NAME:________________________________________ DATE:_________________

BATCH NO:_____________
DIET PRESCRIPTION: KCAL ____ CHO ______ PRO _____ FAT _____

TABLE 3.1
MEAL DISTRIBUTION AND SAMPLE MENU
FOOD ITEMS BREAKFAST LUNCH DINNER
VEGETABLE
FRUIT
MILK
RICE
MEAT/FISH
EGG
SUGAR
FAT
AM SNACK PM SNACK MIDNIGHT SNACK
BREAD/NODDLE/SUBS.
MEAT
FAT
FRUIT
SUGAR
TABLE 3.2

SAMPLE MENU PLAN AND MENU FOR ONE DAY

BREAKFAST

FOOD NO. OF APPROXIMATE SAMPLE MENU CHO PRO FAT CAL

EXCHANGE SERVING SIZE/SERVING

FRUIT

MEAT/
MEAT
SUBSTITUTE

RICE/
BREAD

FAT

MILK

SUGAR

TOTAL
MID-AM SNACK

FOOD NO. OF
APPROXIMATE SAMPLE MENU CHO PRO FAT CAL
EXCHANGE SERVING SIZE/SERVING

BREAD OR
SUBSTITUTE
MEAT

FRUIT
FAT
TOTAL

LUNCH
FOOD NO. OF APPROXIMATE SAMPLE MENU CHO PRO FAT CAL
EXCHANGE SERVING SIZE/SERVING

SOUP

MEAT/
MEAT
SUBSTITUTE

VEGETABLE

RICE

FRUIT

FAT
*
SUGAR

TOTAL

MID-PM SNACK
FOOD NO. OF
APPROXIMATE SAMPLE MENU CHO PRO FAT CAL
EXCHANGE SERVING SIZE/SERVING

BREAD OR
SUBSTITUTE
MEAT

FRUIT
FAT
TOTAL
DINNER
FOOD NO. OF APPROXIMATE SAMPLE MENU CHO PRO FAT CAL
EXCHANGE SERVING SIZE/SERVING

SOUP

MEAT/
MEAT
SUBSTITUTE

VEGETABLE

RICE

FRUIT

FAT
*
SUGAR

TOTAL

BED TIME SNACK

FOOD NO. OF
APPROXIMATE SAMPLE MENU CHO PRO FAT CAL
EXCHANGE SERVING SIZE/SERVING

BREAD OR
SUBSTITUTE
MEAT

FRUIT
FAT
TOTAL

TOTAL DIET PRESCRIPTION BASED ON ACTUAL MEAL DISTRIBUTION AND SAMPLE MENU

KCAL ________ CHO________ PRO ______ FAT _______