PATIENT'S INFO AND ANTHROPOMETRIC DATA

DATE
ROOM NO. OPD
PATIENT'S NAME
AGE
GENDER
BIRTHDATE
HEIGHT (cm) 151 HEIGHT
WEIGHT (kg) 33.5
BODY MASS INDEX 14.69 WEIGHT
NUTRITIONAL STATUS
IDEAL BODY WEIGHT (kg) 46 IDEAL WEIGHT RANGE (kg)
DIAGNOSIS
ATTENDING PHYSICIAN

ENERGY AND MACRONUTRIENT RECOMMENDATION

PHYSICAL ACTIVITY
TER (IBW) 0
TER (ABW) 0

NPC METHOD
KCALORIES 1800 GRAMS
PROTEIN (g/kg ABW) 1 34
PROTEIN (g/kg IBW)
NPC TER 1664
CARBOHYDRATES 0.6 998.4 250
FAT 0.4 665.6 74

DISTRIBUTION METHOD
CALORIES GRAMS
CALORIES 1500
CARBOHYDRATES 0.5 750 188
PROTEIN 0.25 375 94
FATS 0.25 375 42
 DIET PRISCRIPTION
INCREASE INTAKE OF VEGETABLES & FRUITS; LOW SATURATED FAT
LOW SODIUM; LOW CHOLESTEROL DIET
DISTRIBUTION INTO EXCHANGES 188 94
FOOD GROUP EXCHANGES CHO (g) CHON (g)
VEG A 0 0 0
FEET INCH CM VEG B 6 18 6
151 FRUIT 6 60 -
KG POUNDS MILK WHOLE 0 0 0
33.5 LOW FAT 6 72 48
SKIMMED 0 0 0
55 SUGAR 0 0-
RICE 5 115 10
MEAT LOW FAT 9- 72
MEDIUM FAT - 0
HIGH FAT - 0
FAT 3- -
TOTAL 265 136
DEFICIENCY 78 42

CALORIES %DISTRIBUTION AMERICAN DIETETIC ASSOCIATION

136 8 DISTRIBUTION INTO EXCHANGES 188 94
FOOD GROUP EXCHANGES CHO (g) CHON (g)
I. STARCH 6 90 18
1000 56 II. MEAT
666 37 Very Lean 0
Lean 3 21
Medium-Fat 2 14
High-Fat 0
III. VEGETABLES 6 30 12
IV. FRUIT 3 45
V. MILK
SKIM 0 0 0
LOW-FAT 2 24 16
WHOLE 0 0
FAT 3- -
TOTAL 189 81
DEFICIENCY -2 13
ON
S; LOW SATURATED FAT;
EROL DIET
42 1500 DISTRIBUTION INTO MEALS
FAT (g) CALORIES FOOD GROUP EXCHANGES BREAKFAST AM SNACK LUNCH
- 0 VEG A 0
- 96 VEG B 6 1.5
- 240 FRUIT 6 1 1
0 0 MILK WHOLE 0
30 750 LOW FAT 6 0
TR 0 SKIMMED 0
- 0 SUGAR 0
- 500 RICE 5 2 2
9 369 MEAT LOW FAT 9
0 0 MEDIUM FAT 0 2 1
0 0 HIGH FAT 0
15 135 FAT 3 1 1
54 2090 CARBOHYDRRATE (g)
12 590

NON-PROTEIN CALORIE
DISTRIBUTION INTO EXCHANGES 250 34 74
42 1500 FOOD GROUP EXCHANGES CHO (g) CHON (g) FAT (g)
FAT (g) CALORIES VEG A 0 0 0-
- 480 VEG B 3 9 3-
- FRUIT 3 30 - -
0 0 MILK WHOLE 0 0 0
9 165 LOW FAT 0 0 0 0
10 150 SKIMMED 0 0 TR
0 0 SUGAR 0 0- -
150 RICE 7 161 14 -
180 MEAT LOW FAT 0- 0 0
MEDIUM FAT 2- 16 12
0 0 HIGH FAT - 0 0
10 240 FAT 10 - - 50
0 0 TOTAL 200 33 62
15 135 DEFICIENCY -50 -1 -12
44 1500
-2 0
MEALS
PM SNACK DINNER BEDTIME SNACK

