Formulir Deteksi Dini Tumbuh Kembang Anak [PDF]

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FORMULIR DETEKSI DINI TUMBUH KEMBANG ANAK Puskesmas..........................



Kec..........................



Kab/Kota.............................



Prov.......................



. Pemeriksa:................................................. I. a. b. c. d. e. f.



IDENTITAS ANAK Nama:........................................................................... Laki-laki/Perempuan Nama Ayah:........................................................; Nama Ibu:........................................... Alamat:.............................................. Tanggal Pemeriksaan:............/............./20 Tanggal Lahir: ............/............./20 Umur Anak:................... bulan



II. PEMERIKSAAN RUTIN SESUAI JADWAL a. BB:..............Kg; PB/TB:.............Cm BB/TB: a. Baik; b. Kurang; c. Buruk; d. Lebih; e. Rujuk: Ya/Tidak b. Perkembangan Anak: 1. Sesuai 2. Meragukan: a. G. Kasar; b. G. Halus; c. B.Bahasa; d. Sos. Kemandirian; e. Rujuk: Ya/Tidak 3. Penyimpangan: a. G. Kasar; b. G. Halus; c. B.Bahasa; d. Sos. Kemandirian; e. Rujuk: Ya/Tidak III.



KESIMPULAN ....................................................................................................................................................... .......................................................................................................................................................



IV.



TINDAKAN INTERVENSI ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................