I.

DATA KELUARGA D

Jumlah Anggota Anggota keluarga Anggota Keluarga

No kk Enumerator Nama KK anggota keluarga usia usia 6 - 14 th usia 12 - 59 bln
keluarga ≥ 15 tahun
L P L P L
1 Bangsu 4 2 2 0 0 0
2 Iwan susanto 4 1 1 2 0 0
3 Ahyon 5 1 2 1 1 0
4 Acep 6 3 1 0 2 0
5 Hendri Jauhari 4 3 1 0 0 0
6 Isomah 4 1 2 1 0 0
7 Sukron 3 1 1 1 0 0
8 Suwono 5 1 2 1 1 0
9 Izharudin 5 1 2 2 0 0
10 Sali Sutomo 6 1 1 4 0 0
11 Edi Riyanto 4 2 1 1 0 0
12 Mariana 3 1 2 0 0 0
13 Zulfikri 4 1 1 1 2 0
14 Yedi Susanto 4 1 1 1 1 0
15 Supardi 3 1 2 0 0 0
16 Rokikan 1 1 0 0 0
17 Tomo 5 2 2 0 1 0
18 M.reno 3 1 1 0 0 1
19 Lisdaini 4 1 2 1 0 0
20 Suparno 5 2 1 1 1 0
21 Legimun 5 1 2 0 1 1
22 Gimun 2 1 1 0 0 0
23 Warsilo 3 2 1 0 0 0
24 Munajat 4 1 1 0 2 0
25 Samsudin 4 2 1 0 1 0
26 Bahima 2 1 1 0 0 0
27 Asep Hendrawan 5 3 1 1 0 0
28 Acmad Junaidi 5- 2 0 1 0
29 Iwan Susanto 4 1 1 0 0 1
30 Se Imbrun 5 1 3 0 0 1
31 Risnan 4 2 1 1 0 0
32 Ade Efendi 4 1 1 1 0 0
33 Didi 2 1 1 0 0 0
34 Kosmeri H 5 2 2 0 0 0
35 Jonizar 5 3 1 1 0 0
36 Darul Kalam 5 1 1 0 1 0
37 Adnan R 3 1 2 0 0 0
38 Eko Suroso 4 1 1 0 1 0
39 Slamet trioyono 3 2 2 0 0 0
40 Sutowo 4 2 0 0 0 0
41 Mawan supardi 4 3 0 0 0 0
42 Rukana 1 0 1 0 0 0
43 Sudiman 4 2 2 0 0 0
44 Wasis Riyanto 5 4 3 1 0 0
Novian 3 1 2 0 0 0
Wasiyan 3 1 1 0 1 0
Surat Kardi 3 2 1 0 0 0
Emir Tapilus 3 1 1 1 0 0
Jidi Mateosa 4 1 1 1 1 0
Darusi Saleh 4 2 2 0 0 0
Jonral Sarjuni 4 1 2 1 0 0
Asep Sunarya 2 1 1 0 0 0
Nova Mario 3 1 1 0 0 1
Seprizal 3 2 1 0 0 0
Aswani 3 1 2 0 0 0
Hendra 4 1 1 0 0 1
Andi Lala 5 1 1 2 1 0
Hasanudin 5 1 4 0 0 0
Muhamad Reno 3 1 1 0 0 1

83 83 27 19 7
Total 226
166 46 7
. DATA KELUARGA DAN ANGGOTA KELUARGA
Anggota Keluarga Kepemilikan Tersedia Ak yang pernah
usia 12 - 59 bln bayi usia 0-11 Sumber Jamban Jenis
Akte Sarana air didiagnosa
bln air keluarga jamban
kelahiran bersih gangguan jiwa
P L P
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 1 0 0
0 0 0 1 1 0 0 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
 0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 2 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 2 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 2 1 1 0
0 0 0 1 1 1 1 0
0 1 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0
0 0 0 1 1 1 1 0