1.5
1
1

2 1

1800
CALORIES
0
48
120
0
0
0
0
700
0
172
0
450
1490
-310
 DIETARY DEPARTMENT

WEIGHTLOSS PROGRAM

DIET PRESCRIPTION AND SAMPLE MEAL PLAN

DATE: 8/22/2017

PATIENT'S NAME: AGE: GENDER: BIRTHDATE:

LUCIANA BERNABE 58 0 JAN. 19,1959
DIAGNOSIS: WEIGHTLOSS

HEIGHT (cm): WEIGHT (kg):

151 33.5 IDEAL WEIGHT RANGE (Kg):
BODY MASS INDEX (kg/m2): 14.69 0 55
NUTRITIONAL STATUS: 0
IDEAL WEIGHT RANGE (lbs):
0 121

DIET PRESCRIPTION:
INCREASE INTAKE OF VEGETABLES & FRUITS; LOW SATURATED FAT;
LOW SODIUM; LOW CHOLESTEROL DIET
TOTAL CALORIES (kcal): 1500

FOOD EXCHANGE DISTRIBUTION

TOTAL FOOD FOR THE DAY (EXCHANGES)
VEGETABLE A 0 RICE OR SUBSTITUTE 5

VEGETABLE B 6 SUGAR 0
FRUIT 6 MEAT OR SUBSTITUTE:
MILK, WHOLE 0 LOW FAT (LF) 9
MILK, SKIMMED 0 MED. FAT(MF) 0.5
OPTIFAST MILK SHAKE 1 FAT 3.0

DISTRIBUTION INTO MEALS

FOOD GROUP EXCHANGES BREAKFAST AM SNACK LUNCH PM SNACK DINNER B.T. SNACK
VEG A 0 0 0 0 0
VEG B 6 1.5 1.5
FRUIT 6 1 0 1 0
MILK LF 0
SM 0
OPTIFAST 1 1

SUGAR 0 1 1 1
RICE 5 1 1 1 1
MEAT LF 9 2 2
MF 0 0.5
HF 0
FAT 3 3 1.5 3 1.5 0
CARBOHYDRRATE (g)
 SAMPLE MENU
MEAL SERVING SAMPLE MENU MEASURE KCAL
310

