Formulir Pendampingan Identifikasi Ibu Hamil

Hasil Pendampingan Interv

No. Nama Bumil NIK No. HP Alamat

Usia Kehamilan
Tekanan Darah
Temperatur
Usia Bumil

Proteinun
Tes HCG

HbSAG
GDPP
USG

CTG
GDS
TFU

KIE
BB
TB

Hb
36-37 24 cm 11,8 120 _ 130x/ v
1 Mamawiyah 3525174905870001 [Link] 35 155 66.5 36 110/70 mgg mg/dl mnt

18 160 62 36 127/81 30 mgg 19 cm 12,1 120 _ 140x/ v

2 Munaliza 3525175802040001 [Link] mg/dl mnt

3 Badriyah 3525174311810004 [Link] 41 158 92 36 120/70 31 mgg 19 cm 12 120 _ 136x/ v

mg/dl mnt

28-29
26 152 50 36 110/70 mgg 19 cm 12 120 _ 140x/ v
4 Aida fitriana 3525176102960001 [Link] mg/dl mnt

27-28
21 144 35 36 100/70 mgg 18 cm 11,8 120 _ 130x/ v
5 Nora riyah 3525176708010003 [Link] mg/dl mnt
33-34
32 145 63 36 100/60 24 cm 12,8 120 _ 136x/ v
6 Sitti rahema 3525177001900014 083127772171 [Link] Mgg mg/dl mnt

Maghfirotul 3525174608940006 28 150 69 36 100/60 24 mgg _ 12,2 120 _ 130x/

7 rohma 082264471473 [Link] mg/dl mnt

29-30
34 153,5 52 36 110/70 Mgg
_ 12 120 _ 140x/
8 Ria risti wulandari 3525174708890003 [Link] mg/dl mnt

3525174704930015 35-36 23 cn 12,1 120 _ 130x/ v

9 Rabiatul adawiyah 08225782235 [Link] 29 157 50.5 36 100/60 mgg mg/dl mnt

10 Nailul muna 3525175003940002 081331159353 [Link] 29 156 51.4 36 100/60

34-35
Mgg 22 cm
12 120
mg/dl
_ 130x/
mnt
v
33-34 120 136x/
_
11 Samaniyah 3525175506860008 [Link] 36 150 88 36 110/70 11,4 v
Mgg 22 cm mg/dl mnt

14-15 120mg/
Anita rahmawati 3525035505010003 [Link] 21 150 48 36 100/60 Mgg
_ 12 dl
_ + v
12
14-15 120
Indah susanti 3525175412870001 [Link] 36 149 50 36 110/70 Mgg
_ 12,2 mg/dl
_ + v
13
27-28 120mg/ 136x/
[Link] 38 152 60 36 110/70 19 12 v
14 Nur asiyah 3525174410840005 Mgg dl mnt

14-15 120mg/
[Link] 25 155 50 36 90/60 _ 12 + v
15 Nur hasanah 3525176104980001 Mgg dl

12-13 110mg/
[Link] 21 154 33 36 100/60 _ 12 + v
16 Badriyanah 3525176806020001 Mgg dl
17-18 120mg/ 130x/
17 Masrura 3525176304990001 [Link] 26 157 58 36 110/70 Mgg
10 cm 12,1 dl mnt v
23-24 110mg/ 130x/
18 Maisiyah 3525175203880004 [Link] 35 149 50 36 120/80 mgg
16cm 12,1 dl mnt v
110mg/ 130x/
19 Rona masterina 3525175601970014 [Link] 26 155 45 36 110/70 15 mgg _ 12 dl mnt v

Gresik, 2023
Koordinator PKB
Mengetahui,
Tim Pendamping Keluarga Kepala Desa
1. ENDANG MUNAWAROH,[Link]
2. ZUMARATUL AINI
HUSNUL ARIF, [Link]
3. AHMAD MUZAMMIL SENIN, [Link]
NIP. 19820102 2022211 002
 Konsumsi
Intervensi Gizi Rumah Layak Sanitasi BABS Fasilitasi
Seimbang
Suplemen
Makanan

Rujukan

Tidak
Ya
Ya Tidak Baik Tidak Ya Tidak Rujukan Bansos KIE
Fe

ѵ ѵ

ѵ ѵ

ѵ ѵ

ѵ ѵ

ѵ ѵ

ѵ ѵ

v ѵ ѵ

v ѵ ѵ

ѵ ѵ

ѵ ѵ

ѵ ѵ

v ѵ ѵ

v ѵ ѵ

ѵ ѵ

v ѵ ѵ

v ѵ ѵ

v ѵ ѵ
v ѵ ѵ
v ѵ ѵ