 12-03-1958 46 √ X X X X X X X X
 P 02\08\2021 N
122 ATENAH KP.JANTUNGEUN RT 06/03 08-10-1953 45 √ X X X X X X X X

P 02\01\2021 N
123 SANANI KP.JANTUNGEUN RT 06/03 15-05-1948 51 √ X X X X X X X X

P 02\01\2021 N
124 RUSMIAH KP.JANTUNGEUN RT 06/03 21-01-1955 56 √ X X X X X X X X

P 02\01\2021 N
125 SUKARSIH KP.JANTUNGEUN RT 06/03 22-08-1952 57 √ X X X X X X X X

P 02\01\2021 N
126 SUNAH KP.JANTUNGEUN RT 06/03 01-02-1942 57 √ X X X X X X X X

P 02\01\2021 N
127 ASIKAH KP.JANTUNGEUN RT 06/03 05-03-1950 54 √ X X X X X X X X

L 02\01\2021 N
128 ROHMAT KP.JANTUNGEUN RT 06/03 11-11-1946 60 √ X X X X X X X X

L 02\01\2021 N
129 WARJONO KP.JANTUNGEUN RT 06/03 14-07-1951 54 √ X X X X X X X X

L 02\01\2021 N
130 SUMANTA KP.JANTUNGEUN RT 06/03 27-07-1957 60 √ X X X X X X X X

L 02\01\2021 N
131 H.SUGANDA KP.JANTUNGEUN RT 06/03 13-02-1949 70 √ X X X X X X X X

L 02\01\2021 N
132 SATRIA KP.JANTUNGEUN RT 06/03 14-10-1955 59 √ X X X X X X X X

P 02\01\2021 N
133 NARWITA KP.JANTUNGEUN RT 06/03 01-05-1954 61 √ X X X X X X X X

L 02\01\2021 N
134 RUKMAN KP.JANTUNGEUN RT 06/03 05-04-1958 61 √ X X X X X X X X

L 02\01\2021 N
135 HUMAEDI KP.JANTUNGEUN RT 06/03 19-10-1954 68 √ X X X X X X X X

L 1/5/2021 N
136 SUPADIH KP.JANTUNGEUN RT 06/03 15-12-1951 68 √ X X X X X X X X

L 1/5/2021 N
137 HAMID KP.JANTUNGEUN RT 06/03 01-04-1955 67 √ X X X X X X X X

L 1/5/2021 N
138 JAKIM KP.JANTUNGEUN RT 06/03 11-07-1959 79 √ X X X X X X X X

P 1/5/2021 N
139 IBROHIM KP.JANTUNGEUN RT 06/03 13-10-1961 68 √ X X X X X X X X

L 1/5/2021 N
140 AMIAN KP.JANTUNGEUN RT 06/03 17-04-1961 86 √ X X X X X X X X

L 1/5/2021 N
141 DURI KP.JANTUNGEUN RT 06/03 15-06-1950 76 √ X X X X X X X X

P 1/5/2021 N
142 RASRI KP.JANTUNGEUN RT 06/03 21-11-1958 63 √ X X X X X X X X
 P 04\02\2021 N
143 ASMAWI KP.JANTUNGEUN RT 06/03 07-03-1953 63 √ X X X X X X X X

P 04\02\2021 N
144 SARHANAH KP.JANTUNGEUN RT 06/03 08-05-1955 60 √ X X X X X X X X

P 04\02\2021 N
145 ITING KP.JANTUNGEUN RT 06/03 07-06-1954 64 √ X X X X X X X X

P 04\02\2021 N
146 ASMINATI KP.JANTUNGEUN RT 06/03 05-07-1955 82 √ X X X X X X X X

P 04\02\2021 N
147 MARKATI KP.JANTUNGEUN RT 06/03 06-06-1954 68 √ X X X X X X X X

L 04\02\2021 N
148 SAROH KP.JANTUNGEUN RT 06/03 10-05-1935 64 √ X X X X X X X X

P 04\02\2021 N
149 SARKANI KP.JANTUNGEUN RT 06/03 17-09-1955 61 √ X X X X X X X X

P 04\02\2021 N
150 PATIMAH KP.JANTUNGEUN RT 06/03 21-08-1942 61 √ X X X X X X X X

P 07\02\2021 N
151 MASNI KP.JANTUNGEUN RT 06/03 10-07-1935 86 √ X X X X X X X X

P 07\02\2021 N
152 WIDODO KP.JANTUNGEUN RT 07/03 02-03-1962 59 √ X X X X X X X X

P 07\02\2021 N
153 ATA KP.JANTUNGEUN RT 07/03 04-03-1960 66 √ X X X X X X X X

P 07\02\2021 N
154 SAMSUDIN KP.JANTUNGEUN RT 07/03 03-04-1938 83 √ X X X X X X X X

P 07\02\2021 N
155 BASUNI.H KP.JANTUNGEUN RT 07/03 11-12-1940 81 √ X X X X X X X X

P 07\02\2021 N
156 ALAMUN KP.JANTUNGEUN RT 07/03 17-07-1940 81 √ X X X X X X X X

P 07\02\2021 N
157 ROBAI KP.JANTUNGEUN RT 07/03 14-12-1956 65 √ X X X X X X X X

P 07\02\2021 N
158 ARTASIM KP.JANTUNGEUN RT 07/03 06-04-1958 63 √ X X X X X X X X

P 07\02\2021 N
159 SUANDA KP.JANTUNGEUN RT 07/03 06-02-1953 68 √ X X X X X X X X

P 07\02\2021 N
160 RAFEI KP.JANTUNGEUN RT 07/03 28-06-1962 59 √ X X X X X X X X

L 03\03\2021 N
161 IDING SUPARDI KP.JANTUNGEUN RT 07/03 10-10-1940 81 √ X X X X X X X X

L 03\03\2021 N
162 UJANG KP.JANTUNGEUN RT 07/03 15-08-1935 68 √ X X X X X X X X

L 03\03\2021 N
163 UMI KP.JANTUNGEUN RT 07/03 13-04-1940 61 √ X X X X X X X X
 L 03\03\2021 N
164 IYOK KP.JANTUNGEUN RT 07/03 20-01-1955 53 √ X X X X X X X X