0 1 0
0
7 1

Nb:
Jika Ya : 1
Tidak : 0
 III. DATA GOL. DARAH IV. UPAYA PELAYANAN KES
Golongan Darah K
Obat
AK yang di Tidak
gangguan
pasung A B AB O Mengetahui Gravida Partus
jiwa
goldar
0 0 0 1 0 1 2 0 0
0 0 1 0 0 1 2 0 0
0 0 2 3 0 0 0 0 0
0 0 1 0 0 5 0 0 0
0 0 2 0 2 0 0 0 0
0 0 0 4 0 0 0 0 0
0 0 1 0 2 1 0 0 0
0 0 0 2 0 1 2 0 0
0 0 0 0 0 4 1 0 0
0 0 0 1 0 1 4 0 0
0 0 0 3 1 0 0 0 0
0 0 0 3 0 0 0 0 0
0 0 0 1 0 2 1 0 0
0 0 0 1 0 2 1 0 0
0 0 0 1 0 0 2 0 0
0 0 0 0 0 0 1 0 0
0 0 2 0 2 0 1 0 0
0 0 0 0 0 0 3 0 0
0 1 2 1 0 0 1 0 0
0 0 1 0 0 0 4 0 0
0 1 1 0 1 0 3 0 0
0 1 0 0 1 0 1 0 0
0 0 0 0 0 0 3 0 0
0 0 0 0 0 0 4 0 0
0 0 2 0 0 0 2 0 0
0 0 0 0 0 0 2 0 0
0 0 0 1 0 0 4 0 0
0 0 1 0 0 0 4 0 0
0 0 3 0 0 0 1 0 0
0 0 3 1 0 0 1 0 0
0 0 0 0 0 0 4 0 0
0 0 0 0 0 0 4 0 0
0 0 0 0 0 0 2 0 0
0 0 5 0 0 0 0 0 0
0 0 3 0 0 2 0 0 0
0 0 0 1 0 0 4 0 0
0 0 0 0 0 3 0 0 0
0 0 0 0 1 1 2 0 0
0 0 0 0 1 0 2 0 0
0 0 0 0 0 4 0 0 0
0 0 2 0 0 0 2 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 4 0 0
0 0 0 1 0 1 4 0 0
0 0 0 0 3 0 0 0 0
0 0 1 0 0 2 0 0 0
0 0 0 0 0 0 3 0 0
0 0 1 0 1 0 1 0 0
0 0 0 1 0 3 0 0 0
0 0 0 0 0 4 0 0 0
0 0 1 0 0 0 3 0 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 1 1 0 0
0 0 1 0 0 0 2 0 0
0 0 0 0 1 1 1 0 0
0 0 1 0 0 0 3 0 0
0 0 0 0 0 0 5 0 0
0 0 0 0 0 5 0 0 0
0 0 1 0 0 2 0 0 0

40 26 16 48 98
A PELAYANAN KESEHATAN
Kehamilan Persalinan dan Nifas
Usia
Penolong
Abotus Kehamilan Pem. Kehamilan HB Komplikasi
Persalinan
™
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0

NB :
Diisi Jika Ada ibu yang
Jika Nakes = 1
memiliki bayi 0-6bulan
jika Dukun = 0
 Ketersediaan Ketersediaan
Komposisi Makanan
sayur tiap hari buah tiap hari

3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
4 1 1
2 0 0
4 1 1
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 0
3 1 1
3 1 0
2 1 0
2 1 0
1 1 0
 3 1 0
4 1 1
3 1 0
3 1 0
3 1 0
3 1 0
4 1 1
3 1 0
1 1 0
3 1 0
3 1 0
4 1 1
3 1 0
4 1 0
4 1 0
4 1 1
3 1 0
4 1 0
1 1 0
4 1 1
3 1 0

NB : NB :
Jika nasi +sayur= 1 Jika Ya = 1
Jika nasi +lauk= 2 jika Tidak = 0
Jika nasi +sayur+lauk= 3
Jika nasi +sayur+lauk+buah= 4
No. KK Kepemilikan JKN Kebiasaan merokok BAB Jamban Air Bersih
Merokok
1
2
3
4
5
6
7
8
9

NB :
DIISI JIKA YA : 1
JIKA TIDAK : 0
JIKA tidak mungkin (N) : 2
 Gangguan Hasil TD
TB Paru Hipertensi
Jiwa Ayah Ibu Anak

DIISI JIKA HIPERTENSI SISTOLIK

A:1
DAN DISTOLIK
K:0
in (N) : 2
 Melahirkan di
KB ASI Ekslusif Imunisasi
FASKES

DIISI JIKA YA : 1 NB : ISI JIKA ADA BAYI NB : ISI JIKA

JIKA TIDAK : 0 BERUSIA 0-6 BULAN ADA BAYI
BERUSIA 0-11
BULAN
NB :
JIKA YA :1
JIKA TIDAK : 0
 pemantauan pertumbuhan Nilai IKS

