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Contoh Formulir Dietary History

This document contains a dietary history form filled out by Mawar. It lists the foods consumed at each meal with details on preparation method, ingredients, frequency of consumption, portion size, and calculated daily intake in grams. A variety of foods are consumed daily including rice, chicken, fish, eggs, fruits, and noodles prepared in different ways like fried, boiled, and stir-fried.

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Vistha Rachma
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941 views3 pages

Contoh Formulir Dietary History

This document contains a dietary history form filled out by Mawar. It lists the foods consumed at each meal with details on preparation method, ingredients, frequency of consumption, portion size, and calculated daily intake in grams. A variety of foods are consumed daily including rice, chicken, fish, eggs, fruits, and noodles prepared in different ways like fried, boiled, and stir-fried.

Uploaded by

Vistha Rachma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Formulir Dietary History

Nama responden : Mawar

Jam Nama Teknik Mer Bahan Frekuensi konsumsi Porsi per kali makan Berat Rata-rata Rata-rata
makan Masakan pengolahan k makanan hari Minggu Bulan URT Berat menta frekuensi/har asupan
x/minggu x/hari x/minggu x/hari matan h (n) i (f) gram/hari
g (n x f)
07.00 Air putih Direbus aqua Air mineral 4 30 120 1 gls 30 30 4 120

Nasi ditanak - Beras 3 30 90 2 ctg 200 g 80 g 3 240


Ayam goreng - Ayam+minya 3 10 1 ptg 90 g 144 g 1,4 201,6
k
13.00 Nasi ditanak - 3 30 90 2 ctg 200 g 80 g 3 240
Ikan lele goreng - beras 2 8 1 ekor 40 g 96 g 0,26 24,96
Telur goreng - lele+minyak 2 8 1 btr 60 g 42 0,26 10,92
Es teh seduh - telur+minyak 1 30 1 gls 200 200 1 200
teh 1 30 2 sdm 10 10 1 10
gula
17.00 Mangga - - 4 1 buah sdg 250 250 0,13 32,5
mangga
19.00 Nasi goreng - 3 1 3 ctg 200 80 0,42 33,6
goreng nasi 1 btr 60 66 0,42 27,72
telur 1 sdm 10 16 0,42 6,72
ayam 1 sdm 5 5 0,42 2,1
kol

Kwetiau goreng - 2 1 1 prg 100 60 0,28 16,8


kwetiau 1 btr 60 66 0,28 18,48
telur 1 sdm 5 5 0,28 1,4
kol
Bakmi rebus - 2 1 prg 100 60 0,28 16,8
rebus mie 1 btr 60 66 0,28 18,48
telur 1 sdm 10 16 0,28 4,48
ayam 1 sdm 5 5 0,28 1,4
kol
Jam Nama Teknik Mer Bahan Frekuensi konsumsi Porsi per kali makan Berat Rata-rata Rata-rata
makan Masakan pengolahan k makanan menta frekuensi/har asupan
h (n) i (f) gram/hari
Jam Nama Teknik Mer Bahan Frekuensi konsumsi Porsi per kali makan Berat Rata-rata Rata-rata
makan Masakan pengolahan k makanan menta frekuensi/har asupan
h (n) i (f) gram/hari

Pewawancara,

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