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SKRINING IBU HAMIL
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* Indicates required question
NAMA
*
Your answer
TANGGAL LAHIR
*
MM
/
DD
/
YYYY
NIK
*
Your answer
ALAMAT
*
Your answer
KEHAMILAN ANAK KE BERAPA ?
*
Your answer
JARAK KEHAMILAN DENGAN KEHAMILAN SEBELUMNYA
*
Your answer
TANGGAL KUNJUNGAN
*
MM
/
DD
/
YYYY
ADA BUKU KIA
*
YA
TIDAK
PEMERIKSAAN KEHAMILAN
TRIMESTER 1
TANGGAL PERIKSA
MM
/
DD
/
YYYY
TEMPAT PERIKSA
Your answer
PETUGAS
Your answer
TRIMESTER 2
TANGGAL PERIKSA
MM
/
DD
/
YYYY
TEMPAT PERIKSA
Your answer
PETUGAS
Your answer
TRIMESTER 3
TANGGAL PERIKSA
MM
/
DD
/
YYYY
TEMPAT PERIKSA
Your answer
PETUGAS
Your answer
ISI PIRINGKU
*
SESUAI
TIDAK
TABLET TAMBAH DARAH
*
ADA
TIDAK
LILA <23,5 CM
*
YA
TIDAK
PMT UNTUK BUMIL KEK
*
YA
TIDAK
KELAS IBU HAMIL TERAKHIR
TEMPAT
*
Your answer
TANGGAL
*
MM
/
DD
/
YYYY
PENDAMPING
*
Your answer
EDUKASI
*
Your answer
TANDA BAHAYA KEHAMILAN
*
Your answer
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