COUNSELING FORM Name: ________________________________ Weight: ________________ Height: ____________ Age: ________ Sex: _______

BMI (kg/m2): _______________

DBW (Tannhausers Method): ______________________________________________________ TER (Method II) (Bed rest 27.5 ; Sedentary 30 ; Light 35; Moderate- 40; Heavy 45)

Distribution of TER into CHO, CHON, FAT: CHO (50-70%) ; PRO (10-12 % for adults; 10 for infants) ; FAT (20-25% for normal adults, moderately active; 30 35% for children, adolescents, very active)

Exercise (type, frequency, duration): _________________________________________________ Religious beliefs/taboos: ___________________________________________________________ Physical activity: ____ Sedentary (works involves mostly sitting) ____ Light (work involves walking around house, office or plant) ____ Moderate (on feet all day) ____ Heavy (work entails carrying/moving heavy loads, equipment, etc)

Usual food intake FOOD Cereals and Starches Rice Bread Noodles/pasta Other cereals Other baked Goods Potato/Camote Vegetables Leafy, green Others Fruits Banana Juices Others Protein-rich foods Beef Pork Fish/Shellfish Processed Meat Processed Fish Poultry Eggs Milk (type) Dried beans/nuts Fats and oils Cooking oil (type) Butter Margarine (type) Salad dressing Sweets and desserts Sugar Candy/chocolates Ice cream Cakes/pastries Native kakanin Miscellaneous Toyo, patis Bagoong Alcoholic drinks Coffee/tea Daily Weekly Seldom Never Remarks/ Description/ Size per serving

Soft drinks

Other food eaten regularly: ____________________________________________________ Foods particularly liked _______________________________________________________ Foods particularly disliked _____________________________________________________ Allergies ___________________________________________________________________ Vitamin and mineral supplements taken __________________________________________ SAMPLE MEAL PLAN AND MENU FOR ONE DAY 1500 kcal 245-55-35 Total food for the day: Veg A 2 exchanges Veg B 1 exchange Fruit 4 exchanges Milk 1 exchange Food Exchanges Breakfast Fruit Meat, Fish or substitute Rice or substitute Milk for coffee Sugar Mid AM Snack Rice or substitute Meat Lunch Soup Meat, Fish or substitute Veg A Rice Fruit Fat Mid PM Snack Rice or substitute Fat No. of exchanges Sugar 5 exchanges Rice 7 exchanges Meat and Fish 4 exchanges Fat 3 exchanges Sample Menu Appropriate Size per Serving 1 slice (10x6x2cm) or cup 3 (9cm dia x 3cm thick( 2 slices (9x8x1cm each) 2 tablespoon 2 teaspoon 1 pc (6x5x4cm) 1/3 cup

1 1 1 2 1 1

Ripe Papaya Baked Ham Pan Amerikano Evaporated Milk White Sugar Pan de Limon Cottage Cheese Clear broth from tinola Chicken tinola Green Papaya & Sili leaves Boiled Rice Watermelon Cooking oil for tinola Pan de monay Cream cheese

1 2 1 1 1 1 1

1 small leg 1 cup c 1 slice (12x6x3cm) 1 tsp 1 pc (10x9x4cm) 1 tbsp

Fruit Sugar Supper Soup Meat and Fish or substitute Veg B Rice Fruit Fat Bed-time snack Rice or substitute Milk Sugar

1 1 1 1 1 1 1 1

Pineapple Juice White Sugar Parsleyed Beef Broth Broiled Bangus w/ Kalamansi Sauteed Squash Boiled Rice Lakatan Cooking oil for squash

1/3 c (undiluted) 1 tsp

1 slice (7x3x2cm) c c 1 pc (9x3cm) 1 tsp

1 2

Galyetas de patatas Evaporated Milk White sugar

10 pcs of 4x4x1/2 cm each 1/3 cup (undiluted) 2 tsp

SAMPLE MEAL PLAN AND MENU FOR ONE DAY Food exchanges No. of exchanges Sample Menu Approximate size per serving

Other recommendations: ________________________________________________________________

Note: Please discuss FEL