PEMERINTAH KABUPATEN KUTAI KARTANEGARA

UPT PUSKESMAS MUARA JAWA

Jl.Ir.Soekarno Kel.Muara Jawa Ulu Telp.(0541) 691389 Kode Pos 75261

HASIL KEGIATAN KONSELING PADA PENDERITA PENYAKIT MENULAR TB PARU

Tanggal Kunjungan :
1. Nama : ...........................................................................................................................
2. Alamat : ...........................................................................................................................
3. Pekerjaan : ...........................................................................................................................
4. Jumlah Anggota Keluarga : ...........................................................................................................................
5. Luas Rumah : ...........................................................................................................................
6.Jumlah Kamar : ...........................................................................................................................
7. Menu makan sehari-hari : ...........................................................................................................................
8. Ada yang batuk/Tidak : ...........................................................................................................................
9. Ada yang merokok : ...........................................................................................................................
10. Riwayat Penyakit Batuk : ...........................................................................................................................
11. Lama Pengobatan : ...........................................................................................................................