L 03\03\2021 N
165 ARINAH KP.JANTUNGEUN RT 07/03 10-12-1958 58 √ X X X X X X X X

P 03\03\2021 N
166 NURPIAH KP.JANTUNGEUN RT 07/03 07-10-1951 61 √ X X X X X X X X

L 03\03\2021 N
167 SAEMAH KP.JANTUNGEUN RT 07/03 10-11-1952 48 √ X X X X X X X X

L 03\03\2021 N
168 SAMSAH KP.JANTUNGEUN RT 07/03 11-11-1952 47 √ X X X X X X X X

L 03\03\2021 N
169 SARMINAH KP.JANTUNGEUN RT 07/03 10-03-1956 46 √ X X X X X X X X

L 03\03\2021 N
170 RUMSANI KP.JANTUNGEUN RT 07/03 10-10-1957 52 √ X X X X X X X X

L 03\03\2021 N
171 MINAH KP.JANTUNGEUN RT 07/03 06-04-1962 46 √ X X X X X X X X

P 03\03\2021 N
172 NURHAYATI KP.JANTUNGEUN RT 07/03 10-12-1955 45 √ X X X X X X X X

L 10\03\2021 N
173 ARWIRI KP.JANTUNGEUN RT 07/03 05-01-1957 51 √ X X X X X X X X

L 10\03\2021 N
174 JUHANA KP.JANTUNGEUN RT 07/03 07-08-1948 56 √ X X X X X X X X

P 10\03\2021 N
175 BENAH KP.JANTUNGEUN RT 07/03 09-09-1950 57 √ X X X X X X X X

P 10\03\2021 N
176 TISNI KP.JANTUNGEUN RT 08/03 01-07-1940 57 √ X X X X X X X X

P 10\03\2021 N
177 TONIK KP.JANTUNGEUN RT 08/03 08-08-1958 54 √ X X X X X X X X

P 10\03\2021 N
178 MARSANAH KP.JANTUNGEUN RT 08/03 14-12-1958 60 √ X X X X X X X X

P 10\03\2021 N
179 SALBIAH KP.JANTUNGEUN RT 08/03 01-11-1949 54 √ X X X X X X X X

P 10\03\2021 N
180 ISAH KP.JANTUNGEUN RT 08/03 07-09-1956 60 √ X X X X X X X X

L 02\04\2021 N
181 SARIMAH KP.JANTUNGEUN RT 08/03 02-05-1951 70 √ X X X X X X X X

P 02\04\2021 N
182 SANI KP.JANTUNGEUN RT 08/03 09-05-1962 59 √ X X X X X X X X

P 02\04\2021 N
183 SUHARNI KP.JANTUNGEUN RT 08/03 11-11-1960 61 √ X X X X X X X X

P 02\04\2021 +
184 IYAM KP.JANTUNGEUN RT 08/03 06-02-1960 61 √ X X X X X X X X
 P 02\04\2021 N
185 KARNAIL KP.JANTUNGEUN RT 08/03 11-07-1953 68 √ X X X X X X X X

P 02\04\2021 N
186 SATMI KP.JANTUNGEUN RT 08/03 11-10-1960 68 √ X X X X X X X X

P 02\04\2021 N
187 EMIN KP.JANTUNGEUN RT 08/03 11-11-1954 67 √ X X X X X X X X

P 02\04\2021 N
188 ARMIN KP.JANTUNGEUN RT 08/03 12-12-1942 79 √ X X X X X X X X

P 02\04\2021 N
189 NURHAWI KP.JANTUNGEUN RT 08/03 06-03-1960 68 √ X X X X X X X X

P 02\04\2021 N
190 M.SAMIDI KP.JANTUNGEUN RT 08/03 24-05-1935 86 √ X X X X X X X X

P 07\04\2021 N
191 YUNUS KP.JANTUNGEUN RT 08/03 21-05-1943 76 √ X X X X X X X X

P 07\04\2021 N
192 SANUDIN KP.JANTUNGEUN RT 08/03 05-05-1958 63 √ X X X X X X X X

P 07\04\2021 N
193 SAHARA KP.JANTUNGEUN RT 08/03 21-01-1958 63 √ X X X X X X X X

L 07\04\2021 N
194 SARMIDI KP.JANTUNGEUN RT 08/03 27-07-1961 60 √ X X X X X X X X

L 07\04\2021 N
195 ISOL KP.JANTUNGEUN RT 08/03 05-08-1957 64 √ X X X X X X X X

L 07\04\2021 N
196 LAMHARI KP.JANTUNGEUN RT 08/03 09-08-1939 82 √ X X X X X X X X

L 07\04\2021 N
197 NARSUDI KP.JANTUNGEUN RT 08/03 28-09-1953 68 √ X X X X X X X X

L 07\04\2021 N
198 BENAH KP.JANTUNGEUN RT 08/03 11-11-1957 64 √ X X X X X X X X

P 07\04\2021 N
199 NAISAH KP.JANTUNGEUN RT 09/02 17-06-1960 61 √ X X X X X X X X

L 07\04\2021 N
200 NURHAYA KP.JANTUNGEUN RT 09/02 04-05-1960 61 √ X X X X X X X X

L 07\05\2021 N
201 RUSMIN KP.JANTUNGEUN RT 09/02 02-11-1960 86 √ X X X X X X X X

L 07\05\2021 N
202 ARSATI KP.JANTUNGEUN RT 09/02 11-02-1960 59 √ X X X X X X X X

L 07\06\2021 N
203 MAESITA KP.JANTUNGEUN RT 09/02 13-10-1961 66 √ X X X X X X X X

L 07\06\2021 N
204 ASMINAH KP.JANTUNGEUN RT 09/02 17-04-1961 83 √ X X X X X X X X

P 07\06\2021 N
205 MURHAYA KP.JANTUNGEUN RT 09/02 15-06-1950 81 √ X X X X X X X X
 L 07\06\2021 N
206 SARWINI KP.JANTUNGEUN RT 09/02 21-11-1958 81 √ X X X X X X X X

