8/18/2019 Form SGA Gizi

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SUBJECTIVE GLOBAL ASSESMENT

UNIT PELAYANAN GIZI

No RM :

Nama : /

th.

Kamar :

 Tana! ma"#$ : Tana! %a%an&ara : K#n'#nan $( :)*(t("(n : P(r"$r(+"*

)*(t :)*ano"*"/ +(n,a$*t :

Berat Badan (BB)

BB -*a"an,a : TB / PB : IMT :

BB ma"#$ RS : Stat#" G** m(n#r#t IMT :

K(h*!anan BB "(!ama -#!an :

BB -*a"a 0 BB a%a! ma"#$  BB B*a"a

1. T*2a$ a2a3. B(rtam-ah/ m(n#r#n 4 567. P(n#r#nan BB 5 8196. P(n#r#nan BB ; 1965. T*2a$ tah#

A

A

B

C

P(r#-ahan BB "(!ama 3m*n# t(ra$h*r

1. T*2a$ a2a3. T*2a$ a2a ta+* BB 2*-a%ah/ 2*ata"

norma!7. A2a $(na*$an ta+* BB -(!#m norma!. BB t#r#n

A

B

B

C

Asupan Makanan

P(r#-ahan 2a!am '#m!aha"#+an a$h*r8a$h*r *n*2*-an2*n$an 2(nan$(-*a"aan

1. A"#+an $#+ < t*2a$ a2a +(r#-ahan3. A"#+an m(n#r#n 2ar* "(-(!#m "a$*t

taha+ r*nan7. A"#+an r(n2ah ta+* a2a +(n*n$atan. A"#+an "anat t*2a$ $#+ < m(n#r#n

taha+ -(rat 2ar* "(-(!#mn,a

A

B

B

C

Lama 2an 2(ra'at+(r#-ahan a"#+anma$anan

1. 43 m*n# "(2*$*t/ tan+a +(r#-ahan3. ;3m*n# +(r#-ahan r*nan8 "(2an7. T*2a$ -*"a ma$an= +(r#-ahan 2ra"t*"

A

B

CGejala Gastrointestinal

1. Anor($"*a>r($#(n"* Laman,a

1. T*2a$3. Ya

1. T2$ +(rnah3. T*a+ har*7. 387?/m. 183?/m

1. ; 3 m*n#3. 4 3 m*n#

7. M#a! 1. T*2a$3. Ya 1. T2$ +(rnah3. T*a+ har*7. 387?/m. 183?/m

1. ; 3 m*n#3. 4 3 m*n#

. M#ntah 1. T*2a$3. Ya

1. T2$ +(rnah3. T*a+ har*7. 387?/m. 183?/m

1. ; 3 m*n#3. 4 3 m*n#

5. )*ar( 1. T*2a$3. Ya

1. T2$ +(rnah3. T*a+ har*7. 387?/m

. 183?/m

1. ; 3m*n#

3. 4 3m*n#

• J*$a a2a -(-(ra+a ('a!a ata# t*2a$ a2a ('a!a= "(-(ntar8 "(-antar A

8/18/2019 Form SGA Gizi

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• J*$a a2a -(-(ra+a ('a!a ; 3 m*n#

• J*$a ; 1/ "(m#a ('a!a "(t*a+ har*/ t(rat#r ; 3 m*n#

BC

Kapasitas Fungsional

)("$r*+"* $(a2aan @#n"*

t#-#h

1. A$t**ta" norma!= t*2a$ a2a $(!a*nan=

$($#atan / "tam*na t(ta+3. A$t**ta" r*nan= m(na!am* han,a

"(2*$*t +(n#r#nan taha+ r*nan 7. Tan+a a$t**ta"/ 2*t(m+at t*2#r=

+(n#r#nan/ "tam*na taha+ -#r#$

A

B

C

Penyakit Yang Berhubungan Dengan Kebutuhan Gizi

•S(&ara #m#m a2a an#an "tr("

m(ta-o!*$

•B*!a Ya/a2a= $at(or*n,a "tr(" m(ta-o!*$

1. T*2a$3. Ya/ a2a

a. R(n2ahD h(rn*a*n#*na!= *n@($"*=+(n,a$*t 'ant#n

$on("*@ -. S(2anD )M=

Pn(#mon*a &. T*n*D #!&(rat*(

&o!*t*" 2*ar(= $an$(r=+(r*ton*t*" -(rat

A

B

BC

Peeriksaan Fisik 

K(h*!anan !(ma$ "#-$#tan tr*"(+=-*"(+

1. T*2a$ a2a3. Sa!ah "at# t(m+at7. K(2#a t(m+at

A

B

C

K(h*!anan ma""a otot

t!. S(!an$a= "&a+#!a/ t! -(!*$at= t! r#"#$=-(t*"

1. T*2a$ a2a

3. B(-(ra+a t(m+at7. S(m#a t(m+at

A

BC

E2(mat(r2a+at 2* RM= *n@orma"* 2o$t(r/+(ra%at/ t(r!*hat/ t(ra-a

1. S(2*$*t/ t*2a$ a2a3. S(2an t#n$a* 7. B(rat ana"ar$a

A

B

C

A"&*t(" t(r2a+at 2* RM= *n@orma"* 2o$t(r/+(ra%at= t(r!*hat '(!a"

1. T*2a$ a2a3. S(2an7. B(rat

A

B

C

KESELURUFAN SKOR SGA

A. G** Ba*$/ Norma! S$or AH +a2a 596 $at(or* ata# a2a

+(n*n$atan "*n*$anB. G** K#ran/ S(2an S$or BH +a2a 596 $at(or* C. G** B#r#$ S$or CH +a2a 596 $at(or*= tan2a8tan2a "*$ "*n*$an

ENUMERATOR