24 HOURS RECALL FORM

Tanggal : 8, 11, 13 Mei 2017 (pukul 10 siang)

Nama : Rara Ayuningtyas
NIM : 14/363154/KU/17062
BB : 48 kg
TB : 168. 5 cm
BEE : 1325.1 kkal
TEE : 1855.14 kkal (protein 69.57 gr | lemak 51.53 gr | karbohidrat 278.27 gr)
Enumerator : Ade Saputri

Senin, 8 Mei 2017 pukul 10.00 WIB – Selasa, 9 Mei 2017 pukul 10.00 WIB
Household Energy Protein Fat Carbohydrate
No. Timing Menu Gram
Measure (kcal) (gram) (gram) (gram)

Teh 1 gls 200 2 0 0 0.71

Gula 1 sdm 10 30 0 0 7.5
1. Breakfast
Susu milo mix
1 gls 35 150 4 4 25
dancow
Mid-
2. -
morning
1 porsi
Nasi 200 350 8 0 80
sedang
Daging ayam
3. Lunch dilapisi tepung 4 buah 190 9.98 12.04 10.44
roti dan digoreng
Wortel ¼ gelas 25 12.5 0.75 0 2.5
Mayonais 1 sdm 10 57 0.13 4.91 3.51
Telur
2 btr 75 95 10 6 0
ayam
Omelet Mie
4. Mid-day ½ gls 25 87.5 2 0 20
mie kering
Minyak
¼ sdm 2.5 22.5 0 2.5 0
goreng
1 porsi
5. Dinner Nasi 200 350 8 0 80
sedang
 Bihun ½ gls 50 175 4 0 40
Daging
¼ ptg 12.5 23.75 2.5 1.5 0
ayam
Daging
Soto ¼ ptg 12.5 23.75 2.5 1.5 0
sapi
1
Rempela 25 31.6 3.3 2 0
bulatan
Tauge ¼ gls 25 0 0 0 0
Tempe 2 ptg sdg 50 80 6 3 8
Minyak
½ sdm 5 45 0 5 0
goreng
End of 1⁄
6 bh
6. Nanas 75 40 0 0 10
the day sdg
TOTAL 1675.6 64.18 44.41 261.22

Kamis, 11 Mei 2017 pukul 10.00 WIB – Jumat, 12 Mei 2017 pukul 10.00 WIB
Household Energy Protein Fat Carbohydrate
No. Timing Menu Gram
Measure (kcal) (gram) (gram) (gram)

Teh 1 gls 200 2 0 0 0.71

Gula 1 sdm 10 30 0 0 7.5
1. Breakfast
Susu milo mix
1 gls 35 150 4 4 25
dancow
Semangka ¼ pts bsr 37.5 10 0 0 2.5
Mangga ¼ bh bsr 25 20 0 0 5
Nanas 1⁄
6 bh sdg 75 40 0 0 10
Jelly 5 potong 25 39.7 0.4 0.2 9.9
Mid- Salad
2. Susu
morning buah
kental 1⁄ gls 12.5 1.6 0.8 0.8 1
8

manis
Keju
(taburan)
 1 porsi
Nasi 200 350 8 0 80
sedang
1 ptg
Daging ayam 50 95 10 6 0
sedang
3. Lunch
Minyak goreng 1 sdm 10 90 0 10 0
Bayam 1 gls 100 50 3 0 10
Teh 1 gls 200 2 0 0 0.71
Gula 1 sdm 10 30 0 0 7.5
4. Mid-day -
1 porsi
Nasi 200 350 8 0 80
sedang
1 ptg
Daging ayam 50 95 10 6 0
5. Dinner sedang
Kacang panjang 1 gls 100 50 3 0 10
Tempe 2 ptg sdg 50 80 6 3 8
Minyak goreng 2 sdm 20 180 0 20 0
End of Durian 3 bj 50 40 0 0 10
6.
the day Roti bakar 4 bj 100 280 9 4 50
TOTAL 1535.6 55.8 42.8 241.92

Sabtu, 13 Mei 2017 pukul 10.00 WIB – Minggu, 14 Mei 2017 pukul 10.00 WIB
Household Energy Protein Fat Carbohydrate
No. Timing Menu Gram
Measure (kcal) (gram) (gram) (gram)
Teh 1 gls 200 2 0 0 0.71
Gula 1 sdm 10 30 0 0 7.5
Susu milo
1. Breakfast mix 1 gls 35 150 4 4 25
dancow
Roti
4 iris 80 175 4 0 40
tawar
Mid-
2. -
morning
1 porsi
3. Lunch Nasi 200 350 8 0 80
sedang
 Daging 1 ptg
50 95 10 6 0
ayam sedang
Minyak
2 sdm 20 180 0 20 0
goreng
Bihun ¼ gls 25 175 4 0 40
Terong 1 gls 100 0 0 0 0
Tempe 1 ptg sdg 25 40 3 1.5 4
Tahu ½ ptg bsr 50 40 3 1.5 4
Kacang
4. Mid-day tanah 6 sdm 60 240 18 9 24
terkupas
Daging
2 ptg sdg 100 190 20 12 0
sapi
Kentang 2 bj sdg 200 175 4 0 40
5. Dinner
Wortel ¼ gls 25 12.5 0.75 0 2.5
Buncis ¼ gls 25 12.5 0.75 0 2.5
Susu sapi 1 gls 200 110 7 7 9
End of
6. Kraker 5 bh bsr 50 175 4 0 40
the day
TOTAL 2112 129.5 64 303.21