L 07\06\2021 N
207 YUNUS KP.JANTUNGEUN RT 09/02 07-03-1953 65 √ X X X X X X X X

P 07\06\2021 N
208 MEMED KP.JANTUNGEUN RT 09/02 08-05-1955 63 √ X X X X X X X X

P 09\06\2021 N
209 ARSUNI KP.JANTUNGEUN RT 09/02 07-06-1954 68 √ X X X X X X X X

P 09\06\2021 N
210 UNAYAH KP.JANTUNGEUN RT 09/02 05-07-1955 59 √ X X X X X X X X

P 09\06\2021 N
211 RUKMADI KP.JANTUNGEUN RT 10/02 06-06-1954 81 √ X X X X X X X X

P 09\06\2021 N
212 NURJAKA KP.JANTUNGEUN RT 10/02 10-05-1935 68 √ X X X X X X X X

P 09\06\2021 N
213 AHMAD KP.JANTUNGEUN RT 10/02 17-09-1955 61 √ X X X X X X X X

L 09\07\2021 N
214 AMED KP.JANTUNGEUN RT 10/02 21-08-1942 53 √ X X X X X X X X

P 09\07\2021 N
215 SUBRATA KP.JANTUNGEUN RT 10/02 10-07-1935 58 √ X X X X X X X X

P 09\07\2021 N
216 ARWITA KP.JANTUNGEUN RT 10/02 02-03-1962 61 √ X X X X X X X X

P 09\07\2021 N
217 SANAN KP.JANTUNGEUN RT 10/02 04-03-1960 48 √ X X X X X X X X

P 09\07\2021 N
218 ASMIRAN KP.JANTUNGEUN RT 10/02 03-04-1938 47 √ X X X X X X X X

P 04\07\2021 N
219 ARMAAN KP.JANTUNGEUN RT 10/02 11-12-1940 46 √ X X X X X X X X

P 04\07\2021 N
220 ASMARA KP.JANTUNGEUN RT 10/02 17-07-1940 52 √ X X X X X X X X

P 04\07\2021 N
221 UMING KP.JANTUNGEUN RT 10/02 14-12-1956 46 √ X X X X X X X X

P 04\07\2021 N
222 NYANGSANG KP.JANTUNGEUN RT 10/02 06-04-1958 45 √ X X X X X X X X

P 02\08\2021 N
223 USDI KP.JANTUNGEUN RT 10/02 06-02-1953 51 √ X X X X X X X X

P 02\08\2022 N
224 JENAB KP.JANTUNGEUN RT 10/02 28-06-1962 56 √ X X X X X X X X

P 02\08\2023 N
225 NURIYAH KP.JANTUNGEUN RT 10/02 10-10-1940 57 √ X X X X X X X X

P 02\08\2024 N
226 SAWATI KP.JANTUNGEUN RT 10/02 15-08-1935 57 √ X X X X X X X X
 L 04\08\2021 N
227 SUNAH KP.JANTUNGEUN RT 10/02 13-04-1940 54 √ X X X X X X X X

L 04\08\2022 N
228 DEWI KP.JANTUNGEUN RT 10/02 20-01-1955 60 √ X X X X X X X X

L 04\08\2023 N
229 RUKIYAH KP.JANTUNGEUN RT 10/02 10-12-1958 54 √ X X X X X X X X

L 04\08\2024 N
230 RUMSIAH KP.JANTUNGEUN RT 10/02 07-10-1951 60 √ X X X X X X X X

L 04\08\2025 N
231 NARSAH KP.JANTUNGEUN RT 10/02 10-11-1952 70 √ X X X X X X X X

SANAT P 04\08\2026 N
232 KP.JANTUNGEUN RT 11/02 11-11-1952 59 √ X X X X X X X X

MISBA L 04\08\2027 N
233 KP.JANTUNGEUN RT 11/02 10-03-1956 61 √ X X X X X X X X

ROMAH L 02\08\2021 N
234 KP.JANTUNGEUN RT 11/02 10-10-1957 61 √ X X X X X X X X

L 02\08\2022 N
235 JASIMAN B NAWI KP.JANTUNGEUN RT 11/02 06-04-1962 68 √ X X X X X X X X

L 02\08\2021 N
236 ASAN BIN SAPON KP.JANTUNGEUN RT 11/02 10-12-1955 68 √ X X X X X X X X

L 02\08\2021 N
237 USNAH BIN TARKA KP.JANTUNGEUN RT 11/02 05-01-1957 67 √ X X X X X X X X

P 02\08\2021 N
238 SATROH KP.JANTUNGEUN RT 11/02 07-08-1948 79 √ X X X X X X X X

L 02\08\2021 N
239 SAHRUM KP.JANTUNGEUN RT 11/02 09-09-1950 68 √ X X X X X X X X

L 02\08\2021 N
240 NENENG KP.JANTUNGEUN RT 11/02 01-07-1940 86 √ X X X X X X X X

P 02\08\2021 N
241 SURTITAH KP.JANTUNGEUN RT 11/02 08-08-1958 76 √ X X X X X X X X

P 02\08\2021 N
242 ICIH KP.JANTUNGEUN RT 11/02 14-12-1958 63 √ X X X X X X X X

P 02\08\2021 N
243 YATIMAH KP.JANTUNGEUN RT 11/02 01-11-1949 63 √ X X X X X X X X

P 02\08\2021 N
244 SITI AMINAH KP.JANTUNGEUN RT 11/02 07-09-1956 60 √ X X X X X X X X

P 02\08\2021 N
245 UNEH KP.JANTUNGEUN RT 11/02 02-05-1951 64 √ X X X X X X X X

P 02\08\2021 N
246 ABAS KP.JANTUNGEUN RT 11/02 09-05-1962 82 √ X X X X X X X X

L 02\08\2021 N
247 NENI KP.JANTUNGEUN RT 11/02 11-11-1960 68 √ X X X X X X X X
 P 02\08\2021 N
248 BONAH KP.JANTUNGEUN RT 11/02 06-02-1960 64 √ X X X X X X X X

