Ward/ Bed No.

:_______________________________ PEDIATRICS

Name:____________________________ Age: __________ Sex: M F Birthdate: ________________

Address: __________________________ Religion: ______________________

ANTHROPOMETRIC ASSESSMENT: Diagnosis:

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Actual BW: _________ %Std. BW (WFA): __________ _______________________________________
Actual BL: __________ %Std. BL (HFA): ___________ _______________________________________
MAC: ___________ BMI-for- Age: ____________ _______________________________________
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DIET Rx ___________ CHO __________ g CHON _________ g FAT _______ g

Food Likes:
 Sweet  Salty Fatty Others ________________________________________
Food Dislikes: ___________________________________________
Food Allergy: ___________________________________________  None
Bowel Habits: ____________________________  No change
Problems with dry mouth?
 Yes  No
Problems chewing or swallowing food items?
 Yes  No

Medications:  Yes Freq/Amt ___________________________

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Laboratory Results: Nutrition- Related Problems:
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__________________________________________ Do you suffer from any of the following GIT problems?
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 Excessive Belching  Indigestion
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________________________________________  Nausea/Vomiting
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Others:
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Louise Angelica Nuyda Guab ____________________________________________________
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 DIET Rx ___________ CHO __________ g CHON _________ g FAT _______ g

Computation BMI Computation DBW:

TER COMPUTATION

Food Group Ex CHO (g) PRO (g) FAT (g) KCAL

Vegetables
Fruit
Milk (Whole)
Milk (Low Fat)
Milk (Very Low Fat)
Sugar
Rice
Meat (Lean Meat)
Meat (Medium Fat)
Meat (High Fat)
Fat
TOTAL

Louise Angelica Nuyda Guab

 AM Midnight Total
Food Group Breakfast Snack Lunch PM Snack Dinner Snack
Vegetables
Fruit
Milk (Whole)
Milk (Low Fat)
Milk (Very Low Fat)
Sugar
Rice
Meat (Lean Meat)
Meat (Medium Fat)
Meat (High Fat)
Fat

Food Exchanges No. of Exchanges Sample Menu Approximate Size per

Serving
Breakfast

Mid A.M. Snack

Lunch

Louise Angelica Nuyda Guab

 Mid P.M. Snack

Supper

Bed-time snack

Dietary Recommendations:
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Louise Angelica Nuyda Guab

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 Plans for Diet Instructions:
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Plans for Monitoring and Evaluation:
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Louise Angelica Nuyda Guab
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 FOOD INTAKE RECORD
COOKING NO. OF Energy
FOOD ITEMS HHM METHOD EXCHANGES C (g) P (g) F (g) (KCAL) Na* K*
Breakfast

AM Snack

Lunch

PM Snack

Supper

Bedtime Snack

TOTAL
*if applicable

Louise Angelica Nuyda Guab

 FOOD RECALL FORM
CODE:
DATE:
MEAL FOOD ITEMS HHM CALORIES

TOTAL INTAKE:
TER:
DIET Rx

Louise Angelica Nuyda Guab