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PEMERINTAH KOTA SAMARINDA DINAS KESEHATAN KOTA SAMARINDA
UPT. PUSKESMAS MANGKUPALAS Jl. Mas Penghulu RT. 08 No. 67. Tlp. (0541) 261 489 Kec. Samarinda Seberang
Formulir Penjaringan Kesehatan Gigi dan Mulut Ibu Hamil di Posyandu 1. Identitas Ibu Hamil Nama
: ________________________________________________________________________
Tgl lahir
: ________________________________________________________________________
Alamat / Telp
: ________________________________________________________________________
2. Keadaan Umum Usia Kehamilan : ________________________________________________________________________ BB
: ________________________________________________________________________
TB
: ________________________________________________________________________
TD
: ________________________________________________________________________
3. Pemeriksaan Gigi
4. Rekomendasi
Samarinda, _______________________ Petugas Penjaringan
(________________________)
