Formulir Six Minute Walk Test.docx

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FORMULIR SIX MINUTE WALK TEST PUSKESMAS GUMELAR

Tanggal Pemeriksaan : NO

NAMA

NOMOR

TENSI

NADI

MENIT

KETERANGAN

DADA

ISTIRAHAT

ISTIRAHAT

(mampu/tidak

(mmHg)

(x/menit)

mampu)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Petugas Pelaksana

(

)