FORM KONSULTASI GIZI

NAMA :
TEMPAT TGL LAHIR :
PEKERJAAN :
MENIKAH/BELUM MENIKAH :
EMAIL :
INSTAGRAM :

TB/BB :
BB GOALS :

1. Frekuensi makan dalam sehari?

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2. Apa makanan yang paling disukai ?

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3. Makanan yang paling tidak disukai?

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4. Makanan atau minuman yang wajib dikonsumsi setiap hari?

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5. Cemilan yang paling sering dimakan?

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6. Urutkan priotitas yang mana paling disukai
____Kuah
____Bumbu
____Sambal
____Kerupuk
____Saos
____Mayonaise
____Gorengan

7. Makanan apa yang dimakan dalam 7 hari terakhir?

Makan pagi Makan Siang Makan Malam

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8. Aktivitas yang dilakukan sehari – hari ?

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9. Apakah pernah menjalankan diet dalam 2-3 bulan terakhir sebelum

mealplan?
Pola diet seperti apa yang pernah anda lakukan?
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10. Pernahkah anda berolahraga? Olahraga yang seperti apa yang dilakukan?
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11. Preferensi diet yang lebih diinginkan ? (DIISI OLEH DOKTER)

a. Paleo Diet
b. Vegan Diet
c. Intermmitent Fasting (Puasa Berjangka)
d. Hitung Kalori
e. Ketogenic diet