NB : ISI JIKA ADA BALITA

BERUSIA 12-59 BULAN

:
A :1
AK : 0
 PENILAIAN STATUS GIZI BALITA

NO Nama Umur JK BB TB/PB Status Gizi

1 Belli 4L 22 93 Normal
2 dimas n 3L 11 83 Normal
 PENILAIAN STATUS GIZI DEWASA

NO Nama Umur JK BB TB LILA Status Gizi

1 Bangsu 44 L 70 173 - Normal
2 Lailan kususma 40 P 52 169 - Normal
3 Fhebri 22 P 58 153 - Overweight
4 Findra 16 L 60 175 - Normal
5 Iwan Susanto 31 L 58 162 - Normal
6 Andriani Kusta 28 P 52 155 - Normal
7 Liben gilang 9L 30 110 - Normal
8 Ahyon 49 L 73 168 - Normal
9 Susi winarni 42 P 57 150 - Normal
10 Wike youlanda 19 P 48 153 - Normal
11 Rahmad Fadillah 14 L 45 160 - Underweight
12 Melani Putri 9P 30 113 - Normal
13 Acep 55 L 63 169 - Normal
14 Yuni Herlina 45 P 58 152 - Normal
15 Ade Candra 25 L 61 170 - Normal
16 Andre 20 L 52 166 - Underweight
17 Intan 18 P 36 145 - Underweight
18 Safa 15 P 39 148 - Underweight
19 Hendri Jahuari 45 L 60 156 - Normal
20 sumiati 42 P 60 160 - Normal
21 Randi julmansyah 19 L 55 162 - Normal
22 Reko berliansyah 16 L 55 160 - Normal
23 Isomah 66 L 60 160 - Normal
24 Yurma 51 P 50 155 - Normal
25 Andrean 16 L 40 160 - Underweight
26 Irwindo 14 L 45 160 - Underweight
27 Sukron 47 L 60 160 - Normal
28 Elianti 43 P 67 157 - Overweight
29 Andika 12 L 40 130 - Normal
30 Suwono 43 L 60 160 - Normal
31 Siti 40 P 55 152 - Normal
32 Alfiah 16 P 45 130 - Overweight
33 Bimo 9L 30 135 - Underweight
34 Kayla 5L 20 120 - Underweight
35 Izharudin 42 L 76 165 - Overweight
36 Sali Sutomo 40 L 55 160 - Normal
37 Edi Riyanto 44 L 70 175 - Normal
38 Mariana 55 P 56 156 - Overweight
39 Zulfikri 38 L 60 165 - Obesitas
40 Yedi Susanto 38 L 68 173 - Obesitas
41 Supardi 58 L 58 158 - overweight
42 Pini 49 p 52 148 - overweight
43 Reana oktavia 16 p 44 150 - normal
44 Rokikan 63 p 55 150 - normal
45 Tomo 46 L 63 169 - normal
46 Martha tri 43 p 60 155 - normal
47 Eka ade 20 P 45 153 - normal
48 Satria aprilia 15 L 50 158 - normal
49 Rahayu triartoma 7P 30 102 - normal
50 M.reno 20 L 55 165 - normal
51 Mulyani dewi 21 P 50 145 - normal
52 Fadilla dama 2L 18 53 - normal
53 Lisdaini 48 p 67 155 - overweight
54 Ruli setia wiratama 28 L 70 171 - normal
55 Helisa mulia pertiwi 24 P 55 167 - normal
56 Eggo taruna putra 14 L 48 161 - underweight
57 Suparno 40 L 50 162 - normal
58 Iis kartini 37 P 47 152 - normal
59 Urip ramdani 18 L 50 170 - underweight
60 Ahmad redho 11 L 22 105 - normal
61 Irensa rindu 5P 16 85 - normal
62 Legimun 48 L 64 173 - normal
63 sunarti 38 P 56 153 - normal
64 kinanti g 20 P 39 158 - underweight
65 meliana siti 14 P 45 154 - normal
