Lampiran 4.
Universal Pain Assessment Tool
Tingkat Nyeri Dismenorea
Silahkan gunakan salah satu dari skala di bawah ini untuk menunjukkan rata-rata tingkat nyeri yang Anda alami.
Jawaban : a. 0 - 1 : Tidak nyeri tidak sakit
b. 1 – 3 : Nyeri ringan dapat diabaikan
c. 3 – 5 : Nyeri sedang mengganggu tugas
d. 5 – 7 : Nyeri sedang mengganggu konsentrasi
e. 7 – 9 : Nyeri berat mengganggu aktivitas
f. 9 -10 : Nyeri tak tertahankan perlu istirahat ditempat tidur
Lampiran 5. Formulir
Food Recall
24 Jam FORMULIR
FOOD RECALL
24 JAM
Hari Tanggal : Hari ke-
:
Waktu Nama Masakan
Bahan Makanan Banyaknya
Jenis URT
gr Pagi Jam
SiangJam
Malam Jam
Lampiran 6. Formulir
Food Frequency
FORMULIR
FOOD FREQUENCY
Nama :
Hari Tanggal : Nama Bahan
Makanan Frekuensi Konsumsi
Keterangan Tidak Pernah 1-3xhari 4-6xmgg 1-3xmgg 1xbulan
1. Makanan Pokok
a. Nasi
2. Lauk Hewani
a. Telur
b. Daging Ayam
c. Daging Sapi
d. Ikan
e. Udang
f. Kerang
g. Kepiting
h. Tiram
i. Hati
3. Lauk Nabati
a. Tempe
b. Tahu
c. Kacang tanah
d. Kacang merah
e. Kacang hijau
4. Sayuran
a. Bayam b. Kangkung
c. Buncis d. Daun Ubi
e. Tauge f. Sawi
5. Lain-lain
a. Susu
Lampiran 7. Output Data
No Nama
Umur th
Tingkat Nyeri
Status gizi
Asupan B6
akg E
akg Ca
akg Zn
akg 1
Tasya Nabila
13 4
0,22 1
1.2 83.333
2.3 15
15.333 71.6
1200 5.9667
11.2 16
70 2
Cut Alya 13
2 1,92
0.8 1.2
66.667 3.4
15 22.667
954 1200
79.5 6.1
16 38.125
3 Diva
Marisa 13
3 0,82
0.7 1.2
58.333 8.4
15 56
553.5 1200
46.125 5.9
16 36.875
4 Anggi
Pratiwi 14
2 -1,43
0.6 1.2
50 3.2
15 21.333
89.6 1200
7.4667 6.3
16 39.375
5 Khairisa
F 13
3 0,22
0.8 1.2
66.667 4.3
15 28.667 514.9
1200 42.908
5.6 16
35 6
Kesya Aurelya
12 2
-0,49 0.9
1.2 75
5.8 15
38.667 911.6 1200
75.967 10.7
14 76.429
7 Devi
Dayanti 13
2 -1,61
0.6 1.2
50 1.8
15 12
419.4 1200
34.95 4.7
16 29.375
8 Khansa
14 3
1,53 0.3
1.2 25
1.2 15
8 43.5
1200 3.625
2.4 16
15 9
Rania Andira
13 2
-1,83 0.5
1.2 41.667
0.7 15
4.6667 476.4 1200
39.7 2.9
16 18.125
10 Widya
Yustika 13
2 0,13
0.5 1.2
41.667 2.4
15 16
97.9 1200
8.1583 3.1
16 19.375
11 Wan
Annisa 13
3 -0,62
0.7 1.2
58.333 5.1
15 34
391.3 1200
32.608 4.2
16 26.25
12 Sisi
Tazmi 13
4 2,66
0.4 1.2
33.333 5.4
15 36
343.5 1200
28.625 2.9
16 18.125
13 Amira
Salsabila 14
2 2,01
0.4 1.2
33.333 2
15 13.333 143.9
1200 11.992
2.7 16
16.875 14
Elsa Laura
14 2
-1,64 0.5
1.2 41.667
3.7 15
24.667 534.6 1200
44.55 5.3
16 33.125
15 Dalva
Dalton 14
5 1,80
0.7 1.2
58.333 3.4
15 22.667
85.5 1200
7.125 7.2
16 45
16 Adzra
Shafwa 13
4 0,07
0.9 1.2
75 1.4
15 9.3333 103.4
1200 8.6167
4.9 16
30.625 17
Meuthia A
13 2
-0,50 0.8
1.2 66.667
6 15
40 109.4
1200 9.1167
4.4 16
27.5 18
Shana Asyila
13 2
-0,77 1
1.2 83.333
5.7 15
38 1235.
