Name: _____________________________

Weight: ________________ Height: _________________ Age________

BMI: __________________ Current Caloric Needs: ______________________
Goal Weight: _________________ Goal Weight Caloric Needs: ____________________

Diet Prescription: ____% carbohydrate ____% protein ____% fat

Kcal: _____________ CHO ______ g. PRO: _____g. FAT: _____g.

ACTUAL Calories _________kcal ______ g. CHO _____g. PRO _____g. FAT

______ kcal _______ kcal _______ kcal

Name: Number of Exchanges

Snacks
One Exchange is equal to:
Daily Total CHO PRO FAT
B L D 10 2 Eve (gms) (gms) (gms)
Milk 12 8 0,3
Vegetable 5 2 0
Fruit 15 0 0
Starch 15 3 1
Meat 0 7 3
Fat 0 0 5
Notes:

General Exchange Guidelines:

1 Milk (based on nonfat or 1% milk and 1Starch (grains & starchy vegetables)
yogurt)  ½ cooked cereal, grain or starchy
 1 cup milk vegetable
 6oz yogurt (2/3 cup)  1/3 cup cooked rice or pasta
1 Non-Starchy Vegetable  1 oz bread (1 slice)
 ½ cup cooked vegetables  ¾ to 1 oz. most snack foods
 ½ cup vegetable juice 1 Meat (based on a combination of lean &
 1 cup raw vegetables medium fat)
1 Fruit  1 oz meat, poultry or fish
 ½ cup canned (packed in fruit juice)  1 egg
or frozen fruit  1 oz cheese
 1 small fresh fruit (¾ to 1 cup)  1 Tbsp. peanut butter
 ½ cup unsweetened fruit juice  ½ oz. beef jerky
 2 Tbsp. dried fruit 1 Fat
 1 tsp. solid fat or oil
 1 Tbsp. salad dressing

Created by Amanda Tome

October, 2016