66 Gimun 45 L 69 171 - normal
67 Nyani 43 P 50 155 - normal
68 Warsilo 47 L 59 167 - normal
69 Murtina 38 P 80 160 - overweight
70 Bagas 17 L 65 167 - normal
71 Munajat 40 L 60 165 - normal
72 Sudarsih 32 P 60 150 - overweight
73 Mela 14 P 45 145 - overweight
74 Selfia 8p 12 115 - underweight
75 samsudin 43 L 60 165 - normal
76 mutina 42 P 50 155 - normal
77 ahmad redho 19 L 60 160 - normal
78 dinda 11 P 40 130 - normal
79 bahima 68 P 65 150 - overweight
80 julhaji 28 L 50 160 - underweight
81 Asep Hendrawan 50 L 65 170 - Normal
82 Nurhayati 40 P 58 155 - Normal
83 Aji A 22 L 58 163 - Normal
 84 Egi 16 L 43 168 - Normal
85 Dipa 7L 25 121 - Normal
86 Acmad Junaidi 59 L 65 170 - Normal
87 Fatmawati 43 L 54 150 - overweight
88 Siti Aisyah 24 L 50 153 - Normal
89 Nurcahyanti 21 L 47 152 - Normal
90 Anisa Sapitri 11 P 25 110 - Normal
91 Iwan Susanto 31 L 60 168 - Normal
92 Andriyani 28 P 50 154 - Normal
93 Liben Gilang 9L 26 123 - Normal
94 Belli Galang H 4L 13 90 - Normal
95 Se imburun 46 L 70 166 - overweight
96 Susilawati 46 P 59 155 - overweight
97 Eko MS 20 L 60 168 - Normal
98 Dea Silfanti 18 P 42 154 - Normal
99 Risnan 37 L 51 162 - Normal
100 Sulastri 36 P 65 154 - overweight
101 Yuni Hardiyanto 19 L 40 152 - Underweght
102 Vitha Azhari 9L 24 105 - Normal
103 Ade Efendi 48 L 62 168 - Normal
104 Yuli K 39 P 73 165 - overweight
105 Musfidatul. R 15 P 40 150 - Normal
106 Ahmad. Z 10 L 22 125 - Normal
107 Didi 83 L 50 142 - Normal
108 Sahriah 68 P 40 110 - Normal
109 Kosmeri H 53 L 61 162 - Normal
110 Azni Eva 41 P 60 160 - Normal
111 Anggi J 24 L 70 165 - overweight
112 Wahyu H 18 L 55 163 - Normal
113 Selfi Hadi 15 P 51 160 - Normal
114 Jonizar 51 L 52 170 - Underweght
115 Ervi M 43 P 56 155 - Normal
116 Jeny M 26 L 70 165 - overweight
117 Jery A 17 L 45 165 - Underweght
118 Jovi A 12 L 28 140 - Underweght
119 Darul Kalam 45 L 80 170 - overweight
120 Ira Wati 37 P 54 149 - Normal
121 Jihan Afifah 14 P 33 146 - Underweght
122 Zakiah 10 P 26 120 - Normal
123 M. Mahdi 7L 24 110 - Normal
124 Adnan R 60 L 50 163 - Normal
125 Ana Bani 50 p 60 155 - Normal
126 Desi Martini 31 P 63 153 - overweight
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
 1. Komponen Rumah
No. Langit -langit Dinding Lantai Jendela Kamar jendela ruang Ventilasi
KK Tidur keluarga
1 2 2 2 1 1 2
2 2 2 2 1 1 1
3 2 2 2 1 1 2
4 2 2 2 1 1 2
5 2 1 2 1 1 2
6 2 2 2 1 1 2
7 2 2 2 1 1 2
8 2 2 1 1 2 2
9 2 2 2 1 1 2
10 2 1 2 1 1 1
11 2 2 2 2 1 1
12 2 2 2 1 2 1
13 2 2 2 1 1 2
14 2 2 2 2 2 2
15 2 1 2 1 1 1
16 2 2 2 1 1 2
17 2 1 2 1 1 1
