A
B
C
D
KUISIONER PENGUMPULAN DATA DAN STATUS GIZI LANSIA 2014 KOTA MALANG JURUSAN GIZI KESEHATAN FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA MALANG JL. VETERAN MALANG – 614 T!"#. $0%41& 604'1 F(). $0%41& 64* JAWA TIMUR+INDONESIA
KRITERIA RESPONDEN + ,(- ,(-/ / ! ! (,( (,( + Y(/ 35(5(/(7( 35(5(/(7( (3("((3("(- 7!#8/3!/ !/37 !/37 $9"( :(:# /, 35(5(/(7(& 35(5(/(7(&;; 9"( ,3( :(:# 35(5(/(7( ,3( :( :!/<(3 7,!7( 7!#8/3!/
KODE KUISIONER Kode A = Puskesmas 1. P P! !:( :( D/ D/8= 8=8 8 2. P P! !:( :( K!/3 K!/3(" ("( (7 7 %. P P! !:( :( J(/, J(/, 4. P P! !:( :( M8<8 M8<8"( "(/ / . P P! !:( :( >#,8 >#,8: :"= "=8 8 6. P P! !:( :( M"= M"=87! 87!<8 <8 *. P P! !:( :( K!3 K!3/K /K(/ (/3(/ 3(/ ?. P P! !:( :( G7 G79 9 '. P P! !:( :( B(7! B(7!/ / 10. P!:( P!:( >(3! >(3!( ( 11. P!:( P!:( P(/3(/5(/ P(/3(/5(/ 12. P!:( P!:( A7<85/(/ A7<85/(// /
Kode B = Kode Kelurahan (,!7(/,/ !"7(-(/ =(/ 3(:9" 3:(/+:(/ #!:() Kode C = Kode Sasaran 1. B(= B(= $0+1 $0+11 1 9" 9"(/ (/&& 2. B(, B(,,( ,( $12 $12+2 +2% % 9"( 9"(/& /& %. B(" B(",( ,( $24 $24+ +' ' 9"( 9"(/& /& 4. U( S! S!8"( 8"(. R!:(<( P P,7 ,7 6. WUS *. I9 H(:" ?. I9 M!/= !/= '. L(/( Kode D = Kode Resonden
Nama en!am"#l da$a Nama P% Sasaran DATA DASAR 1.
N(:( A" R!#8/3!/
2.
T(/ T(/( ("" "(- "(-77 $33 $33+: +::+ :+== ==== ==&& @ ( ( "(/ "(/( ( (bisa ditanyakan ke orang yang tinggal bersama, jika responden lupa atau ditanyakan tahun lahirnya saja)
%. 4.
A"(:(, R!#8/3!/ J!/ !"(:/
.
T/ T/ (" !/3 !/37 @ 9!7 9!7(: (:( ( !"( !"(7 7(C (C
6.
J( , ,/(" 9! 9!7(:( (:( ! !"(7 (7(; (#( (<(C !9,(/ ...
,-/ 00 V7",(@P7(!/: $+' ,-& 01 U( "(/<, 3/@!/!!/ $60+64 ,-& 02 L(/( 9!78 ,/ :!/3!7,( 9!79(( #!/=(, $6 ,-& 00 "(+"( 01 #!7!:#(/ 00 !/3 !/37 7 01 9!7(:( !"(7(
I& PEN'U PEN'UKU KURA RAN N ANTROPO ANTROPOET ETRI RI P(! 8 6
A
Pen!ukuran I *.
BB $&
?.
T/ L,, $:&
'.
T/ 9(3(/ !,:( $:& (Laki-laki : 64,19 – (,!4 " #L ($m)) % (1,&' " (th)) (erempuan : &4,&& – (,4 " #L ($m)) % (!*! " (th))
B
C
Pen!ukuran II
D
Ra$a*ra$a
+et : ntuk pengukuran antropometri dilakukan pengukuran yang paling memungkinkan
II& IN+EKSI 10.
S!9!7(#( !7/ A/3( :!/("(: (, $3("(: 1 9"(/ ,!7(-7&
(.
F"
9.
S!( N((
.
D(7!
S!7/ $ 4) @9"(/& P!7/((,,) (,-)
J(7(/ $1 – %) @9"(/&
T3(
(,)
III& ./'IENE DAN SANITASI 11.
A#((- A/3( :!"((/ (. > ,(/(/ !9!": :((/ $menggunakan sabun& 9. > ,(/(/ !3(- BAB $menguunakan sabun& . F7!!/ :(/3 3("(: !-(7
3.
F7!!/ (, 3("(: !-(7
!.
P!:9!7-(/ 37 3("(: !:/ ,!7(-7 (obserasiditanya langsung, tergantung kondisi)
T3( $00& T3( $00&
Y( $01& Y( $01&
00 ,3( #!7/(01 1 (" 02 2 (" 0% 2 (" 00 ,3( #!7/(01 1 (" 02 2 (" 0% 2 (" M(,( K( K To$al J( ,8,(" /=(; 0, 1 #8/ $7(/& 01 2 #8/ $#& 02 % #8/ $9(&
+et : ntuk pilihan ja.aban /embersihan diri0 di $entang jika dilakukan, sedangkan total diisi jumlah yang dibersihkan
I0& POLA KONSUSI 12.
