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SKRINING HEPATITIS-B
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NAMA LENGKAP *
TANGGAL LAHIR *
MM
/
DD
/
YYYY
NIK *
REKAM MEDIS
NO TELEPON/HP *
ALAMAT *
KOTA/KABUPATEN *
PROVINSI *
PENDIDIKAN TERAKHIR
 *
PEKERJAAN *
STATUS PERKAWINAN *
SUDAH HAMIL BERAPA KALI?
SUDAH MELAHIRKAN BERAPA KALI?
SUDAH KEGUGURAN BERAPA KALI?
USIA KEHAMILAN ... MINGGU
TAKSIRAN PERSALINAN
MM
/
DD
/
YYYY
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