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FORMULIR VCT
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FORMULIR VCT
formulir vctDeskripsi lengkap...
Author:
Munandar Alif
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RAHASIA
FORMULIR VCT Nomor Registrasi Alam Alamat at
: .... ...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... Kota Kota/K /Kab ab :... :..... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ....
Seksualitas Seksualitas::
: 1. Laki-laki Laki-laki 2. Perempuan Perempuan Umur : ........ ........tahun tahun
Status Status Perka" Perka"ina inann
: 1. #enika #enikahh 2. !iak !iak #enika #enikahh $. Pernah Pernah #enika #enikahh %umlah %umlah anak anak kanun kanung: g: ..... ........ ..... ..... ...... ...... ..... ....o ..oran rangg
Satu Satuts ts Keha Kehami mila lann
: 1. !rime rimest ster er & 2. &&
Umur Umur anak anak terke erke*i *ill
: ... ........ ...... ....... .......... ......tahun ahun// bul bulan an
Kelo Kelomp mpok ok Risi Risiko ko
: 1. PS+ PS+ ,1. ,1. Lang Langsu sung ng 2. !iak iak lang langsu sung ng Lama Laman naa .... ...... .... ... .ln ln/! /!hn hn 2. 0aria
$. &&& &&& '. !iak iak (ami (amill
Peniikan Peniikan !erakhir:... erakhir:....... ........ ........ ........ ........ ........ ........ ........ ......
). !ia !iakk tahu tahu
$. Penasun+ Lamana : ..........ln/!hn '.a . Pelanggan PS 3. Pasien !
4. Pasangan Pasangan Risti 5. Lainna........... Lainna.................,boleh ......,boleh iisi lebih ari satu Peke Peker6 r6aa aann
: 1. !iak iak eke eker6 r6aa
!anggal Konseling Pre !es (&7 Status Pasien Alasan !esting (&7
#engetahui Aana !es 9ari Pernah tes (&7 sebelumna
Keseiaan untuk !est Ka6ian !ingkat Risiko (ubungan seks =aginal berisiko Anal seks berisiko ergantian peralatan suntik !ran
2. eke eker6 r6a+ a+ %eni %eniss Peke Peker6 r6aa aann :... :..... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... 88 88 / 88 88 / 88 88 1. aru 2. Lama 1. &ngin tahu sa6a 2. #umpung gratis $. Untuk beker6a '. Aa ge6ala tertentu . Akan menikah 3. #erasa berisiko 4. Ru6ukan : .................... .................... 5. !es ulang ,"ino" perio ). Lainna 1. rosur 2. Koran $. !7 '. '. 9okter . . !eman 3. 3. Petugas utrea*h 4. Poster 5. La Konselor ). Lainna :.................. :.................. 1. ;a+ 9imana ......................... Kapan : .......................hr/ln/!hn (asil : 1. Negati< 2. Positi< $. !iak tahu 2. !iak 1. ;a 2. !iak 1. ;a+ Kapan ..................hr/ln/!hn 2. !iak 1. ;a+ Kapan ..................hr/ln/!hn 2. !iak 1. ;a+ Kapan ..................hr/ln/!hn 2. !iak 1. ;a+ Kapan ..................hr/ln/!hn 2. !iak 1. ;a+ Kapan ..................hr/ln/!hn 2. !iak ........................................................................................................................ ... 88 88/ 88 88/ 88 88 1. Rapi !es 2. >&A $. Kombinasi 1. Non Reakti< 2. Reakti< N am a R e a g e n : 1. Non Reakti< 2. Reakti< N am a R e a g e n : 1. Non Reakti< 2. Reakti< N am a R e a g e n : 1. Negati< 2. Positi< $. &neterminate 88 88/ 88 88/ 88 88 1. ;a 2. !iak 1. Ru6uk Ru6uk #K 2. Ru6uk Ru6uk ke RS $. Ru6uk Ru6uk Rehab Rehab '. Ru6uk Ru6uk ke LS# . 9atang 9atang kembali kembali karena masa 6enela 6enela 3. Ru6uk Ru6uk ke okter 1.
#obile 7?!
2. Klinik Utama
$. Klinik satelit
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