P 02\08\2021 N
249 TINI KP.JANTUNGEUN RT 11/02 11-07-1953 61 √ X X X X X X X X

P 02\08\2021 N
250 RODIAH KP.JANTUNGEUN RT 11/02 11-10-1960 61 √ X X X X X X X X

P 02\08\2021 N
251 OCIH KP.JANTUNGEUN RT 11/02 11-11-1954 86 √ X X X X X X X X

P 02\08\2021 N
252 TASWI KP.JANTUNGEUN RT 11/02 12-12-1942 59 √ X X X X X X X X

P 02\08\2021 N
253 ROHANI KP.JANTUNGEUN RT 11/02 06-03-1960 66 √ X X X X X X X X

P 02\08\2021 N
254 NURAENI KP.JANTUNGEUN RT 11/02 24-05-1935 83 √ X X X X X X X X

P 02\08\2021 N
255 AMINAH KP.JANTUNGEUN RT 11/02 21-05-1943 81 √ X X X X X X X X

P 02\08\2021 N
256 WARDI KP.JANTUNGEUN RT 11/02 05-05-1958 81 √ X X X X X X X X

P 02\08\2021 N
257 ASBULOH KP.JANTUNGEUN RT 11/02 21-01-1958 65 √ X X X X X X X X

P 02\08\2021 N
258 HALIMAH KP.JANTUNGEUN RT 12/02 27-07-1961 63 √ X X X X X X X X

P 02\08\2021 N
259 UNUNG KP.JANTUNGEUN RT 12/02 05-08-1957 68 √ X X X X X X X X

L 02\08\2021 N
260 SADIAH KP.JANTUNGEUN RT 12/02 09-08-1939 59 √ X X X X X X X X

L 02\08\2021 N
261 RENE KP.JANTUNGEUN RT 12/02 28-09-1953 81 √ X X X X X X X X

L 02\08\2021 N
262 MARIAM KP.JANTUNGEUN RT 12/02 11-11-1957 68 √ X X X X X X X X

L 02\08\2021 N
263 SUPIYEM KP.JANTUNGEUN RT 12/02 17-06-1960 61 √ X X X X X X X X

L 02\08\2021 N
264 ASIM KP.JANTUNGEUN RT 12/02 04-05-1960 53 √ X X X X X X X X

P 02\08\2021 N
265 MAYANI KP.JANTUNGEUN RT 12/02 02-11-1960 58 √ X X X X X X X X

L 02\08\2021 N
266 SUARNIH KP.JANTUNGEUN RT 12/02 11-02-1960 61 √ X X X X X X X X

L 02\08\2021 N
267 ROHANAH KP.JANTUNGEUN RT 12/02 11-11-1957 48 √ X X X X X X X X

L 02\08\2021 N
268 MADALI KP.JANTUNGEUN RT 12/02 17-06-1960 47 √ X X X X X X X X
 L 02\08\2021 N
269 ONIH KP.JANTUNGEUN RT 12/02 28-09-1953 46 √ X X X X X X X X

L 02\08\2021 N
270 KIYAI MADHANI KP.JANTUNGEUN RT 12/02 11-11-1957 52 √ X X X X X X X X

P 02\08\2021 N
271 JUJU KP.JANTUNGEUN RT 12/02 17-06-1960 46 √ X X X X X X X X

L 02\08\2021 N
272 JAMAT KP.JANTUNGEUN RT 12/02 04-05-1960 45 √ X X X X X X X X

L 02\08\2021 N
273 BARWI KP.JANTUNGEUN RT 12/02 02-11-1960 51 √ X X X X X X X X

P 02\08\2021 N
274 HASAN BISRI KP.JANTUNGEUN RT 12/02 11-02-1960 56 √ X X X X X X X X

P 02\08\2021 N
275 ARSIAH KP.JANTUNGEUN RT 12/02 11-02-1960 57 √ X X X X X X X X

P 02\08\2021 N
276 RISMAH KP.JANTUNGEUN RT 12/02 11-11-1957 57 √ X X X X X X X X

P 02\08\2021 N
277 ARSAAH KP.JANTUNGEUN RT 12/02 17-06-1960 54 √ X X X X X X X X

P 02\08\2021 N
278 IMAH KP.JANTUNGEUN RT 12/02 28-09-1953 60 √ X X X X X X X X

P 02\08\2021 N
279 JAKA KP.JANTUNGEUN RT 12/02 11-11-1957 54 √ X X X X X X X X

L 02\08\2021 N
280 IPEH KP.JANTUNGEUN RT 12/02 17-06-1960 60 √ X X X X X X X X

P 02\08\2021 N
282 ERNA KP.JANTUNGEUN RT 12/02 04-05-1960 70 √ X X X X X X X X

P 02\09\2021 N
283 ROHADI KP.JANTUNGEUN RT 12/02 02-11-1960 59 √ X X X X X X X X

P 02\09\2021 N
284 JAJANG KP.JANTUNGEUN RT 12/02 11-02-1960 61 √ X X X X X X X X

P 02\09\2021 N
285 TATA KP.JANTUNGEUN RT 12/02 11-02-1960 61 √ X X X X X X X X

P 02\09\2021 N
286 TURKINI KP.JANTUNGEUN RT 12/02 11-11-1957 68 √ X X X X X X X X

P 02\09\2021 N
287 DEDE KP.JANTUNGEUN RT 12/02 17-06-1960 68 √ X X X X X X X X

P 02\09\2021 N
288 TATANG KP.JANTUNGEUN RT 12/02 28-09-1953 67 √ X X X X X X X X

P 02\09\2021 N
289 NELI KP.JANTUNGEUN RT 12/02 11-11-1957 79 √ X X X X X X X X

P 02\09\2021 N
290 LEDI KP.JANTUNGEUN RT 12/02 17-06-1960 68 √ X X X X X X X X
 P 02\11\2021 N
291 PIDA KP.JANTUNGEUN RT 12/02 04-05-1960 86 √ X X X X X X X X

P 02\11\2021 N
292 SUKINAH KP.JANTUNGEUN RT 12/02 02-11-1960 76 √ X X X X X X X X

P 02\11\2021 N
293 TURKINI KP.JANTUNGEUN RT 12/02 11-02-1960 63 √ X X X X X X X X

L 02\11\2021 N
294 YAYAN KP.JANTUNGEUN RT 12/02 11-02-1960 63 √ X X X X X X X X

L 02\11\2021 N
295 UBUD KP.JANTUNGEUN RT 12/02 11-11-1957 60 √ X X X X X X X X

L 02\11\2021 N
296 JOKO KP.JANTUNGEUN RT 12/02 17-06-1960 64 √ X X X X X X X X

SANIM L 02\11\2021 N
297 KP.JANTUNGEUN RT 12/02 28-09-1953 82 √ X X X X X X X X

SARNATI L 02\11\2021 +
298 KP.JANTUNGEUN RT 12/02 11-11-1957 68 √ X X X X X X X X

UBAY P 02\12\2021 N
299 KP.JANTUNGEUN RT 12/02 17-06-1960 64 √ X X X X X X X X

SUKANAH L 02\12\2021 N
300 KP.JANTUNGEUN RT 12/02 04-05-1960 61 √ X X X X X X X X

IJAM P 02\12\2021 N
301 KP.JANTUNGEUN RT 12/02 02-11-1960 61 √ X X X X X X X X

RATI P 02\12\2021 N
302 KP.JANTUNGEUN RT 12/02 11-02-1960 64 √ X X X X X X X X

MUHAMAD YAHYA L 02\12\2021 N

303 KP.JANTUNGEUN RT 12/02 17-06-1960 82 √ X X X X X X X X

DAIROH P 02\12\2021 N
304 KP.JANTUNGEUN RT 12/02 04-05-1960 68 √ X X X X X X X X

ENGKAT L 02\12\2021 N
305 KP.JANTUNGEUN RT 12/02 02-11-1960 64 √ X X X X X X X X

K : Konseling
R: Rujukan
Mengetahui
Kepala Puskesmas

________________
 PEMERIKSAAN LABORATORIUM SEDERHANA
Gangguan Gangguan Ganggunan
Ginjal Penglihatan Pendengaran Kolesterol Gula Darah Asam Urat Hb
(mg/dl) (mg/dl) (mg/dl) (gr/dl) Penyuluhan Pemberdayaan Januari Februari

