Status Pasien K Sanitasi.docx

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PEMERINTAH DAERAH KABUPATEN/KOTA ....................... PUSKESMAS

: ______________________

KECAMATAN

: ______________________

KARTU STATUS KESEHATAN LINGKUNGAN No. Reg

:

Nama pasien/klien : _________________ Nama KK : _____________________ Umur

: ____________________ ( hari/bulan/tahun)

Jenis Kelamin

: Laki-laki/Perempuan *)

Pekerjaan

: ________________

Alamat

: ___________________________________________________ : Dusun ___________________ RT/RW ___________________ : Desa _________________________

Golongan

: Umum/Askes/ lain-lain : ____________________ Konseling

Tanggal

Inspeksi Kesehatan Lingkungan

Kondisi/masalah Saran/rekomendasi Tanggal

Hasil

Intervensi

Keterangan

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