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1.Identitas

1 Nama Anak : .....................................................

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2 Nomor register : ..................................................................

3 Nama Orang Tua Ayah/Ibu : .....................................................

..............4 Alamat : .....................................................

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2.Data Kelahiran

1 Tanggal lahir : ......................................2 Umur Kehamilan : ................... ln.3 Kelahiran Tunggal/Kembar : 1 anak / 2 anak4 erat a!an "ahir : .............kg# $an%ang a!an : .............&m' "ingkaran Ke(ala : .............&m) Kelahiran Ke : ...................................* Tanggal lahir a!ik kan!ung

berikutnya tanggal

: ..................................

3.Pemberian Makan1 Umur (ertama kali !iberi makan atau minuman

lain +$,A-I: ................

2 Umur berhenti menyusu : ................

4.Peristiwa penting yang mempengaruhi pertumbuhan Anak( anggal !" Misalnya

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#A$%KA& I " '$ A$% P'$ ')A)

1. A(akah anak ibu sakit atau ti!ak selama 1 bulan terakhir ini..............................................................................................................................................................................................

#A$%KA& II " M'$*A+I P'$ ')A).

1. +enga(a (ertumbuhan anak ibu lambat................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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*eklis pemantauan penilaianpertumbuhan

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#A$%KA& III P'+0)A&A$ P #A MAKA$ DA$ A A0 M'$ 0 0I

1. A(akah anak ibu masih menyusu !an men!a(at makanan lebih se!ikit!ari biasanya

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#A$%KA& I P'M)'+IA$ MAKA$ A$AK ' 0AI D'$%A$ 0M0+"1. A(akah ibu masih

menyusui ..........................................................................................2. era(a kali selama sehari

semalam ...............................................................................

3. A(akah ibu mem(unyai kesulitan !alammenyusui........................................................4. A(akah anak memlekat !engan baik saat menyusu !an

!isususi..............................................................................................................................................................................................................................................................................................................................................................................................................................................................

#. agaimana ara ibu menyia(kan susu 0ormula !anmakanan.........................................

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............................'. era(a kali ibu memberi susu 0ormula !an makanan selama seharisemalam

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............................#A$%KA& +I,A A P'$ AKI A$% )'+0#A$%

1. A(akah anak ibu seringsakit............................................................................................

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............................#A$%KA& I KA I K'M0$%KI$A$ P'$ ')A) MA A#A& IA# DA$

#I$%K0$%A$1. A(akah ibu mem(unyai kamar man!i !an& .............................................................

2. ari mana ibu men!a(at untuk kebutuhan rumahtangga..............................................

3. A(akah air selalu!imasak ..............................................................................................

4. era(a banyak anggota keluarga yang tinggal !i rumah sekaranini .............................

#. agaimana kesehatan anggota keluargasekarang ........................................................

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............................#A$%KA& II '$ 0KA$ P'$ ')A) )'+ AMA I)0 A A0 P'$%A 0&.

1. +enurut ibu menga(a anak ibu men!erita 2T + i5i kurang i5i buruk....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

#A$%KA& III.M'M)'+IKA$ K $ '#I$%........................................................................................................................................................................................................................................................................................................................................

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*atatan Kun5ungan "

anggal#ahir

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anggalKun5ungan

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