BB/TB TD Tindakan BB/TB TD Tindakan

2 1 2 1 2 1 2 1 2 1 2 1 2 Tgl Lain-lain Tgl Lain-lain
(IMT) (mmHg) Tatalaksana K R (IMT) (mmHg) Tatalaksana K R
25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

koles; 126 gds;225 Y

X X X Y X ### 45/155 120/80

koles; 251 gds;140 Y

X X X x X ### 54/157 134/93

koles; 113 gds;157 Y

X X X x X ### 52/147 140/90

koles; 110 gds; 168 Y

X X X x X ### 62/165 150/100 RUJUK K PKM

koles; 146 gds;105 Y

X X X x X ### 50/155 120/80

koles; 163 gds;135 Y

X X X x X ### 45/143 140/90

koles; 170 gds;148 Y

X X X x X ### 48/137 110/70

koles; 168 gds; 152 Y

X X X x X ### 55/162 130/90

koles; 170 gds; 312 Y

X X X x X ### 45/138 142/84

koles; 181 gds;341 Y

X X X x X ### 48/145 150/100 RUJUK K PKM

koles; 192 gds;207 Y

X X X Y X ### 49/146 120/80

koles; 147 gds; 163 Y

X X X x X ### 45/155 100/70

koles; 143 gds;165 Y

X X X x X ### 55/43 90/70

koles; Y
gds;143
131
X X X x X ### 54/150 110/70

koles; 178 gds;183 Y

X X X x X ### 50/145 100/70

koles; 181 gds;168 Y ###

X X X x X 50/155 120/80
 koles; 120 gds;151 Y ###
X X X x X 45/143 140/90

koles; 126 gds;130 Y ###

X X X x X 48/137 110/70

koles; 171 gds;190 Y ###

X X X x X 55/162 130/90

koles; 146 gds;155 Y ###

X X X x X 45/138 142/84

koles;167 gds;161 Y ###

X X X Y X 54/150 110/70

koles;143 gds;123 Y ###

X X X x X 50/145 100/70

koles;156 gds;162 Y ###

X X X x X 43/150 130/90

koles;187 gds;221 Y ###

X X X x X 45/145 120/82

koles;203 gds;98 Y ###

X X X x X 35/140 150/90 RUJUK KE PKM

koles;143 gds;152 Y ###

X X X x X 45/140 120/70

koles;202 gds;143 Y ###

X X X x X 34/144 110/70

koles;176 gds;175 Y ###

X X X x X 40/145 140/80

koles;175 gds;197 Y ###

X X X x X 54/150 110/70

koles;180 gds;154 Y ###

X X X x X 50/145 100/70

koles;103 gds;142 Y ###

X X X Y X 43/150 130/90

koles;178 gds;182 Y ###

X X X x X 55/145 120/70

koles;112 gds;167 Y ###

X X X x X 56/150 90/70

koles; 126 gds;225 Y ###

X X X x X 50/145 100/70

koles; 251 gds;140 Y ###

X X X x X 43/144 120/80

koles; 113 gds;157 Y

X X X x X

koles; 110 gds; 168 Y

X X X x X
 koles; 146 gds;105 Y
X X X x X

koles; 163 gds;135 Y

X X X x X

koles; 170 gds;148 Y

X X X x X

koles; 168 gds; 152 Y

X X X Y X

koles; 170 gds; 312 Y

X X X x X

koles; 181 gds;341 Y

X X X x X

koles; 192 gds;207 Y

X X X x X

koles; 147 gds; 163 Y

X X X x X

koles; 143 gds;165 Y

X X X x X

koles; Y
gds;143
131
X X X x X

koles; 178 gds;183 Y

X X X x X

koles; 181 gds;168 Y

X X X x X

koles; 120 gds;151 Y

X X X x X

koles; 126 gds;130 Y

X X X Y X

koles; 171 gds;190 Y

X X X x X

koles; 146 gds;155 Y

X X X x X

koles;167 gds;161 Y
X X X x X

koles;143 gds;123 Y
X X X x X

koles;156 gds;162 Y
X X X x X

koles;187 gds;221 Y
X X X x X

koles;203 gds;98 Y
X X X x X
 koles;143 gds;152 Y
X X X x X

koles;202 gds;143 Y
X X X x X

koles;176 gds;175 Y
X X X Y X

koles;175 gds;197 Y
X X X x X

koles;180 gds;154 Y
X X X x X

koles;103 gds;142 Y
X X X x X

koles;178 gds;182 Y
X X X x X

koles;112 gds;167 Y
X X X x X

koles; 126 gds;225 Y

X X X x X

koles; 251 gds;140 Y

X X X x X

koles; 113 gds;157 Y

X X X x X

koles; 110 gds; 168 Y

X X X x X

koles; 146 gds;105 Y

X X X Y X

koles; 163 gds;135 Y

X X X x X

koles; 170 gds;148 Y

X X X x X

koles; 168 gds; 152 Y

X X X x X

koles; 170 gds; 312 Y

X X X x X

koles; 181 gds;341 Y

X X X x X

koles; 192 gds;207 Y

X X X x X

koles; 147 gds; 163 Y

X X X x X

koles; 143 gds;165 Y

X X X x X
 koles; Y
gds;143
131
X X X x X

koles; 178 gds;183 Y

X X X Y X

koles; 181 gds;168 Y

X X X x X

koles; 120 gds;151 Y

X X X x X

koles; 126 gds;130 Y

X X X x X

koles; 171 gds;190 Y

X X X x X

koles; 146 gds;155 Y

X X X x X

koles;167 gds;161 Y
X X X x X

koles;143 gds;123 Y
X X X x X

koles;156 gds;162 Y
X X X x X

koles;187 gds;221 Y
X X X x X

koles;203 gds;98 Y
X X X Y X

koles;143 gds;152 Y
X X X x X

koles;202 gds;143 Y
X X X x X

koles;176 gds;175 Y
X X X x X

koles;175 gds;197 Y
X X X x X

koles;180 gds;154 Y
X X X x X

koles;103 gds;142 Y
X X X x X

koles;178 gds;182 Y
X X X x X

koles;112 gds;167 Y
X X X x X

koles; 126 gds;225 Y

X X X x X
 koles; 251 gds;140
X X X x X

koles; 113 gds;157

X X X x X

koles; 110 gds; 168

X X X x X

koles; 146 gds;105

X X X x X

koles; 163 gds;135

X X X x X

koles; 170 gds;148

X X X x X

koles; 168 gds; 152

X X X x X

koles; 170 gds; 312

X X X x X

koles; 181 gds;341

X X X x X

koles; 192 gds;207

X X X x X

koles; 147 gds; 163

X X X x X

koles; 143 gds;165

X X X x X

koles;
gds;143
131
X X X x X

koles; 178 gds;183

X X X x X

koles; 181 gds;168

X X X x X

koles; 120 gds;151

X X X x X

koles; 126 gds;130

X X X x X

koles; 171 gds;190

X X X x X

koles; 146 gds;155

X X X x X

koles;167 gds;161
X X X x X

koles;143 gds;123