B!7(#( (" A/3( :((/ ,(:( $,(/#( /(& 3("(: !-(7C
1%.
S!9,(/
01 % (,( % 02 % (" 00 ,3( :!/<(5(9@,3( ,(- 00 M((/(/ #88 3(/ (=7 01 M((/(/ #88 "( -!5(/@/(9(, 02 M((/(/ #88 "( -!5(/ 3(/ /(9(, 0% M((/(/ #88 (=7 3(/ 9(P(! - 8 6
A
14.
A#((- A/3( :!/8/: #"!:!/C
B
C
D
04 M((/(/ #88; "( -!5(/@/(9(, 3(/ (=7 0 M((/(/ #88; "( -!5(/; /(9(,; (=7 3(/ 9(00 Y( 01 T3( (lanjut ke no* 16)
2aat .a.an$ara kata supplemen dapat diganti dengan /itamin, mineral, atau kata lain yang mudah dipahami oleh lansia, dengan kata lain tetap bertujuan untuk mendapatkan data terkait konsumsi suplemen
1.
J!/ #"!:!/ (#( =(/ 38/:C
3intalah esponden untuk menunjukkan kemasan suplemen yang dikonsumsi dan $atat kandungannya ($ontoh : pada suplemen multiitamin, it 5 *** mg, it ***mg) 16. A#((- A/3( ( :((/(/ =(/ 00 Y( (/C 01 T3( 1*. A#((- A/3( ( :/: 3(/ 00 Y( :((/(/ =(/ :(/C 01 T3( 1?. A#((- A/3( ( 87!/(/ $,3( 00 Y( ,!7:( "(&C 01 T3(
0& PEN/AKIT DE'ENERATI+ 1 KONDISI +ISIK 1'.
A#((- A/3( :!:#/=( 75(=(, !"(7( $(=(-@9@(!@/!/!& =(/ :!/("(: #!/=(, 3!!/!7(,C
01 Y( 02 T3( $lanjut ke nomer !1& 00 T3( T(- @ T3( M!/<(5(9
2aat .a.an$ara kata ‘penyakit degeneratif’ bisa diganti dengan penyakit menurun atau kata lain yang bermakna sama dengan penyakit degenerati7
20.
R5(=(, #!/=(, 3!!/!7(, (#( =(/ 33!7,(C (diba$akan pilihannya) 00 =( 01 ,3(
(. P!/=(, <(/,/ 9. K!// :(/ . A(: 7(, 3. H#!7,!/ !. S,78! 66. T3( 7!"!(/
21
A#((- (/3( ((, / :!:" #!/=(, 3!!/!7(,!C
22.
A#(
**. "(//=(; !9,(/ 01 Y( 02 T3( $lanjut ke nomer !'& 00 T3( T(- @ T3( M!/<(5(9 (. P!/=(, <(/,/ 9. K!// :(/ . A(: 7(, 3. H#!7,!/ !. S,78! 66. T3( 7!"!(/
2%.
24.
A#((- A/3( :!/("(: !",(/ 3("(: :!//=(- (,( :!/!"(/ !,(# (" :((/C A#((- =(/ :!/=!9(9(/ !",(/ ,!7!9, ,!7<(3C
**. "(//=(; !9,(/ 00 Y( 01 T3( (lanjut ke no* !8) 00 J:"(- =(/ 7(/ 01 T3( :!:#/=( 02 S(, @(, ,!/878(/ 66 T3( 7!"!(/ ** L(/+"(/; !9,(/
0I&
LI+E ST/LE P(! 2 8 6
A
2.
A#( !(,(/ =(/ 9(( A/3( "((/ !-(7+-(7 37:(- C (diba$akan pilihannya)
26.
A#((- A/3( 9!78"(-7((C
2*.
A#(
2?.
B!7(#( (" A/3( 9!78"(-7(( 3("(: 1 :/C
2'.
A#((- A/3( :!788 @ #!7/(:!788C B!7(#( 9(,(/ 788 =(/ A/3( -(9(/ 3("(: !-(7C
%0.
0II& %1. %2.
%%. %4.
%.
%*.
%?.
C
D
00 D(: 3 7:(01 M8:8/ 02 B!7!9/@ ! "(3(/@ 9!,!7/( ** L(/+"(/; !9,(/ ... 00 T3( $lanjut no* !9& 01 Y( 00 B!7!#!3( 01 L(7+"(7 02 J("(/ (/,( 0% S!/(: 66 T3( 7!"!(/ ** L(/+"(/; !9,(/... 00 % (" 01 % (" 66 T3( R!"!(/ 00 Y( 01 T3( (Lanjut ke no* '1) 00 % 9(,(/ 01 2+% 9(,(/ 02 1 9(,(/ 66 T3( R!"!(/
PEN'ETA.UAN 'I3I DAN KESE.ATAN
A#((- A/3( :!/!,(- ,!/,(/ 9(-(=( :!788C A#((- A/3( :!/!,(- ,!/,(/ 9(-(=( 3(7 !7/ :((/+:((/(/ 87!/(/C A#((- A/3( ,(- ,!/,(/ #!/=(, ,"(/ !78#8C M!/7, A/3(; 9((:(/((:((/(/ =(/ !-(, 3(/ 9!7C (diba$akan pilihannya)
00 T3( 01 Y( 00 T3( 01 Y(
P!//((/ (7(: =(/ 9(/=( #(3( :((/(/ 3(#(, :!/=!9(9(/ #!/=(, (#(C (diba$akan pilihannya)
