RM.

RI/PJ-9

RSUD REDA BOLO

Jl. Weelonda, Desa Watukawula, PERMINTAAN KONSELING GIZI
Kec. Kota Tambolaka
Kab. Sumba Barat Daya No. Rekam Medis :...............................................................................
Nama Lengkap :...............................................................................
Tanggal Lahir :...............................................................................
Jenis Kelamin :...............................................................................
Ruangan :...............................................................................

Yth. Dietisien / Ahli Gizi Dokter Penanggung Jawab :

Tanggal : .......................................

Jam : ..................... WITA

Mohon dilakukan :  Analisis Asupan Makanan  Konseling Gizi

Berat Badan ........................................ Kg

Tinggi Badan ........................................ Cm

Hasil Pemeriksaan Laboratorium / Pemeriksaan Klinik Penting :
................................................................................................................................................................................................
................................................................................................................................................................................................

Diagnosis Medis :
Pengobatan Penting :

Diet yang dianjurkan :

PENDAPAT DIETISEN / AHLI GIZI

Pengkajian Gizi :
a. Antropometri : BB :......................... LLA :....................... Perubahan BB : ................. Kg
TB :......................... IMT :.......................
b. Biokimia :
c. Fisik / Klinik :
d. Riwayat Gizi :
e. Riwayat Personal :

Diagnosis Gizi :

Intervensi Gizi :
a. Tujuan :

b. Intervensi :

c. Konseling Gizi / :
Edukasi
Rencana Monitoring dan Evaluasi Gizi :

Wee Londa, …..................... Jam : ...........

WITA

Dietisien / Ahli Gizi,

(....................................................)