X X X x X
 koles;156 gds;162
X X X x X

koles;187 gds;221
X X X x X

koles;203 gds;98
X X X x X

koles;143 gds;152
X X X x X

koles;202 gds;143
X X X x X

koles;176 gds;175
X X X x X

koles;175 gds;197
X X X x X

koles;180 gds;154
X X X x X

koles;103 gds;142
X X X x X

koles;178 gds;182
X X X x X

koles;112 gds;167
X X X x X

koles; 126 gds;225

X X X x X

koles; 251 gds;140

X X X x X

koles; 113 gds;157

X X X x X

koles; 110 gds; 168

X X X x X

koles; 146 gds;105

X X X x X

koles; 163 gds;135

X X X x X

koles; 170 gds;148

X X X Y X

koles; 168 gds; 152

X X X x X

koles; 170 gds; 312

X X X x X

koles; 181 gds;341

X X X x X
 koles; 192 gds;207
X X X x X

koles; 147 gds; 163

X X X x X

koles; 143 gds;165

X X X x X

koles;
gds;143
131
X X X x X

koles; 178 gds;183

X X X x X

koles; 181 gds;168

X X X x X

koles; 120 gds;151

X X X Y X

koles; 126 gds;130

X X X x X

koles; 171 gds;190

X X X x X

koles; 146 gds;155

X X X x X

koles;167 gds;161
X X X x X

koles;143 gds;123
X X X x X

koles;156 gds;162
X X X x X

koles;187 gds;221
X X X x X

koles;203 gds;98
X X X x X

koles;143 gds;152
X X X x X

koles;202 gds;143
X X X Y X

koles;176 gds;175
X X X x X

koles;175 gds;197
X X X x X

koles;180 gds;154
X X X x X

koles;103 gds;142
X X X x X
 koles;178 gds;182
X X X x X

koles;112 gds;167
X X X x X

koles; 126 gds;225

X X X x X

koles; 251 gds;140

X X X x X

koles; 113 gds;157

X X X x X

koles; 110 gds; 168

X X X Y X

koles; 146 gds;105

X X X x X

koles; 163 gds;135

X X X x X

koles; 170 gds;148

X X X x X

koles; 168 gds; 152

X X X x X

koles; 170 gds; 312

X X X x X

koles; 181 gds;341

X X X x X

koles; 192 gds;207

X X X x X

koles; 147 gds; 163

X X X x X

koles; 143 gds;165

X X X x X

koles;
gds;143
131
X X X Y X

koles; 178 gds;183

X X X x X

koles; 181 gds;168

X X X x X

koles; 120 gds;151

X X X x X

koles; 126 gds;130

X X X x X

koles; 171 gds;190

X X X x X
 koles; 146 gds;155
X X X x X

koles;167 gds;161
X X X x X

koles;143 gds;123
X X X x X

koles;156 gds;162
X X X x X

koles;187 gds;221
X X X Y X

koles;203 gds;98
X X X x X

koles;143 gds;152
X X X x X

koles;202 gds;143
X X X x X

koles;176 gds;175
X X X x X

koles;175 gds;197
X X X x X

koles;180 gds;154
X X X x X

koles;103 gds;142
X X X x X

koles;178 gds;182
X X X Y X

koles;112 gds;167
X X X x X

koles; 126 gds;225

X X X x X

koles; 251 gds;140

X X X x X

koles; 113 gds;157

X X X x X

koles; 110 gds; 168

X X X x X

koles; 146 gds;105

X X X x X

koles; 163 gds;135

X X X x X

koles; 170 gds;148

X X X x X
 koles; 168 gds; 152
X X X x X

koles; 170 gds; 312

X X X Y X

koles; 181 gds;341

X X X x X

koles; 192 gds;207

X X X x X

koles; 147 gds; 163

X X X x X

koles; 143 gds;165

X X X x X

koles;
gds;143
131
X X X x X

koles; 178 gds;183

X X X x X

koles; 181 gds;168

X X X x X

koles; 120 gds;151

X X X x X

koles; 126 gds;130

X X X x X

koles; 171 gds;190

X X X Y X

koles; 146 gds;155

X X X x X

koles;167 gds;161
X X X x X

koles;143 gds;123
X X X x X

koles;156 gds;162
X X X x X

koles;187 gds;221
X X X x X

koles;203 gds;98
X X X x X

koles;143 gds;152
X X X x X

koles;202 gds;143
X X X x X

koles;176 gds;175
X X X x X
 koles;175 gds;197
X X X Y X

koles;180 gds;154
X X X x X

koles;103 gds;142
X X X x X

koles;178 gds;182
X X X x X

koles;112 gds;167
X X X x X

koles; 126 gds;225

X X X x X

koles; 251 gds;140

X X X x X

koles; 113 gds;157

X X X x X

koles; 110 gds; 168

X X X x X

koles; 146 gds;105

X X X x X

koles; 163 gds;135

X X X Y X

koles; 170 gds;148

X X X x X

koles; 168 gds; 152

X X X x X

koles; 170 gds; 312

X X X x X

koles; 181 gds;341

X X X x X

koles; 192 gds;207

X X X x X

koles; 147 gds; 163

X X X x X

koles; 143 gds;165

X X X x X

koles;
gds;143
131
X X X x X

koles; 178 gds;183

X X X x X

koles; 181 gds;168

X X X Y X
 koles; 120 gds;151
X X X x X

koles; 126 gds;130

X X X x X

koles; 171 gds;190

X X X x X

koles; 146 gds;155

X X X x X

koles;167 gds;161
X X X x X

koles;143 gds;123
X X X x X

koles;156 gds;162
X X X x X

koles;187 gds;221
X X X Y X

koles;203 gds;98
X X X x X

koles;143 gds;152
X X X x X

koles;202 gds;143
X X X x X

koles;176 gds;175
X X X x X

koles;175 gds;197
X X X x X

koles;180 gds;154
X X X x X

koles;103 gds;142
X X X x X

koles;178 gds;182
X X X x X

koles;112 gds;167
X X X x X

koles; 126 gds;225

X X X Y X

koles; 251 gds;140

X X X x X

koles; 113 gds;157

X X X x X

koles; 110 gds; 168

X X X x X
 koles; 146 gds;105
X X X x X

koles; 163 gds;135

X X X x X

koles; 170 gds;148

X X X x X

koles; 168 gds; 152

X X X x X

koles; 170 gds; 312

X X X x X

koles; 181 gds;341

X X X x X

koles; 192 gds;207

X X X Y X

koles; 147 gds; 163

X X X x X

koles; 143 gds;165

X X X x X

koles;
gds;143
131
