Format Kuesioner Pengkajian Keperawatan Keluarga

 

D. GK_FDR AYI\MK@I_ XI@CADJMD@ AIXI_DSDRD@ AIEYD_CD Gdsmemtds ]d`ais

@k. _icmstir

 @dfd Xirdwdt yd`c Fi`cadjm

Rd`ccde Xi`cadjmd`

4.

BDRD AI AIEYD_CD

 @dfd Aipded Aieudrcd

Odndsd \indrmndrm

Dedfdt _ufdn & Riep

Jdrda ]d`ais Rirbiadt

Dcdfd & \uau

Dedt Rrd`spkrtdsm

Bdtd D`ccktd Aieudrcd

Nuo  @k

@dfd

bc` AA

Yfur

JA JA \uau Xi`bmbmad` Rirdanmr

Xiairjdd` \ddt M`m

\tdtus Cmzm

RRW (RB,

(RO, OO, OFM)

 @, \, X)

\tdtus

Dedt

Mfu`msdsm Bdsdr

Od`tu/ Xrktisd

Ed`jutd`

 @k

@dfd

Xi`dfpmed` Yfuf

\tdtus Aisindtd` \ddt M`m

_mwdydt Xi`ydamt/ Deircm

?.

BDRD BDRD XI@CAD XI@CADJMD JMD@ @ M@BMWM M@BMWMBY BY ]D@C ]D@C \DAMR \DAMR (tir (tiredf edfpmr pmr))

f?/Krd`c :

Fiedauad` datmvmtds gmsma sitmdp ndrm: ]d/ Rmbda* Rm bda* .............................................. .................................................... ......

]d/Rmbda*.................................................  .......................................................................  

2.

AIFDF AIFDFXYD XYD@ @ AIEYD_C AIEYD_CD D FIEDAYA FIEDAYAD@ D@ RYCD\ RYCD\ XIFI XIFIEMN EMND_D D_DD@ D@ AI\INDRD@ D@CCKRD AIEYD_CD

 

4) Dbdadn pirndtmd` aieudrcd aipdbd d`ccktd`yd yd`c fi`birmtd sdamt:  Dbd



 Rmbda, adri`d................................................ adri`d.............................................................................. .......................................................... ...................................... ..........



?) Dpdadn aieudrcd fi`citdnum fdsdedn aisindtd` yd`c bmdedfm d`ccktd bdedf aieudrcd`yd:  ]d



 Rmbda



) Dpdadn aieudrcd fiedauad` updyd pi`m`cadtd` pi`m`cadtd` aisindtd` yd`c bmdedfm bmdedfm d`cck d`ccktd td aieudrcd`y aieudrcd`ydd sildrd datmg:  ]d



 Rmbda, jiedsad` ....................................................... ................................................................................... .......................................................... ................................ ..



=) Dpdadn aieudrcd fi`citdnum aioutund` pi`ckodtd` fdsdedn aisindtd` yd`c bmdedfm yd`c bmdedfm d`ccktd aieudrcd`yd : 



 ]d  Rmbda, jiedsad`................................................. jiedsad`............................................................................. .......................................................... ...................................... ........ 48) Dpdadn aieudrcd bdpdt fiedauad` ldrd firdwdt d`ccktd aieudrcd bi`cd` fdsdedn aisindtd` yd`c bmdedfm`yd:  ]d

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 Rmbda, jiedsad` ....................................................... ................................................................................... .......................................................... ................................ ..



44) Dpd Dpdadn adn aieudr aieudrcd cd bdpdt bdpdt fiedau fiedauad` ad` pi`lic pi`licdnd dnd` ` fdsded fdsdedn n aisind aisindtd` td` yd`c yd`c bmdedf bmdedfmm d`c d`cckt cktdd aieudrcd`yd:  ]d

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 Rmbda, jiedsad`................................................. jiedsad`............................................................................. .......................................................... ....................................... .........



4?) Dpdadn aieudrcd fdfpu fifiemndrd dtdu fifkbmgmadsm em`cau`cd` yd`c fi`buau`c aisindtd` d`ccktd aieudrcd yd`c fi`cdedfm fdsdedn aisindtd` :  ]d

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 Rmbda, jiedsad` ..................................................... ................................................................................... .......................................................... ................................ ....

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4