BEVERAGE 1 GREEN TEA & 1 TSP LEMON 1 CUP

VEG.A & B/SALAD 1 PUMPKIN SOUP 1 CUP 16
MEAT/SUBS. LF 1 CHICKEN BREAST 1PC 41
MF 0.5 BOILED EGG 1/2PC 43
RICE/SUBS 1 CONGEE BROWN RICE 1 CUP 100
MILK 0
SUGAR 1 SUGAR/ STEVIA 1 TSP 20
FAT 2 CANOLA OIL 1 TSP 90
AM SNACK 10:00 AM 265
FRUIT 2 PEAR 1 PC MED. SIZE 80
VEG.A & B 0
NUTS 1 CASHEW/PEANUTS 1 TBSP 185
MILK LF 0
FAT 0
SUGAR 0
LUNCH 12:00 NN STEAMED LAPULAPU 234
BEVERAGE CHO (g) GREEN TEA & 1 TSP LEMON 1 CUP
VEG.A & B/SALAD 2 TAWAIN PECHAY 1 CUP 32
MEAT/SUBS. LF 2 STEAMED LAPULAPU 2PC 82
MF 0
RICE/SUBS 1 BROWN RICE 1/2 CUP 100
MILK SM 0
SUGAR 1 SUGAR/ STEVIA 1 TSP 20
FAT 0
PM SNACK 4:00 PM CHICKEN PESTO PANINI 445
FRUIT 2 APPLE 1 PC MED. SIZE 80
VEG.A & B/SALAD 0 0
NUTS 1 CASHEW/PEANUTS 1 TBSP 185
MEAT/SUBS. LF 0 0
RICE/SUBS 1 WHEAT BREAD 2 PCS 100
FAT 1 PEANUT BUTTER 1 TSP 80
SUGAR 0
DINNER 7:00 PM OPTIFAST MILK SHAKE 278
FRUITS 1 PRUNES 1 PC 40
VEG.A & B/SALAD 2 STEAMED BROCCOLI, 1 CUP 32
MEAT/SUBS. LF 0 CARROTS, SPINACH 0
MF 0
RICE/SUBS 0
MILK OPTI 1 OPTIFAST MILK SHAKE 1 CUP 201
SUGAR 0 0
FAT 1 VIRGIN OIL 1 TSP 45
BEDTIME SNACK 0
FRUIT 0
VEG.A & B/SALAD 0
NUTS
MEAT/SUBS. LF 0
RICE/SUBS 0
FAT 0
SUGAR 0
TOTAL 1532
* BEST SOURCES OF NUTS & SEEDS (almonds, cashews, flaxseeds (ground),
peanuts, pumpkin seeds, sesame seeds, sunflower seeds, and walnuts.
 RECOMMENDED MEAL PLAN
1550KCAL/DAY
MEAL SERVING UNIT
BREAKFAST ________AM
BEVERAGE 1 c
VEG. A&B/SALAD 1 c/pc
MEAT/FISH/CHICKEN/ LF 2
sl/pc
SEAFOODS/EGG MF 0.5
RICE/BREAD/OATMEAL 1 c/pc
MILK LF c
SUGAR 1 tsp/Tbsp
FRUITS c/pc
FAT/OIL 2 tsp/Tbsp
A.M. SNACK _______AM
FRUITS 2 c/pc
VEG. A&B/SALAD c/pc
NUTS 1 tsp/Tbsp
MILK LF c
SUGAR tsp/Tbsp
FAT/OIL tsp/Tbsp
LUNCH ______NN
BEVERAGE 1 c
VEG. A&B/SALAD 2 c/pc
MEAT/FISH/CHICKEN/ LF 2 sl/pc
SEAFOODS/EGG MF
RICE/BREAD/OATMEAL 1/2 c/pc
MILK SM Bottle
SUGAR 1 tsp/Tbsp
FRUITS c/pc
FAT/OIL tsp/Tbsp
P.M. SNACK _______PM
FRUITS 2 c/pc
VEG. A&B/SALAD c/pc
NUTS 1 tsp/Tbsp
RICE/BREAD/OATMEAL 1 c/pc
SUGAR tsp/Tbsp
FAT/OIL 1 tsp/Tbsp
DINNER ______PM
BEVERAGE c
VEG. A&B/SALAD 1 c/pc
MEAT/FISH/CHICKEN/ LF sl/pc
SEAFOODS/EGG MF
RICE/BREAD/OATMEAL c/pc
MILK OPTIFAST 1 sachet
SUGAR tsp/Tbsp
FRUITS 1 c/pc
FAT/OIL 1 tsp/Tbsp
BEDTIME SNACK _______PM
FRUITS c/pc
VEG. A&B/SALAD c/pc
NUTS tsp/Tbsp
MILK LF c
SUGAR tsp/Tbsp
FAT/OIL tsp/Tbsp
* 1 SERVING OF MEAT= 2 PC MATCHBOX/1 PC D.C.
 QUANTITY CARBOHYDRATES PROTEIN FAT TOTAL Na
CONTENT
(Unit) G KCAL G KCAL G KCAL CALORIES mg
NUTRITIONAL/S
ENSURE GOLD 1 SCP 5.33 21.32 1.43 5.72 1.26 11.34 38.38 32.3
ENSURE FIBER 1 SCP 5.32 21.28 1.43 5.72 1.26 11.34 38.34 32.0
GLUCERNA TC 1 SCP 5.50 22.00 2.03 8.12 1.66 14.94 45.06 42.2
IMPACT 1 SCP 1.65 6.60 11.75 47.00 0.30 2.70 56.30 20.0
EGGWHITE PWD 1 SCP 2.60 10.40 10.40 41.60 0.01 0.05 52.05 168.0
PREMIUM EW PWD 1 SCP 0.00 0.00 12.86 51.44 0.00 0.00 51.44 182.1
ISOCAL 1 SCP 10.47 41.88 2.72 10.88 3.50 31.50 84.26 41.7
NEPRO 1 CAN 52.80 211.20 16.60 66.40 22.00 198.00 475.60 200.0
NUTREN DM 1 SCP 3.56 14.24 1.64 6.56 1.60 14.40 35.20 34.4
NUTREN FBR 1 SCP 4.45 17.80 1.40 5.60 1.35 12.15 35.55 33.0
NUTREN OPT 1 SCP 4.19 16.76 1.44 5.76 1.38 12.42 34.94 17.3
PEPTAMEN 1 SCP 5.25 21.00 1.70 6.80 1.65 14.85 42.65 33.5
PROSURE 1 SCP 5.41 21.64 1.77 7.08 0.68 6.12 34.84 40.0
SUPPRTN DRNK 1 BOT 23.2 92.80 20.00 80.00 13.40 120.60 293.40 95.0
SUPPRTN RTH 1 BAG 59.0 236.00 50.00 200.0 33.50 301.50 737.50 237.5
ENERVON PRIME 1 SCP 4.66 18.64 2.46 9.84 0.66 5.94 34.42
FRESUBIN 1 BAG 65.0 260.00 19.00 76.00 17.00 153.00 489.00 665.0
NEPRISOL D 1 SCP 9.8 39.00 3.25 13.00 1.50 13.50 65.50 13.0
DIABETASOL 1 SCP 9.0 36.00 2.40 9.60 1.95 17.55 63.15 24.0
PEDIASURE PLUS 1 SCP 6.0 24.03 1.36 5.44 1.78 16.05 45.51 17.2
ENSURE CAN 1 CAN 34.0 136.00 10.00 40.00 8.40 75.60 251.60 220.0
PROPASS 1 SCP 1.0 4.00 6.00 24.00 0.50 4.50 32.50 15.0
NOVASOURCE RENAL 1 TETRA 43.8 175.20 21.60 86.40 10.00 90.00 475.00 223.0
NEPRO HP 1 CAN 37.90 151.60 19.10 76.40 22.70 204.30 432.30 250.0
MISCELLANEOUS
QUANTITY CARBOHYDRATES PROTEIN FAT TOTAL Na
CONTENT
(Unit) G KCAL G KCAL G KCAL CALORIES mg
VEGETABLES
CHAYOTE 1 CUP 1.50 6.00 0.50 2.00 0.00 0.00 8.00 4.0
CARROTS 1 CUP 3.00 12.00 1.00 4.00 0.00 0.00 16.00 70.0
SQUASH 1 CUP 3.00 12.00 1.00 4.00 0.00 0.00 16.00 70.0
MALUNGGAY 1 CUP 1.50 6.00 0.50 2.00 0.00 0.00 8.00 4.0
FRUITS
BANANA 1 PC 10.00 40.00 0.00 0.00 0.00 0.00 40.00 6.0
PAPAYA 1 SL 10.00 40.00 0.00 0.00 0.00 0.00 40.00 6.0
APPLE 0.5 PC 10.00 40.00 0.00 0.00 0.00 0.00 40.00 1.5
RICE & EQUIVALENT
LUGAW 1 CUP 23.00 92.00 2.00 8.00 0.00 0.00 100.00 2.0
OATMEAL 1 CUP 0.00 0.00 0.00 0.00 0.00 0.00 0.00
LOAF BREAD 1 PC 11.50 46.00 1.00 4.00 0.00 0.00 50.00 115.0
RICE 1 CUP 46.00 184.00 4.00 16.00 0.00 0.00 200.00
POTATO 1 CUP 46.00 184.00 4.00 16.00 0.00 0.00 200.00
SKYFLAKES 1 PC 5.33 21.32 0.67 2.68 1.67 15.03 39.03 56.67
POLYCOSE 1 SCP 9.4 37.6 0.00 0.00 0.00 0.00 37.6 11.0
MEAT AND EQUIVALENT
EGGWHITE 1 PC 0.00 0.00 4.00 16.00 0.00 0.00 16.00 110.0
WHOLE EGG 1 PC 0.00 0.00 8.00 32.00 6.00 54.00 86.00 110.0
CHICKEN 2 TBSP 0.00 0.00 16.00 64.00 2.00 18.00 82.00
BEEF 1 CUP 0.00 0.00 0.00 0.00 0.00 0.00 0.00
WHEY PROTEIN 1.00 SCP 1.65 6.60 11.75 47.0 0.30 2.70 56.30 20.0
WHEY IMPACT 1.00 SCP 1.65 6.60 12.00 48.0 0.14 1.22 55.82 19.4
BENEPROTEIN 1 SCP 0 0 6 24 0 0 24 15
VITAMEAL 1 CUP 104 416 23 92 9 81 589 810

