Nama :

NIM :
Kelas :

FORMAT ASUPAN GIZI IBU MENYUSUI

I. Biodata Ibu

Nama :
Usia :
Agama :
Pekerjaan :
BB/TB :
Menyusui anak ke- :
Jumlah anak :

II. Asupan Gizi Ibu

Keluhan ibu :........................................................................................................

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

Makanan / minuman yang disukai :.....................................................................

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

Makanan / minuman yang tidak disukai :............................................................

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

Makanan / minuman yang dilarang :...................................................................

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III. Gizi Sehari Ibu

 Waktu Bahan Ukuran rumah BERAT
Nama Masakan
makan Makanan tangga (GR)
Pagi

Selingan
pagi

Siang

Selingan
sore

Malam
Total