PIPK SK SEMAMBU, 25350 KUANTAN, PAHANG. Lampiran

RPI/PIPK/1

TEMUDUGA IBUBAPA

No.Rujukan :……………….............

Tarikh :……………………….

A. MAKLUMAT PERIBADI MURID

Nama : .....................................................................................

No. Sijil Lahir : ................................................... No. My Kid/KP : ...................................................

Tarikh Lahir : ................................................... Umur : ..................................................

Jantina : ................................................... Keturunan : ...................................................

Agama : ...................................................

Bil. adik-beradik : ............................................... Bil. Dlm. keluarga : ...................................................

No.Pendaftaran JKM : ................................................... Kategori : ...................................................

Alamat : ..............................................................................................................................................

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No Telefon : .........................................

B. MAKLUMAT IBU/BAPA/PENJAGA

Bapa : ...........................................................................................................

Nama : ...........................................................................................................

Nombor K/P : ...........................................................................................................

Pekerjaan : ............................................................................................................

Alamat Majikan : ............................................................................................................

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No. Telefon Pejabat : ...............................................

No. HP : ................................................

Ibu : ...........................................................................................................

Nama : ...........................................................................................................

Nombor K/P : ...........................................................................................................

Pekerjaan : ............................................................................................................

Alamat Majikan : ............................................................................................................

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No. Telefon Pejabat : ...............................................

No. HP : ................................................

Penjaga : ...........................................................................................................

Nama : ...........................................................................................................

Nombor K/P : ...........................................................................................................

Pekerjaan : ............................................................................................................

Alamat Majikan : ............................................................................................................

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No. Telefon Pejabat : ...............................................

No. HP : ................................................

C. PERSEKITARAN KEDIAMAN :

Tinggal dengan siapa : ............................................................................................................

Siapa mengasuh : .............................................................................................................

Bil. Ahli Keluarga : .............................................................................................................

Kawasan Penempatan : .............................................................................................................

D. SEJARAH PERUBATAN

Sebelum Lahir : ...........................................................................................................

: ............................................................................................................

: .............................................................................................................

Semasa Lahir : .............................................................................................................

: .............................................................................................................

: ..............................................................................................................

Selepas Lahir : ...............................................................................................................

: ...............................................................................................................

: ...............................................................................................................

Dianogsis Doktor/Pakar Perubatan : ...................................................................................................

Nama Doktor/Pakar : ...................................................................................................

Jenis Masalah Yang Dikenalpasti : ...................................................................................................

E. LAIN-LAIN MASALAH PERUBATAN

Pintar Cerdas

Celebralpalsy

Sindrom Down

ADHD

ADD

Autisme

Disleksia

Hyperaktif

Slowleaner

Lelah

Spastik

Penglihatan Rabun

Buta

Pendengaran Ringan

Sederhana

Teruk

Mental Ringan

Sederhana

Teruk

Sawan Kekerapan Dalam Sehari :

Jenis Rawatan/Ubat :

Lain-Lain Penyakit (Nyatakan) :

F. JENIS IMUNISASI YANG TELAH DITERIMA

Hepatitis A/B

Campak

Polio

Rubella

Lain-Lain (Nyatakan) :

G. EMOSI/TINGKAH LAKU

Jenis perlakuan luar biasa : Contoh goyang tangan : ..........................................

Ketakutan pada sesuatu : .......................................................................................

Benci pada sesuatu : ..............................................................................................

Minat pada sesuatu :

H. PERKEMBANGAN SOSIAL

Pernah mendapat didikan Taska/Tadika? Ya/Tidak

Boleh berinteraksi dengan orang lain? Ya/Tidak

Nyatakan Siapa : .....................................................................................................

Rumusan aktiviti yang dilakukan seharian

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Bahasa yang kerap digunakan di rumah?

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Mendengar Lagu

Membaca

Lain-Lain (Nyatakan) :