SUGAR 1 TSP 5.00 20.00 0.00 0.00 0.00 0.00 20.00 0.0
SALT 0.5 TSP 1000.0
OLIVE OIL 1 TSP 0.00 0.00 0.00 0.00 5.00 45 45.0 0.0
CANOLA OIL 1 TSP 0.00 0.00 0.00 0.00 5.00 45 45.0 0.0
ENSURE (IMPTD) 1 SCP 5.35 21.4 1.42 5.68 1.42 12.8 39.9 29.9
ORAL IMPACT 1 SCHT 40.20 160.8 16.80 67.2 8.30 74.7 302.7 320
ENSURE ACTI-M2 1 SCP 5.39 21.54 1.44 5.75 1.26 11.37 38.66 32.5
 K Ph
mg mg DISTRIBUTION
CHO CHON FATS
60.1 24.2 55.54977 14.9036 30
69.6 20.5 55.50339 14.91914 30
74.0 33.7 48.82379 18.02042 33
70.0 0.0 11.72291 83.48135 5
0.0 0.0 19.98271 79.93083 0
0.0 0.0 0 100 0
104.2 41.7 49.7033 12.91241 37
250.0 165.0 44.40706 13.96131 42
34.9 20.0 40.45455 18.63636 41
47.9 21.9 50.07032 15.75246 34
26.9 15.7 47.96795 16.4854 36
53.2 29.8 49.23798 15.94373 35
53.3 28.0 62.11251 20.32147 18
256.0 240.0 31.62918 27.26653 41
640.0 600.0 32 27.11864 41
54.15456 28.58803 17
775.0 315.0 53.16973 15.54192 31
21.3 59.54198 19.84733 21
51.8 30.0 57.00713 15.2019 28
59.4 37.8 52.79603 11.94437 35
370.0 155.0 54.05405 15.89825 30
45.0 0.0 12.30769 73.84615 14
194.0 166.0 36.88421 18.18947 19
250.0 170.0 35.06824 17.67291 47