X X X x X

koles; 178 gds;183

X X X x X

koles; 181 gds;168

X X X x X

koles; 120 gds;151

X X X x X

koles; 126 gds;130

X X X x X

koles; 171 gds;190

X X X x X

koles; 146 gds;155

X X X x X

koles;167 gds;161
X X X Y X

koles;143 gds;123
X X X x X

koles;156 gds;162
X X X x X

koles;187 gds;221
X X X x X

koles;203 gds;98
X X X x X
 koles;143 gds;152
X X X x X

koles;202 gds;143
X X X x X

koles;176 gds;175
X X X x X

koles;175 gds;197
X X X x X

koles;180 gds;154
X X X x X

koles;103 gds;142
X X X Y X

koles;178 gds;182
X X X x X

koles;112 gds;167
X X X x X

koles;180 gds;154
X X X x X

koles;103 gds;142
X X X x X

koles;178 gds;182
X X X x X

koles;112 gds;167
X X X x X

koles;103 gds;142
X X X x X

koles;178 gds;182
X X X x X

koles;112 gds;167
X X X x X
 PEMERIKSAAN FISIK DAN TINDAKAN

Maret April Mei Juni Juli

BB/TB TD Tindakan BB/TB TD Tindakan BB/TB TD Tindakan BB/TB TD Tindakan BB/TB

Tgl Lain-lain Tgl Lain-lain Tgl Lain-lain Tgl Lain-lain Tgl
(IMT) (mmHg) Tatalaksana K R (IMT) (mmHg) Tatalaksana K R (IMT) (mmHg) Tatalaksana K R (IMT) (mmHg) Tatalaksana K R (IMT)
54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83
###
45/140 120/70

###
34/144 110/70
###
40/145 140/80

###
55/162 130/90

###
45/138 142/84

###
48/145 150/100 RUJUK PKM

###
49/146 120/80

###
45/155 100/70

###
55/43 90/70

###
54/150 110/70

###
50/145 100/70

###
45/143 140/90

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
54/150 110/70

###
50/145 100/70

###
50/155 120/80

###
45/143 140/90

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70
###
50/155 120/80

###
45/143 140/90

###
50/155 120/80

###
45/143 140/90

###
48/137 110/70

###
55/162 130/90

###
50/155 120/80

###
45/143 140/90

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
54/150 110/70

###
50/145 100/70

###
43/150 130/90

###
45/145 120/82

###
54/157 134/93

###
52/147 140/90

###
62/165 150/100

###
50/155 120/80

###
45/143 140/90

###
48/137 110/70
###
55/162 130/90

###
45/138 142/84

###
48/145 150/100

###
49/146 120/80

###
45/155 100/70

###
55/43 90/70

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
48/145 150/100

###
49/146 120/80

###
45/155 100/70

###
55/43 90/70

###
50/145 100/70

###
43/150 130/90

###
45/145 120/82

###
54/150 110/70

###
50/145 100/70

###
50/155 120/80

###
45/143 140/90

###
48/137 110/70
###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
45/138 142/84

###
55/162 130/90

###
50/155 120/80

###
45/143 140/90

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
54/150 110/70

###
50/145 100/70

###
43/150 130/90

###
45/145 120/82

###
54/150 110/70

###
55/162 130/90

###
50/155 120/80

###
45/143 140/90

###
48/137 110/70

###
48/137
###
55/162

###
45/138

###
54/150

###
50/145

###
43/150

###
45/145

###
54/150

###
50/145

###
50/155

###
45/143

###
54/150

###
50/145

###
50/155

###
45/143

###
54/150

###
50/145

###
50/155

###
45/143

###
54/150

###
50/145

###
50/155
###
45/143
Pengelola Program Kesehatan Lansia

________________
SAAN FISIK DAN TINDAKAN

Juli Agustus September Oktober November

TD Tindakan BB/TB TD Tindakan BB/TB TD Tindakan BB/TB TD Tindakan BB/TB TD

Lain-lain Tgl Lain-lain Tgl Lain-lain Tgl Lain-lain Tgl
(mmHg) Tatalaksana K R (IMT) (mmHg) Tatalaksana K R (IMT) (mmHg) Tatalaksana K R (IMT) (mmHg) Tatalaksana K R (IMT) (mmHg)
84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
110/70
130/90

142/84

110/70

100/70

130/90

120/82

110/70

100/70

120/80

140/90

110/70

100/70

120/80

140/90

110/70

100/70

120/80

140/90

110/70

100/70

120/80
140/90

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70
###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70
###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70
###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70
###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70
###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70
###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80
Kesehatan Lansia

________
November Desember Keterangan

Tindakan BB/TB TD Tindakan

Lain-lain Tgl Lain-lain
Tatalaksana K R (IMT) (mmHg) Tatalaksana K R
113 114 115 116 117 118 119 120 121 122 123 124
###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70
###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80

###
48/137 110/70

###
55/162 130/90

###
45/138 142/84

###
50/145 100/70

###
50/155 120/80

###
50/145 100/70

###
48/154 120/80
 LAPORAN PROGRAM PELAYANAN KESEHATAN LANJUT USIA

PROVINSI :
KABUPATEN :
TAHUN :
BULAN :

SASARAN PELAYANAN KESEHATAN SARANA SDM

Jumlah yang dibina Jumlah Lansia dengan
PUSKESMAS
Jumlah tenaga yang mendapatkan
/ yang mendapat pelayanan kesehatan tingkat kemandirian pelatihan Lansia dan Geriatri

