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KOHORT LANSIA (LANJUT USIA)
DESA / KELURAHAN : ............................................................................. PUSKESMAS
: ............................................................................. UMUR
3
>70
2
NAMA 60-69
1
NO. REGISTER
45-59
NO.
4
5
6
1
7
Gangguan Gangguan Mental Kognitif Emosional
Tingkat Kemandirian (AKS / ADL)*
L/P
8
2
A
B
C
A
B
C
9
10
11
12
13
14
1
2
1
2
15
16
17
18
TAHUN : ...............................
TAHUN : ...............................
TAHUN : ............................... KET
JAN
FEB MAR APR MEI JUN JUL AGST
SEP OKT NOP DES
JAN
FEB MAR APR MEI JUN JUL AGST SEP OKT NOP DES
JAN
FEB MAR APR MEI JUN JUL AGST SEP OKT NOP DES
19
20
27
31
32
43
44
21
22
23
24
25
26
28
29
30
33
34
35
36
37
38
39 40
41
42
a
a
a
b
b
b
c
c
c
d
d
d
e
e
e
f
f
f
g
g
g
a
a
a
b
b
b
c
c
c
d
d
d
e
e
e
f
f
f
g
g
g
a
a
a
b
b
b
c
c
c
d
d
d
e
e
e
f
f
f
g
g
g
45
46
47
48
49
50
51
52
53
54
55
