CLASSICAL KETOGENIC DIET

DIETITIAN NOTE

Name Age
Date Gender
Nutrition Assessment
Current Weight Height/
Length
Ideal Body Weight
Energy Requirement /
RDA/ RNI
Protein Requirement /
RDA/ RNI
KD Ratio
KD Regime / KD Meal (Per day)
Energy:
Protein:
Fat:
CHO:
% Energy:
% MCT:

Comment/ Checklist/ Nutrition Diagnosis

Nutrition Intervention/ Plan / Calculation

Guidelines for Manual A: Calorie requirement
 Calculation B: Ratio &
Dietary Composition Ratio Dietary Composition
2:1 22
3:1 31
4:1 40

C: Dietary Unit Quantity Calorie Requirement ÷ Dietary Unit

Composition
D: Fat Allowance Ratio x Dietary Unit Quantity
E: Protein + CHO Ratio x Dietary Unit Quantity
Allowance
F: Protein Allowance Same as RDA/RNI
G: CHO Allowance E- protein allowance
Ratio

Regime/ Meal Plan (Per day)

Energy:
Protein:
Fat:
CHO:
% Energy:
% MCT:

Attended Dietitian

MCT- KETOGENIC DIET

DIETITIAN NOTE
 Name Age
Date Gender
Nutrition Assessment
Current Weight Height/
Length
Ideal Body Weight
Energy Requirement /
RDA/ RNI
Protein Requirement /
RDA/ RNI
% MCT
Current intake (Per day)
(meal + MCTs) Energy:
Protein:
Fat:
CHO:
% Energy:
% MCT:

Comment/ Checklist/ Nutrition Diagnosis

Nutrition Intervention/ Plan / Calculation

Calorie Prescription
% MCT gram or ml /d
% CHO gram or ml /d
% LCT gram or ml /d
% Protein gram or ml /d
 Meal plan (Per day)
Energy:
Protein:
Fat:
CHO:
% Energy:
% MCT:

Attended Dietitian