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RUMAH SAKIT DAERAH KALISAT

JL. MH. Thamrin No.31 Telp.(0331) 591038 Fax.593997


Kalisat Jember 68193
Formulir Pengkajian Gizi
(Harap diisi dengan lengkap)
Nama Pasien
Nomer RM

:.
:

DOMAIN
A1. FH
FH-1.1.1.1

DATA

FH-1.2.2.2

Types of food

FH-1.4.2.4

Food additives

FH-1.5.1.1

Total fat

FH-1.5.2.1

Total protein

FH-1.5.3.1

Total carbohydrate

FH-1.6.2.7

Sodium intake

FH-3.1.1

Prescription, medication use

FH-7.3.3
A2. AD
AD-1.1.1
A3.BD
BD-1.10.1

Physical activity frequency

BD-1.10.2
A4.PD
PD-1.1.1

Hematocrit

PD-1.1.3

Cardivascular-pulmonary

PD-1.1.6

Head and eyes

PD-1.1.9

Vital signs

A5.CH
CH-1.1.1

Age

CH-1.1.2

Gender

CH-2.1.2

Cardiovascular

CH-2.1.4

Extcretory

CH-3.1.6

Occupation

B.DIAGNOSIS

Total energy intake

Height
Hemoglobin

Overall apperance

RM.

IDENTIFIKASI PROBLEM

FORM ASUHAN GIZI B


C.INTERVENSI

C2. PRESKRIPSI DIET

C3.IMPLEMENTASI

JADWAL PEMBERIAN MENU MAKANAN SESUAI KEBUTUHAN


WAKTU

MENU MAKANAN

1.

2.

3.
4.

FORM ASUHAN GIZI C


D.MONEV
DOMAIN
FH-1.6.2

DATA
Mineral ( natrimu

FH-1.1.1.1

Total energy intake

FH-1.5.1.1

Total fat

FH-1.5.2.1

Total protein

FH-1.5.3.1

Total carbohydrate

EVALUASI TARGET

Kalisat,_______________________

(______________________)