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<table class="MsoNormalTable" border="1" cellspacing="0" cellpadding="0" width="938" style="border: none;"><tbody><tr>
 <td width="47" style="width:23.4pt;border:solid windowtext 1.0pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
 No.<o:p></o:p>
 </td>
 <td width="115" style="width:57.7pt;border:solid windowtext 1.0pt;border-left:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Kategori<o:p></o:p>
 </td>
 <td width="218" style="width:108.8pt;border:solid windowtext 1.0pt;border-left:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Skala<o:p></o:p>
 </td>
 <td width="106" style="width:53.2pt;border:solid windowtext 1.0pt;border-left:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Skor<o:p></o:p>
 </td>
 <td width="92" style="width:45.8pt;border:solid windowtext 1.0pt;border-left:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Tgl :<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 <td width="90" style="width:45.0pt;border:solid windowtext 1.0pt;border-left:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Tgl :<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 <td width="90" style="width:45.0pt;border:solid windowtext 1.0pt;border-left:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Tgl :<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 <td width="90" style="width:45.0pt;border:solid windowtext 1.0pt;border-left:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Tgl :<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 <td width="90" style="width:45.0pt;border:solid windowtext 1.0pt;border-left:
 none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Tgl :<o:p></o:p>
 Jam :<o:p></o:p>
 </td>
 </tr>
 <tr>
 <td width="47" valign="top" style="width:23.4pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 1<o:p></o:p>
 </td>
 <td width="115" style="width:57.7pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
 Tidak
 ada nyeri<o:p></o:p>
 </td>
 <td width="218" style="width:108.8pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
 -<o:p></o:p>
 </td>
 <td width="106" style="width:53.2pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
 0<o:p></o:p>
 </td>
 <td width="92" style="width:45.8pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 </tr>
 <tr>
 <td width="47" valign="top" style="width:23.4pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
  
  
 2<o:p></o:p>
 </td>
 <td width="115" style="width:57.7pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
 Nyeri
 ringan<o:p></o:p>
 </td>
 <td width="218" style="width:108.8pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
 masih dapat
 ditahan dapat berkomunikasi dengan baik sedikit mengganggu aktivitas
 sehari-hari<o:p></o:p>
 </td>
 <td width="106" style="width:53.2pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
  
  
 1-3<o:p></o:p>
 </td>
 <td width="92" style="width:45.8pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 </tr>
 <tr>
 <td width="47" valign="top" style="width:23.4pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
  
  
 3<o:p></o:p>
 </td>
 <td width="115" style="width:57.7pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
  
 Nyeri
 sedang<o:p></o:p>
 </td>
 <td width="218" style="width:108.8pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
 wajah tampak
 meringis gangguan nyata terhadap aktivitas sehari-hari<o:p></o:p>
 </td>
 <td width="106" style="width:53.2pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
  
 4-6<o:p></o:p>
 </td>
 <td width="92" style="width:45.8pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 </tr>
 <tr>
 <td width="47" valign="top" style="width:23.4pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
  
  
 4<o:p></o:p>
 </td>
 <td width="115" style="width:57.7pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
  
 Nyeri
 Berat<o:p></o:p>
 </td>
 <td width="218" style="width:108.8pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
 pasien tidak
 dapat berkomunikasi tidak dapat melakukan aktivitas sehari-hari<o:p></o:p>
 </td>
 <td width="106" style="width:53.2pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
  
 7-10<o:p></o:p>
 </td>
 <td width="92" style="width:45.8pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" style="width:45.0pt;border-top:none;border-left:none;border-bottom:
 solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;mso-border-top-alt:
 solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 </tr>
 <tr>
 <td width="486" colspan="4" valign="top" style="width:243.1pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Total<o:p></o:p>
 </td>
 <td width="92" valign="top" style="width:45.8pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 </tr>
 <tr>
 <td width="486" colspan="4" valign="top" style="width:243.1pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt">
 Nama dan paraf
 yang melakukan penilaian<o:p></o:p>
 </td>
 <td width="92" valign="top" style="width:45.8pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 <td width="90" valign="top" style="width:45.0pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-top-alt:solid windowtext .5pt;mso-border-left-alt:solid windowtext .5pt;
 mso-border-alt:solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt">
  
 </td>
 </tr>
</tbody><tbody></tbody><tbody></tbody><tbody></tbody></table>

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