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NAME: ____________________________________________________ SCORE: _____________

DATE PERFORMED: __________________________________________

Materials:
 Activity Sheet
 Ball Pen
 Food Exchange List Manual

Task 1. Compute your own Desirable Body Weight (DBW) using the BMI-Derived Formula.
Task 2. Compute your Total Energy Requirement (TER) by Physical Activity Level (PAL) of 35.
Task 3. Caloric Distribution.
Carbohydrate (55%), Protein (15%), Fat (30%)
Task 4. State your Diet Prescription.

Day: ___________________________

Service Meal/Food(s) Household Plate Intake CHO CHON FAT Calories


Measures Waste (g) (g) (g) (kcal)
Breakfast

AM Snacks

Lunch

PM Snacks

Dinner

Bedtime
Snacks
Total

CAL % ADEQUACY:

CHO % ADEQUACY:

CHON% ADEQUACY:

FAT % ADEQUACY:

INTERPRETATION: ______________________________________________________________

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