1 1200
102.93 10.4
16 65
19 Dwita
Oktavani 13
3 0,04
0.5 1.2
41.667 9.4
15 62.667 353.2
1200 29.433
4.5 16
28.125 20
Nafisah Syahda
12 2
0,95 0.9
1.2 75
4 15
26.667 1031.
7 1200
85.975 8
14 57.143
21 Sabrina
Mutiara 13
3 2.13
0.6 1.2
50 5.8
15 38.667
52.5 1200
4.375 6
16 37.5
22 Alfdira
Husna 12
2 2,18
1.1 1.2
91.667 4.2
15 28
570.2 1200
47.517 7.4
14 52.857
23 Nadya
Putri 13
4 0,29
0.8 1.2
66.667 4.3
15 28.667
951 1200
79.25 6.5
16 40.625
24 Nadira
Azzahra 14
3 1,40
0.5 1.2
41.667 2.6
15 17.333 124.6
1200 10.383
3.6 16
22.5 25
Sarah 11
2 1,18
0.8 1.2
66.667 5.6
15 37.333 581.7
1200 48.475
5.8 14
41.429
Sartika 26
Nabila Risqi
12 2
1,25 0.9
1.2 75
4.1 15
27.333 965
1200 80.417
8.2 14
58.571 27
Cut Balqis
14 5
0,42 0.8
1.2 66.667
5.9 15
39.333 105.7 1200
8.8083 4.5
16 28.125
28 Nabila
Febrina 12
3 0,28
1.2 1.2
100 3.2
15 21.333
2064 1200
172 12.7
14 90.714
29 S.
Reinnata 13
2 -0,47
1.2 1.2
100 3
15 20
1435 1200
119.58 10.9
16 68.125
30 Zahra
Afifah 12
4 1,49
0.4 1.2
33.333 2.2
15 14.667
55.6 1200
4.6333 3.5
14 25
31 Siti Alya
Putri 11
4 2,30
0.5 1.2
41.667 1.7
15 11.333
87 1200
7.25 4.5
14 32.143
32 Farah
Naurah 13
5 -1,06
0.5 1.2
41.667 2.5
15 16.667 500.8
1200 41.733
4.8 16
30 33
Khalisa Nabila
12 2
-0,03 0.8
1.2 66.667
3.2 15
21.333 585.2 1200
48.767 5.9
14 42.143
34 Aisha C
13 4
1,12 1.6
1.2 133.33
2.8 15
18.667 2905.
5 1200
242.13 17
16 106.25
35 Natasya
Patricia 14
3 2,59
0.3 1.2
25 1.4
15 9.3333 326.9
1200 27.242
4.1 16
25.625 36
Annisya Azzahra
12 2
0,59 1.1
1.2 91.667
7.5 15
50 860.8
1200 71.733
9.2 14
65.714 37
Fidelia 13
3 -0,30
0.2 1.2
16.667 2.9
15 19.333
17.7 1200
1.475 2.1
16 13.125
38 Lailan
noor 12
5 1,27
1.3 1.2
108.33 5.3
15 35.333 380.5
1200 31.708
8.1 14
57.857 39
Nabila Fisya
12 2
-0,14 0.9
1.2 75
1.7 15
11.333 157.5 1200
13.125 5.9
14 42.143
40 Balqis
Salsabila 12
4 1,95
0.7 1.2
58.333 4.7
15 31.333 152.3
1200 12.692
9.2 14
65.714 41
Nadya Adlin
12 2
1,07 0.8
1.2 66.667
1.1 15
7.3333 68
1200 5.6667
2.8 14
20 42
Akifah Najla
12 3
2,67 0.9
1.2 75
4.1 15
27.333 162.9 1200
13.575 5.5
14 39.286
43 Nadya
Fithrie 12
3 0,06
1.4 1.2
116.67 3.2
15 21.333 415.3
1200 34.608
9.7 14
69.286 44
Syakirah 12
4 -0,39
1.5 1.2
125 9.9
15 66
765.9 1200
63.825 15.6
14 111.43
Data Kategorik
No Nama
Umur th
Tingkat Nyeri
Status gizi
Jumlah Asupan Vit. B6
Vit. E Kalsium
Zink 1
Tasya Nabila
13 3
1 2
1 1
2 2
Cut Alya 13
2 4
1 1
2 1
3 Diva Marisa
13 3
1 1
1 1
1 4
Anggi Pratiwi
14 2
1 1
1 1
1 5
Khairisa F 13
