Berat Badan : .........................kg Tinggi Badan : ........................cm Makan Pagi Makan Siang Makan Malam
Indeks Massa Tubuh (IMT) : ......................................................kg/m Nasi Nasi Nasi
DIET
Status Gizi : ................................................................... Telur Bumbu Balado Pepes ikan jamur Ayam Panggang
Energi : ...............................kkal Lemak : ........................................ gram Tumis Buncis Kering tempe Bumbu Rujak
GARAM RENDAH
Protein: ..............................gram Karbohidrat : ........................................ gram Pisang Sayur bening bayam Oseng Tahu Cabe Hijau
labu kuning Cah Sayuran
Apel Jeruk
PEMBAGIAN MAKAN SEHARI
Makan dan minumlah sesuai kebutuhan
Makan Pagi jam 06.00 - 08.00 Selingan Selingan
Nama Makanan Berat (gram) URT*
untuk mengontrol tekanan darah dan
Puding buah Kue Lapis Beras
..................... ..................... .....................
keseimbangan cairan tubuh
Lauk Hewani : ..................... ..................... .....................
..................... ..................... ..................... CATATAN KONSELOR
Sayuran : ..................... ..................... .....................
Buah : ..................... ..................... .....................
Minyak** : ..................... ..................... .....................
Selingan pagi jam 10.00 :
...........................................................................................................
Makan Siang jam 12.00 - 13.00
Nama Makanan Berat (gram) URT*
..................... ..................... .....................
Lauk Hewani : ..................... ..................... .....................
..................... ..................... .....................
Sayuran : ..................... ..................... .....................
Buah : ..................... ..................... .....................
Minyak** : ..................... ..................... .....................
dan tauco
PRINSIP DIET