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PEMANTAUAN IBU HAMIL

1. NIK Ibu :__________________________________________________________

2. Nama Ibu :__________________________________________________________

3. Alamat :__________________________________________________________

4. Tgl. Ibu :__________________________________________________________

5. Tgl. Kunjungan :__________________________________________________________

6. Jumlah Anak :__________________________________________________________

7. Usia Kehamilan :__________________________________________________________

8. Tinggi Fundus :__________________________________________________________

9. Tinggi Badan :__________________________________________________________

10. Berat Badan :__________________________________________________________

11. Indeks Massa Tubuh :__________________________________________________________

12. Riwayat Penyakit :__________________________________________________________

13. Kadar Hemoglobin :__________________________________________________________

14. Lingkar Lengan Atas :__________________________________________________________

15. Taksiran Berat Janin :__________________________________________________________

16. Metode KB :__________________________________________________________

17. Rokok Terpapar :__________________________________________________________

18. Penyuluhan KB : Ya/Tidak__________________________________________________

19. Dapat Suplemen : Ya/Tidak__________________________________________________

20. Jenis Penyuluhan : Kelompok/Perorangan_______________________________________

21. Fasilitas Rujukan :__________________________________________________________

22. Bantuan Sosial :__________________________________________________________

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