3 1
1 1
1 1
6 Kesya
Aurelya 12
2 1
1 1
1 1
7 Devi
Dayanti 13
2 1
1 1
1 1
8 Khansa
14 3
4 1
1 1
1 9
Rania Andira
13 2
1 1
1 1
1 10
Widya Yustika
13 2
1 1
1 1
1 11 Wan Annisa
13 3
1 1
1 1
1 12 Sisi Tazmi
13 3
5 1
1 1
1 13
Amira Salsabila
14 2
5 1
1 1
1 14 Elsa Laura
14 2
1 1
1 1
1 15
Dalva Dalton
14 4
4 1
1 1
1 16
Adzra Shafwa
13 3
1 1
1 1
1 17 Meuthia A
13 2
1 1
1 1
1 18
Shana Asyila
13 2
1 2
1 2
1 19
Dwita Oktavani
13 3
1 1
1 1
1 20
Nafisah Syahda
12 2
1 1
1 2
1 21
Sabrina Mutiara
13 3
5 1
1 1
1 22
Alfdira Husna
12 2
5 2
1 1
1 23 Nadya Putri
13 3
1 1
1 2
1
24 Nadira
Azzahra 14
3 4
1 1
1 1
25 Sarah
Sartika 11
2 4
1 1
1 1
26 Nabila
Risqi 12
2 4
1 1
2 1
27 Cut Balqis 14
4 1
1 1
1 1
28 Nabila
Febrina 12
3 1
2 1
2 2
29 S. Reinnata 13
2 1
2 1
2 1
30 Zahra
Afifah 12
3 4
1 1
1 1
31 Siti Alya
Putri 11
3 5
1 1
1 1
32 Farah
Naurah 13
4 1
1 1
1 1
33 Khalisa
Nabila 12
2 1
1 1
1 1
34 Aisha C 13
3 4
2 1
2 2
35 Natasya
Patricia 14
3 5
1 1
1 1
36 Annisya
Azzahra 12
2 1
2 1
1 1
37 Fidelia 13
3 1
1 1
1 1
38 Lailan noor 12
4 4
2 1
1 1
39 Nabila
Fisya 12
2 1
1 1
1 1
40 Balqis
Salsabila 12
3 4
1 1
1 1
41 Namira
Yasmine 12
2 4
1 1
1 1
42 Akifah
Najla 12
3 5
1 1
1 1
43 Nadya
Fithrie 12
3 1
2 1
1 1
44 Syakirah 12
3 1
2 1
1 2
Analisis Univariat 1.
Usia Usia
Frequency Percent Valid Percent Cumulative
Percent Valid 11
2 4.5
4.5 4.5
12 15
34.1 34.1
38.6 13
19 43.2
43.2 81.8
14 8
18.2 18.2
100.0 Total
44 100.0
100.0
2. Tingkat Nyeri
Tingkat Nyeri
Frequency Percent Valid Percent Cumulative
Percent Valid nyeri ringan
19 43.2
43.2 43.2
nyeri sedang 21
47.7 47.7
90.9 nyeri berat
4 9.1
9.1 100.0
Total 44
100.0 100.0
3. Status Gizi
Status Gizi
Frequency Percent Valid Percent Cumulative
Percent Valid normal
26 59.1
59.1 59.1
risiko gemuk 11
25.0 25.0
84.1 gemuk
7 15.9
15.9 100.0
Total 44
100.0 100.0
4. Vitamin B6
Vitamin B6
Frequency Percent Valid Percent Cumulative
Percent Valid kurang
34 77.3
77.3 77.3
cukup 10
22.7 22.7
100.0 Total
44 100.0
100.0
5. Vitamin E
Vitamin E
Frequency Percent Valid Percent Cumulative
Percent Valid kurang
44 100.0
100.0 100.0
6. Kalsium
Kalsium
Frequency Percent Valid Percent Cumulative
Percent Valid kurang
36 81.8
81.8 81.8
cukup 8
18.2 18.2
100.0 Total
44 100.0
100.0
7. Zink
Zink
Frequency Percent Valid Percent Cumulative
Percent Valid kurang
40 90.9
90.9 90.9
cukup 4
9.1 9.1
100.0 Total
44 100.0
100.0
Tabulasi Silang 1.
Kejadian Dismenorea Tingkat Nyeri Berdasarkan Konsumsi Vitamin dan Mineral
