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Lampiran 1

46

DATA SKRINING
Tanggal pemeriksaan :
Nama :
No.kode pasien :
No. rekam medis :

Kriteria penerimaan :
a. Diagnosis klinis depresi
b. Bersedia disertakan dalam penelitian
Kriteria eksklusi :

Lampiran 2

47

FORMULIR PERSETUJUAN
INFORMED CONSENT
Saya yang bertanda tangan dibawah ini:
Nama

Usia

Jenis kelamin

Alamat lengkap

Hubungan dengan penderita

Setelah mendapat keterangan secukupnya dan mengerti manfaat

penelitiaan tersebut dibawah ini, yang berjudul :
EFEK SUPLEMENTASI FISH OIL TERHADAP STATUS GIZI, PROFIL LIPID
DAN TNF- PADA PASIEN DEPRESI
dengan menandatangai formulir ini, saya setuju ikut dalam penelitian ini secara
sukarela, dengan catatan bila sewaktu-waktu merasa dirugikan dalam bentuk
apapun, berhak membatalkan persetujuan ini.
Makassar,
Yang menyetujui,
(..................................)
Keluarga/ penderita

Mengetahui:

Saksi:

penanggung jawab penelitian :

(............................)

Lampiran 3

(......................)

48

PENGUKURAN ANTROPOMETRI

Hari/Tanggal Pengukuran

No. Responden :

Nama

Umur

Alamat

Pemeriksa :

No

JENIS PENGUKURAN

HASIL PENGUKURAN
KETERANGAN

ANTROPOMETRIK
1

Tinggi Badan

................ cm

Berat Badan

................ kg

IMT

............ kg/m2

BB Ideal

................kg

Catatan :

Lampiran 4
PEMERIKSAAN LABORATORIUM

49

Tanggal Pemeriksaan :

Nama

Tanggal Hasil

Umur

No. Responden

Alamat :

No

JENIS

Hasil

PEMERIKSAAN

Pemeriksaan

Nilai Rujukan

Kimia Darah
1

CHOL TOT

HDL

LDL

TRIGLISERIDA

TNF-

Lampiran 5
FORMULIR FOOD RECALL
Hari/Tanggal :
No. Responden

( .... )
Nama

Umur

50

Pencatat

Alamat :
JUMLAH

WAKTU/
MENU

JENIS MAKANAN

URT

GRAM

PAGI :

SELINGA
N:
SIANG:

SELINGA
N:
MALAM:

SELINGA
N:
Lampiran 6

No. Responden :

KUESIONER PENELITIAN
A. IDENTITAS RESPONDEN
NAMA

TEMPAT TGL LAHIR

UMUR

JENIS KELAMIN

KET

51

AGAMA

SUKU

ALAMAT

NO. TELP / HP

B. IDENTITAS KELUARGA
NAMA

UMUR

ALAMAT

NO. TELP / HP

C. KARAKTERISTIK RESPONDEN
PENDIDIKAN

PEKERJAAN

Tidak sekolah/SD/SMP/SMA/Akademi/PT

D. RIWAYAT KESEHATAN:
RIWAYAT PENYAKIT
-

HIPERTENSI
:
o DIKETAHUI SEJAK TAHUN/UMUR
o BEROBAT TERATUR

o JENIS OBAT YANG DIKONSUMSI

PENYAKIT JANTUNG

o DIKETAHUI SEJAK TAHUN/UMUR

o BEROBAT TERATUR

o JENIS OBAT YANG DIKONSUMSI

DIABETES MELLITUS

o DIKETAHUI SEJAK TAHUN/UMUR

o BEROBAT TERATUR

o JENIS OBAT YANG DIKONSUMSI

YA
TIDAK
: ....................... / ................
YA
TIDAK

: ...........................................
YA
TIDAK

: ....................... / ................
YA
TIDAK

: ...........................................
YA
TIDAK

: ....................... / ................
YA
TIDAK

ASAM URAT
:

o DIKETAHUI SEJAK TAHUN/UMUR

o BEROBAT TERATUR
:

o JENIS OBAT YANG DIKONSUMSI

PENYAKIT/GANGGUAN JIWA
o DIKETAHUI SEJAK TAHUN/UMUR
o BEROBAT TERATUR
:

: ...........................................
YA

TIDAK

: ....................... / ................
YA
TIDAK
: ...........................................
:
: ....................... / ................
YA
TIDAK

52

o JENIS OBAT YANG DIKONSUMSI

LAIN-LAIN
:

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

RIWAYAT LAIN
-

RIWAYAT MEROKOK

RIWAYAT MENGKONSUMSI
ALKOHOL

YA
TIDAK
Tahun ............... s/d ................
:

YA
TIDAK
Tahun ............... s/d ...............

E. STATUS KESEHATAN:
GANGGUAN KESEHATAN
-

sebutkan

F. RIWAYAT MAKAN:

YA
:

TIDAK

..................................
................................