01 O,!8#878 02 H#!7,!/ 0% G/<(" 00 T3( ,(- @ T3( :!/<(5(9 ** L(/+"(/; !9,(/... ...
00 T3( 01 Y( 00 T3( ,(- 01 M((/(/ (, 883 02 B(/=( :((/ "( 0% B(/=( :((/ 9(- 3(/ (=7 04 G !:9(/ ** L(/+"(/; !9,(/... ...
0III& %6.
B
A#((- A/3( #!7/(- :!:#!78"!#!/="-(/ !!-(,(/ C S!9,(/ (#( :(,!7 #!/="-(/ =(/ #!7/(- A/3( 3(#(,(/ 3("(: % 9"(/ ,!7(-7 C D(7 :(/( :9!7 /87:( ,!/,(/ #!/="-(/ !!-(,(/ =(/ ,!"(39!7(/C
AKSES IN+ORASI
00 T3( (Lanjut ke no* '&) 01 Y(
I4& PANTAN'AN AKAN TERKAIT BUDA/A %'. 40.
A#((- A/3( :!:#/=( :((/(/ #(/,(/(/C A#((- ("((/ #(/,(/(/ :((/(/ ,!7!9,C (diba$akan pilihannya)
00 Y( 01 T3( (Lanjut ke no* 41) 01 A"!7 02 K(7!/( (3( -9/(//=( 3!/(/ #!/=(, P(! 5 8 6
A
B
C
D
0% D7- !"(7( 04 K!9(((/@!#!7(=((/ !<( 3" 00 T3( ,(- @ T3( :!/<(5(9 66 T3( 7!"!(/ ** L(/+"(/; !9,(/...
4& KEAPUAN EN/IAPKAN AKANAN 41.
A#((- 3("(: !-(7+-(7 A/3( :!/=(#(/ :((/(/ !/37C
42.
S(#( =(/ :!/=(#(/ :((/(/ !-(7+-(7 A/3(C (diba$akan pilihannya)
00 Y( (lanjut ke no*4') 01 T3( 02 J(7(/ 00 A/( 01 M!/(/, 02 > 0% P!:9(/, 66 T3( 7!"!(/ ** L(/+"(/; !9,(/...
4I& PSIKOLO'I (Responden Lebih Baik Diajak Untuk Bercerita Dengan Pertanyaan Pancingan !U Bisa Dilihat sesuai dengan "kspresi Responden saat Di#a#ancarai $ 4%.
44.
4. 46.
4*. 4?.
A#((- A/3( !7/ :!7(( 98(/ 3!/(/ 7,/,( A/3( !-(7 + -(7C A#((- A/3( :!7(( 9!7!:(/(, !#(/<(/ 5(, 3("(: :!"((/ !(,(/ !-(7 + -(7C A#((- A/3( !7/ :!7(( #, ((C A#((- A/3( :!7(( 9!7:(("(- 3!/(/ 3(=( /(, A/3(C A#((- A/3( :!7(( 9(-(( 3!/(/ -3# A/3( ((, /C A#((- (/3( "!9- :!:"9!73(: 37 3 7:(- 3(7#(3( !"(7 7:(- 3(/ :!"((/ (,,( C
00 Y( 01 T3( 00 T3( 01 Y(
00 Y( 01 T3( 00 Y( 01 T3( 00 T3( 01 Y( 00 T3( 01 Y(
4II& PELA/ANAN KESE.ATAN 4'.
K!:(/((- A/3( 9!789(, !,( (,C (paling sering)
0.
B((:(/( (7( A/3( :!/< ! ,!:#(, A/3( 9!789(,C (paling sering)
1.
A#((- 3 ,!:#(, ,/(" A/3( (3( #8=(/3 "(/(C A#((- A/3( #!7/(- #!7 ! #8=(/3 "(/(C
2.
00 D8,!7 0% P8=(/3 01 P!:( 04 D/ 02 M(/,7 @ 93(/ ** L(/+"(/; !9,(/... 00 J("(/ ( 01 A/,(/ :: 02 N( !/3(7((/ #79(3 ** L(/ – "(/; !9,(/... 00 T3( (Lanjut ke 2ingle ood e$all !4& 01 Y( 00 T3( 01 Y( 66 T3( 7!"!(/
P(! 6 8 6
A
B
C
D
SIN'LE +OOD RECALL -5 .OURS 7ak$u akan
enu
Bahan akanan
%umlah Ukuran Rumah Tan!!a (URT)
'ram
P(! 8 8 6
A
B
C
D
P(! 9 8 6