18 2 2 2 2 1 2
19 2 2 2 1 1 2
20 2 2 2 1 1 2
21 2 2 2 1 1 2
22 1 0 1 0 1 1
23 2 2 2 1 1 1
24 1 1 2 1 1 1
25 2 2 2 1 1 2
26 2 0 1 1 1 1
27 1 1 2 1 1 2
28 2 2 2 1 1 2
29 2 1 2 1 1 2
30 2 2 2 1 1 2
31 2 1 2 1 1 1
32 2 2 2 2 1 1
33 2 2 2 1 1 1
34 2 2 2 1 1 2
35 2 2 2 1 1 2
36 2 2 2 1 1 2
37 2 2 2 1 1 2
 31 2. Sarana Sanitasi 25
Lubang asap Pencahayaan Skor Subtotal Sarana air Jamban SPAL Tempat skor
dapur bersih sampah
2 2 14 434 4 4 3 3 14
1 2 12 372 3 4 3 3 13
2 2 14 434 4 4 3 3 14
2 2 14 434 4 4 3 3 14
1 2 12 372 3 4 4 3 14
2 1 13 403 3 4 3 3 13
2 2 14 434 3 4 4 3 14
2 2 14 434 3 4 3 3 13
2 2 14 434 4 4 4 3 15
2 1 11 341 4 4 3 2 13
2 2 14 434 4 4 4 2 14
2 2 14 434 4 4 4 3 15
2 2 14 434 4 4 4 3 15
2 2 16 496 4 4 3 3 14
1 2 11 341 3 4 3 1 11
2 2 14 434 4 4 3 2 13
2 2 12 372 3 3 3 1 10
2 2 15 465 4 4 3 2 13
2 2 14 434 4 4 2 1 11
1 2 13 403 4 4 3 3 14
2 2 14 434 4 4 3 3 14
1 1 6 186 4 4 0 2 10
2 2 13 403 2 4 3 3 12
1 2 10 310 3 4 2 3 12
2 1 13 403 3 4 3 2 12
1 2 9 279 3 4 2 2 11
2 2 12 372 4 0 0 1 5
2 2 14 434 4 4 2 1
2 2 13 403 4 3 2 2
2 2 14 434 4 4 2 1
1 2 11 341 4 4 2 3
2 2 14 434 4 2 3 3
1 2 12 372 4 4 3 4
2 2 14 434 3 4 2 3
2 2 14 434 4 4 2 2
1 2 13 372 4 4 2 3
2 2 14 372 4 4 4 4
 3. Perilaku
Subtotal Membuka jendela kamar Membuka jendela Membersihkan ruang
tidur ruang keluarga dan halaman
350 2 2 2
325 2 2 2
350 2 2 2
350 2 1 2
350 2 2 2
325 2 2 2
350 2 2 2
325 2 2 2
375 2 2 2
325 2 2 2
350 2 2 2
375 2 2 2
375 2 2 2
350 2 2 2
275 2 2 2
325 2 2 2
250 2 2 2
325 2 2 2
275 2 2 2
350 2 2 2
350 1 1 2
250 1 1 2
300 2 2 2
300 2 2 2
300 2 2 2
275 1 2 2
125
275
275
275
325
300
375
300
300
325
375
rilaku 44
membuang tinja bayi dan membuang sampah Skor Subtotal TOTAL KATEGORI
balita ke jamban pada tempatnya
0 2 8 352 1136
0 2 8 352 1049
0 2 8 352 1136
0 2 7 308 1092
0 2 8 352 1074
0 2 8 352 1080
0 2 8 352 1136
0 2 8 352 1111
0 2 8 352 1161
0 2 8 352 1018
0 2 8 352 1136
0 2 8 352 1161
0 2 8 352 1161
0 2 8 352 1198
0 2 8 352 968
0 2 8 352 1111
2 2 10 440 1062
0 2 8 352 1142
0 1 7 308 1017
2 2 10 440 1193
2 2 8 352 1136
2 2 8 352 788
0 2 8 352 1055
0 2 8 352 962
0 2 8 352 1055
0 2 7 308 862
jika Rumah Sehat = 1
jika Rumah Tidak Sehat = 0
 Lansia
No
Umur Penyakit diderita KMS Pemeriksaan Kesehatan
1 62
2
3
4
5
6
7
8
9

Nb: NB : NB :
Jika Hipertensi :1 Jika Ada = 1 Jika Puskesmas = 1
Jika Asam Urat : 2 jika Tidak Ada = 0 jika Dokter = 2
Jika dll : 3 Jika Posyandu = 3
Jika tidak ada: 0 Jika tidak ada = 0
 Keg. Lansia

NB :
Jika Pengajian = 1
jika Arisan = 2
Jika Olahraga = 3
jika Wirausaha = 4
jika tidak ada = 0