Jumlah Jumlah Lansia yang diberdayakan Jumlah Kelompok Lansia / Posyandu Lansia/ Posbindu
Jumlah Lansia
NO. NAMA PUSKESMAS JUMLAH DESA / Pra Lansia
( ≥ 60 tahun)
Jumlah Lansia Risti (≥ 70 tahun) Pra Lansia Lansia Lansia Risti Tingkat Kemandirian B Tingkat Kemandirian C Jumlah Puskesmas yang melaksanakan pelayanan kesehatan santun Puskesmas Puskesmas
KELURAHAN (45-59 tahun) Tingkat Kemandirian A (Mandiri) Panti
(45-59 tahun) (≥ 60 tahun) (≥ 70 tahun) (Ketergantungan ringan/sedang) (Ketergantungan Berat/Total) lansia dengan yang
Werdha yg Jumlah Posyandu Lansia Melaksanakan
Dokter Perawat
dibina Puskesmas Aktif Long Term Care
Bulan lalu Bulan ini Total Bulan lalu Bulan ini Total Bulan lalu Bulan ini Total Absolut Absolut Absolut Absolut
Pratama Madya Purnama Mandiri Total Strata I Strata II Strata III Total
L P T L P T L P T L P T L P T L P T L P T L P T L P T Bulan Bulan % Bulan Bulan % Bulan Bulan % Bulan Bulan %
L P T L P T L P T Total Total Total Total
Abs. Abs. Abs. Abs. Abs. Abs. Abs. % Abs. % Abs. % Abs. Abs. Abs. Abs. Abs. Abs. Abs. % Abs. % Abs. % Abs. Abs. Abs. Abs. Abs. Abs. Abs. % Abs. % Abs. % lalu ini lalu ini lalu ini lalu ini Abs. Abs. Abs. Abs. Abs. Abs. Abs. Abs. Abs. % Abs. % Abs. % Abs. % Abs. %
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84

TOTAL
Laporan bulanan
Laporan tahunan
Mengetahui
Kepala Dinas Kesehatan Kabupaten/Kota Pengelola Program Kesehatan Lansia

________________ ________________
 LAPORAN PROGRAM PELAYANAN KESEHATAN LANJUT USIA

PROVINSI :
TAHUN :
BULAN :

SASARAN PELAYANAN KESEHATAN SARANA SDM

Jumlah yang dibina Jumlah Lansia dengan
PUSKESMAS
Jumlah tenaga yang mendapatkan
/ yang mendapat pelayanan kesehatan tingkat kemandirian pelatihan Lansia dan Geriatri
Jumlah
Jumlah Lansia
Pra Lansia Jumlah Lansia Risti (≥ 70 tahun) Jumlah Lansia yang diberdayakan Jumlah Kelompok Lansia / Posyandu Lansia/ Posbindu
NO. NAMA KABUPATEN / KOTA JUMLAH DESA / (45-59 tahun)
( ≥ 60 tahun)
Pra Lansia Lansia Lansia Risti Tingkat Kemandirian B Tingkat Kemandirian C Jumlah Puskesmas yang melaksanakan pelayanan kesehatan santun
KELURAHAN Tingkat Kemandirian A (Mandiri) Panti Puskesmas dengan Puskesmas yang
(45-59 tahun) (≥ 60 tahun) (≥ 70 tahun) (Ketergantungan ringan/sedang) (Ketergantungan Berat/Total) lansia
Werdha yg Jumlah Posyandu Lansia Melaksanakan Long Dokter Perawat
dibina Puskesmas Aktif Term Care

Bulan lalu Bulan ini Total Bulan lalu Bulan ini Total Bulan lalu Bulan ini Total Absolut Absolut Absolut Absolut
Pratama Madya Purnama Mandiri Total Strata I Strata II Strata III Total
L P T L P T L P T L P T L P T L P T L P T L P T L P T Bulan Bulan % Bulan Bulan % Bulan Bulan % Bulan Bulan %
L P T L P T L P T Total Total Total Total
Abs. Abs. Abs. Abs. Abs. Abs. Abs. % Abs. % Abs. % Abs. Abs. Abs. Abs. Abs. Abs. Abs. % Abs. % Abs. % Abs. Abs. Abs. Abs. Abs. Abs. Abs. % Abs. % Abs. % lalu ini lalu ini lalu ini lalu ini Abs. Abs. Abs. Abs. Abs. Abs. Abs. Abs. Abs. % Abs. % Abs. % Abs. % Abs. %
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84

TOTAL
Laporan bulanan Laporan bulanan
Laporan tahunan Laporan tahunan
Mengetahui
Kepala Dinas Kesehatan Provinsi Pengelola Program Kesehatan Lansia

________________ ________________
DATA LAPORAN PROGRAM PELAYANAN KESEHATAN LANJUT USIA

PROVINSI :
TAHUN :
BULAN :

Pra L

NO NAMA KABUPATEN IMT Kolesterol

Ggn ME Hipertensi DM
Tinggi
L K
1 2 3 4 5 6 7 8

Data Dikumpulkan per Tahun

* Dapat diisi sesuai dengan Penyakit Terbanyak

Mengetahui
Kepala Dinas Kesehatan Provinsi

________________
 Morbidas Pada Pra Lansia dan Lansi
Pra Lansia (umur 45-59 Tahun)

Asam urat
Ggn Ginjal Ggn Kognitif Ggn ME Ggn Penglihatan Ggn Pendengaran Lain-lain (sebutkan)*
tinggi

9 10 11 12 13 14 15
Lansia dan Lansia

IMT Kolesterol Asam urat

Hipertensi DM Ggn Ginjal Ggn Kognitif
Tinggi tinggi
L K
16 17 18 19 20 21 22 23

Pengelola Program Kesehatan Lansia

________________
 Ggn Penglihatan Ggn Pendengaran Lain-lain (sebutkan)*

24 25 26

ansia
DATA LAPORAN MORBIDITAS PRA LANSIA DAN LANSIA

KABUPATEN :
TAHUN :
BULAN :

Pra Lansia (umu

NO NAMA PUSKESMAS IMT Kolesterol

Ggn ME Hipertensi DM
Tinggi
L K
1 2 3 4 5 6 7 8

Data Dikumpulkan per Tahun

* Dapat diisi sesuai dengan Penyakit Terbanyak

Mengetahui
Kepala Dinas Kesehatan Kabupaten/Kota

________________
 Morbidas Pada Pra Lansia dan Lansia
Pra Lansia (umur 45-59 Tahun)

Asam urat
Ggn Ginjal Ggn Kognitif Ggn Penglihatan Ggn Pendengaran Lain-lain (sebutkan)* Ggn ME
tinggi

9 10 11 12 13 14 15
a Lansia dan Lansia
Lansia (umur ≥ 60 Tahun)

IMT Kolesterol Asam urat

Hipertensi DM Ggn Ginjal Ggn Kognitif
Tinggi tinggi
L K
16 17 18 19 20 21 22 23

Pengelola Program Kesehatan Lansia

________________
 Ggn Penglihatan Ggn Pendengaran Lain-lain (sebutkan)*

24 25 26

Lansia