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  Data Ofine Surveilans PTM berbasis F

No

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

1920

21

22

23

24

25

26

27

28

2930

31

32

33

34

35

36

37

38

3940

41

TanggalPemeriksaan *

IDENTITAS

No RekamMeis

No KTP *

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42

43

44

45

46

47

48

49

50

xxx xxx xxx xxx

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  TP

Nama Pasien Tem!at "a#ir Tanggal "a#ir $enis

Kelamin

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Alamat "engka! No %P No Tel!& Ruma#

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xxx xxx xxx

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Status Suku Peker'aan(olongan

Dara#

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)A)ANARA IMT

Keterangan Merokok  Kurang

Aktivitas

Fisik 

KurangMakan

Sa+ur

KonsumsiAlko#ol

Tinggi,aan

,erat,aan

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Tekanan Dara# (ula Dara# Kolesterol

Sistol Diastol Trigliseria"ingkarPerut

(ula Dara#Se-aktu

(ula Dara#Puasa

KolesterolTotal

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"D" %D"

ArusPun.ak

Eks!irasi/APE0

KaarAlko#ol

Perna1asan

TesAm1etamin

2rin

,en'olanAbnormal

Pa+uara

Pa!Smear

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Kriotera!i Diagnosa 3 Diagnosa 4%asil

Periksa

I5A

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DIA(NOSA P

Diagnosa 6 Diagnosa 7 Diagnosa 8 EK(

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emeriksaan Penun'ang

Raiologi Diru'uk  Dara#

"engka!

2rin Rutin9

Mikrosko!ik 

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xxx xxx xxx xxx

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tgl_periksa rekam_medis nik nama tgl_lahir

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alamat gender telp diagnosa1 diagnosa2 diagnosa3 diagnosa4

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diagnosa5 merokok urang_aktiftaurang_sayu sumsi_alko tb bb

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lp sistol diastol gds gdp ape

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 olan_payu positi!_i"a krioterapi papsmear tempat_lahir no_telprumagolongan_d

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status suku pekeraan keterangan kolesterol_to t rigliserida

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ldl hdl kadar_alko tesam!eta ekg radiologi darah_leng

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urin_rutin diruuk

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2 !ktp