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    This document is a form for early detection of child development in children. It collects identifying information about the child such as name, age, address and medical history. It assesses the child's growth including weight, height and head circumference. It evaluates the child's development in areas such as gross motor skills, fine motor skills, speech, socialization and independence. It screens for potential conditions like autism. It documents any counseling provided to parents or interventions recommended for the child's development. Referrals to other services are also noted if needed.

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    This document is a form for early detection of child development in children. It collects identifying information about the child such as name, age, address and medical history. It assesses the child's growth including weight, height and head circumference. It evaluates the child's development in areas such as gross motor skills, fine motor skills, speech, socialization and independence. It screens for potential conditions like autism. It documents any counseling provided to parents or interventions recommended for the child's development. Referrals to other services are also noted if needed.

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    © All Rights Reserved
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    75 views1 page

    Form Sdidtk

    Uploaded by

    caringin mhc
    This document is a form for early detection of child development in children. It collects identifying information about the child such as name, age, address and medical history. It assesses the child's growth including weight, height and head circumference. It evaluates the child's development in areas such as gross motor skills, fine motor skills, speech, socialization and independence. It screens for potential conditions like autism. It documents any counseling provided to parents or interventions recommended for the child's development. Referrals to other services are also noted if needed.

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    of 1

    FORMULIR DETEKSI DINI TUMBUH KEMBANG ANAK

    WƵƐŬĞƐŵĂƐ͙͙͙͙͙͙͙͙͗͘͘͘͘͘͘͘<ĞĐ͙͙͙͗͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘<ĂďͬŬŽƚĂ͙͙͙͙͙͗͘͘͘͘͘͘͘͘͘͘͘͘͘͘WƌŽǀ͙͙͙͗͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘
    /͘/Ed/d^E<
    ϭ͘EĂŵĂ  ͗͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘>ĂŬŝͲůĂŬŝͬWĞƌĞŵƉƵĂŶ͗͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘
    2. Nama Ayah : ............................................... Nama lbu: ......................................................
    ϯ͘ůĂŵĂƚ  ͗͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘
    ϰ͘dĂŶŐŐĂůWĞŵĞƌŝŬƐĂĂŶ ͗ͬͬ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϮϬ͘͘͘͘͘͘͘͘͘͘͘͘͘
    ϱ͘dĂŶŐŐĂů>ĂŚŝƌ  ͗ͬͬ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ϮϬ͘͘͘͘͘͘͘͘͘͘͘͘͘
    6. Umur Anak : ........bulan…….... hari .............

    //͘EDE^/^͗
    1. Keluhan Utama: ...........................................................................................................................
    2. Apakah anak punya masalah tumbuh kembang : .......................................................................

    /ůů͘WDZ/<^EZhd/E^^h/:t>
    ϭ͗͘ͺͺͺͺͺͺͺ<Ő͖Wͬd͗ͺͺͺͺͺŵͬ͘d͗Ă͘EŽƌŵĂůď͘<ƵƌƵƐĐ͘<ƵƌƵƐ^ĞŬĂůŝĚ͘'ĞŵƵŬ
    Sangat Kurus
    Ϯ͘WͬhĂƚĂƵdͬh͗Ă͘dŝŶŐŐŝď͘EŽƌŵĂůĐ͘WĞŶĚĞŬĚ͘^ĂŶŐĂƚWĞŶĚĞŬ
    ϯ͘><͗͘͘͘͘͘͘͘ŵ͘><ͬh͗Ă͘EŽƌŵĂůď͘DŝŬƌŽƐĞĨĂůĐ͘DĂŬƌŽƐĞĨĂů
    4. Perkembangan anak:
    1). Sesuai Jumlah jawaban Ya: Jumlah jawaban Tidak:
    2). Meragukan: Jumlah jawaban Ya: Jumlah jawaban Tidak:
    a. Gerak. Kasar c. Bicara bahasa
    b. Gerak. Halus d. Sosialisasi. Kemandirian
    ϯͿ. Penyimpangan: Jumlah jawaban Ya: Jumlah jawaban Tidak:
    a. Gerak. Kasar c. Bicara bahasa
    b. Gerak. Halus d. Sosialisasi. Kemandirian
    5. Daya Dengar:
    a. Normal b. Curiga ada gangguan
    6. Daya Lihat:
    a. Normal b. Curiga ada gangguan
    7. Perilaku dan Emosional:
    a. Normal b. Curiga ada gangguan

    /s͘WDZ/<^Ed^/E/<^ůͬ:/<<>h,E
    ϭ͘ƵƟƐŵĞĂ͘ZŝƐŝŬŽƟŶŐŐŝĂƵƟƐŵĞď͘ZŝƐŝŬŽĂƵƟƐŵĞĐ͘ŶŽƌŵĂů
    2. GPPH a. Kemungkinan GPPH b. normal

    s͘<^/DWh>E
    .............................................................................................................................................................
    .............................................................................................................................................................
    .............................................................................................................................................................
    s/͘d/E<E/EdZsE^/
    ϭ͘<ŽŶƐĞůŝŶŐƐƟŵƵůĂƐŝďĂŐŝŝďƵͬƉĞŶŐĂƐƵŚ͗Ă͘ŝďĞƌŝŬĂŶď͘dŝĚĂŬĚŝďĞƌŝŬĂŶ
    Ϯ͘/ŶƚĞƌǀĞŶƐŝƐƟŵƵůĂƐŝƉĞƌŬĞŵďĂŶŐĂŶ͗
    a. Gerak Kasar b. Gerak Halus c. Bicara dan Bahasa d. Sosialisasi dan Kemandirian
    e. Tanggal evaluasi intervensi: ........................................................................................................
    ϯ͘dŝŶĚĂŬĂŶƉĞŶŐŽďĂƚĂŶůĂŝŶ͗͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘
    ........................................................................................................................................................
    4. Dirujuk dengan surat rujukan ke: ....................................................................................................
    .........................................................................................................................................................
    Pemeriksa:

    87

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