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PEMERINTAH KABUPATEN GUNUNG MAS

PUSKESMAS TUMBANG TALAKEN


KECAMATAN MANUHING
Jl.Negara No.46 Tumbang Talaken Kecamatan Manuhing

STATUS PERSALINAN

NO RMK : ................................. Umur : ...................................


Nama : ................................. Jenis Kelamin : ...................................
Pekerjaan : ................................. Agama : ...................................
Nama Ayah/Ibu/Suami/Istri : ................................. Catatan Khusus : ...................................
Alamat : ................................. Alergi : ...................................
Kecamatan : ................................. Kelainan Darah : ...................................
Kabupaten : ................................. NIK KTP : ...................................
No BPJS/KIS/ASKES : .................................
No HP : .................................

TANGGAL DIAGNOSA THERAPI T.T


DOKTER
HPHT :
HTP :
TD :...................mnHg.
N :...................x/m
T :...................oc
R : ............... ..x/m
BB : ..................kg
TB : ..................cm
L.Perut : ..................cm

Keluhan :

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