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Formulir E-Ppgbm Ibu Hamil [PDF]

KABUPATEN / KOTA : PUSKESMAS : PETUGAS ENTRI/TPG :

KE NO KEHAMILAN BERAPA*

TANGGAL LAHIR

NOMOR KK*

NIK*

NAMA*

BERA

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Formulir Skrining Gizi Ibu Hamil
Formulir Skrining Gizi Ibu Hamil

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Ibu Hamil
Ibu Hamil

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Kak Eppgbm

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SOP .Konseling Ibu Hamil
SOP .Konseling Ibu Hamil

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KAK Kelas Ibu Hamil
KAK Kelas Ibu Hamil

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Caring Pada Ibu Hamil
Caring Pada Ibu Hamil

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Kak Kelas Ibu Hamil

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Pengisian Kartu Ibu Hamil

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Kak Kelas Ibu Hamil

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KABUPATEN / KOTA : PUSKESMAS : PETUGAS ENTRI/TPG :



KE NO KEHAMILAN BERAPA*



TANGGAL LAHIR



NOMOR KK*



NIK*



NAMA*



BERAT BADAN AWAL HAMIL (Kg)



TINGGI BADAN AWAL HAMIL (CM



HPHT (DD-MMYYYY)*



HB



GOLONGAN DARAH



PENGGUNAAN KONTRASEPSI SEBELUM KEHAMILAN INI



RIWAYAT PENYAKIT YANG DIDERITA IBU



BUKU KIA*



RIWAYAT ALERGI YA



TIDAK



NAMA SUAMI*



NIK SUAMI*



TELP/HP SUAMI*



PROVINSI* KAB / KOTA* KECAMATAN* PUSKESMAS PEMBINA*



DESA/KELURA POSYANDU HAN* PEMBINA



ALAMAT LENGKAP*



TANGGAL UKUR



BERAT BADAN



RT RW JAN



FEB



MAR



APR



MEI



JUN



JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



FORMAT ELEKTRONIK PELAPORAN PENCATATAN GIZI BERBASIS MASYARAKAT (E-PPGBM)



PENGUKURAN TINGGI BADAN



BERAT BADAN JUN



JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



JUN



LILA JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



IMT JUN



JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



TINDA JUN



JUL



AGST



SEPT



JAN



FEB



TINDAKAN MAR



APR



MEI



JUN



TANGGAL PEMERIKSAAN JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



JUN



JUL



KELUHAN SEKARANG AGST



SEPT



JAN



FEB



MAR



APR



MEI



JUN



TEKANAN DARAH JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



JUN



JUL



AGST



PEMERIKSAAN UMUR KEHAMILAN SEPT



JAN



FEB



MAR



APR



MEI



JUN



TINGGI FUNDUS JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



JUN



LETAK JANIN JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



JUN



DENYUT JANTUNG JANIN/MENIT JUL



AGST



SEPT



JAN



FEB



MAR



APR



MEI



PMT



T JANTUNG JANIN/MENIT SUMBER PMT JUN



JUL



AGST



PEMBERIAN PUSAT



SEPT TANGGAL PEMBERIAN



PEMBERIAN KE



JUMLAH PEMBERIAN (BUNGKUS)



PEMBERIAN DAERAH TAHUN PRODUKSI



TANGGAL PEMBERIAN



PEMBERIAN KE JUMLAH PEMBERIAN (KALORI)



FORMAT ELEKTRONIK PELAPORAN PENCATA KABUPATEN / KOTA : PUSKESMAS : PETUGAS ENTRI/TPG :



KE NO KEHAMILAN BERAPA*



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



TANGGAL LAHIR



NOMOR KK*



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



NIK*



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



BERAT BADAN AWAL HAMIL (Kg)



NAMA*



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



TINGGI BADAN AWAL HAMIL (CM 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



HPHT (DD-MMYYYY)*



GOLONGAN DARAH



HB



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0



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FORMAT ELEKTRONIK PELAPORAN PENCATATAN GIZI BERBASIS MASYARAKAT (E-PPGBM)



PENGGUNAAN KONTRASEPSI SEBELUM KEHAMILAN INI



RIWAYAT PENYAKIT YANG DIDERITA IBU



BUKU KIA*



RIWAYAT ALERGI YA



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



NAMA SUAMI*



NIK SUAMI*



TELP/HP SUAMI*



PROVINSI* KAB / KOTA* KECAMATAN* PUSKESMAS PEMBINA*



TIDAK 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0



0



0



0



0



0



0



0



0



0



0



0



DESA/KELURA POSYANDU HAN* PEMBINA



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



ALAMAT LENGKAP*



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



RT RW



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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0



0



0



0



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FORMAT ELEKTRONIK PELAPORAN PENCATATAN KABUPATEN / KOTA PUSKESMAS PETUGAS ENTRI/TPG



: : :



TANGGAL UKUR NO



BERAT BADAN



NAMA* JAN



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



FEB



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



MAR



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



APR



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



MEI



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JUN



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JUL



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



AGST



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



SEPT



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JAN



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



FEB



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



MAR



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



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APR



MEI



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JUN



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AGST



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0



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0



0



0



0



0



0



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0



0



K PELAPORAN PENCATATAN GIZI BERBASIS MASYARAKAT (E-PPGBM)



PENGUKURAN TINGGI BADAN SEPT



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JAN



FEB



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



MAR



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



APR



MEI



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JUN



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



LILA JUL



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



AGST



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



SEPT



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JAN



FEB



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



MAR



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



APR



MEI



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



IMT JUN



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JUL



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



AGST



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



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SEPT



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JAN



FEB



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



MAR



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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



APR



MEI



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



TINDAKAN JUN



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JUL



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AGST



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JAN



FEB



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MAR



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APR



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TINDAKAN JUN



JUL



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



AGST



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



SEPT



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FORMAT ELEKTRONIK PELAPORAN PENCATATAN GI KABUPATEN / KOTA PUSKESMAS PETUGAS ENTRI/TPG



: : :



TANGGAL PEMERIKSAAN NO



KELUHAN SEKARANG



TEKANAN DARAH



NAMA* JAN



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



FEB



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MAR



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



APR



MEI



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JUN



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JUL



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AGST



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SEPT



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JAN



FEB



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MAR



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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



APR



MEI



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JUN



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JUL



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



AGST



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



SEPT



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



JAN



FEB



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



MAR



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0



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