K Ph
mg mg
DATE:
120.0 30.0 NOVEMBER 23 2015
220.0 10.0
220.0 10.0
240.0 30.0
13
229.6 10.0 21.25
240.0 20.0
60.0 5.0

60.0 35.0

30.0 17.5

1.0 1.2

95.0 115.0
95.0 115.0

70.0 0.0
81.3 0.0
35 15
840

0.0 0.0

0.0 0.0
0.0 0.0
55.08
402 216
60.6 24.3
 PRICE OFFERED BY SUPPLIER(ABBOT, NESTLE, KA
NUTRITIONALS SIZE (G/ML) PRICE/CAN OR BAG PRICE/G OR ML G/SCOOP
REGULAR
ENSURE GOLD 1800 2,160.43 1.20 8.967
NUTREN FIBER 800 962.00 1.20 8.237
NUTREN OPTIMUM 800 1,071.25 1.34 7.857
FRESUBIN 500 190.16 0.38 -
DIABETIC FORMULA
GLUCERNA SR TC 900 1,355.51 1.51 10.42
NUTREN DIABETES 800 1,172.88 1.47 7.897
DIABETASOL 600 589.04 0.98 15.00
OTHERS
NEPRO HP 237 162.71 0.69 -
PROSURE 380 679.47 1.79 8.333
PEPTAMEN 430 861.96 2.00 8.809
BENEPROTEIN 227 712.50 3.14 7.000
IMPACT WHEY 454 710.00 1.56 15.000
NUTRIVE BENECOL 26.52
ALITRAQ 76 205.88 2.71 -

* WITHOUT MARK UP FROM SUPPLIER PRICE

LIER(ABBOT, NESTLE, KALBE & FRESINIUS KABE)
# OF SCOOP/CAN PRICE/SCOOP CAL/G CAL/SCOOP KCAL/CAN PRICE/CAL
REGULAR
200.736 10.76 4.28 38.379 7704 0.28
97.123 9.90 4.32 35.584 3456 0.28
101.820 10.52 4.44 34.885 3552 0.30
- - 1.00 500 0.38
BETIC FORMULA
86.372 15.69 4.33 45.119 3897 0.35
101.304 11.58 4.60 36.326 3680 0.32
40.000 14.73 4.20 63.000 2520 0.23
OTHERS
- - 1.793 - 425 0.38
45.602 14.90 4.02 33.499 1527.6 0.44
48.814 17.66 4.56 40.169 1960.8 0.44
32.429 21.97 3.57 24.990 810.39 0.88
30.267 23.46 3.753 56.295 1703.86 0.42

- -