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SKRINING KESEHATAN ANAK USIA SEKOLAH & REMAJA
HIPERTENSI & OBESITAS
UPTD Pusksmas Rawat Inap Rangkasbitung
Sasaran: seluruh usia anak dan remaja
Dilakukan setiap tahun
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Nama lengkap
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Your answer
Usia
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Your answer
Jenis kelamin
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Perempuan
Laki-laki
Nama sekolah
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Tanggal Lahir
(HH/BB/TTTT)
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MM
/
DD
/
YYYY
Pendidikan Terakhir
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SD/MI/Sederajat
SMP/MTS/Sederajat
SMA/SMK/MA
No Telepon / Whatsapp pribadi
AKTIF yang dapat dihubungi
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Alamat Lengkap
(Sesuai KK/KTP)
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RT/RW
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Kelurahan
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Cijoro Lebak
Cijoro Pasir
Rangkasbitung Barat
Rangkasbitung Timur
Muara Ciujung Barat
Muara Ciujung Timur
Other:
Apakah Anda konsumsi alkohol / minuman keras?
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