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FORMULIR PENGKAJIAN STATUS GIZI

Ruang Rawat

Judul Subyektif

Judul Perubahan Berat Badan

Judul Perubahan Kebiasaan Makan

Judul Gangguan Gastrointestinal

Judul Analisis Rata – Rata Asupan Makanan Perhari

Analisis Rata – Rata Asupan Makanan Perhari <table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="624" style="width: 467.75pt; margin-left: -0.25pt;">
 <tbody><tr style="mso-yfti-irow:0;mso-yfti-firstrow:yes;height:30.0pt">
 <td width="151" nowrap="" rowspan="2" valign="bottom" style="width:113.35pt;
 border:solid windowtext 1.0pt;mso-border-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:30.0pt">
  <o:p></o:p>
 </td>
 <td width="66" rowspan="2" style="width:49.7pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:30.0pt">
 Energi (Kal)<o:p></o:p>
 </td>
 <td width="153" colspan="2" valign="bottom" style="width:114.5pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-top-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:30.0pt">
 Protein <o:p></o:p>
 (g)<o:p></o:p>
 </td>
 <td width="62" rowspan="2" style="width:46.7pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:30.0pt">
 Lemak   (g)<o:p></o:p>
 </td>
 <td width="62" rowspan="2" style="width:46.7pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:30.0pt">
 KH(g)<o:p></o:p>
 </td>
 <td width="67" rowspan="2" style="width:50.1pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:30.0pt">
 Sayuran(g)<o:p></o:p>
 </td>
 <td width="62" rowspan="2" style="width:46.7pt;border:solid windowtext 1.0pt;
 border-left:none;mso-border-left-alt:solid windowtext .5pt;mso-border-alt:
 solid windowtext .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:30.0pt">
 Buah(Porsi)<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:1;height:15.0pt">
 <td width="65" nowrap="" style="width:48.95pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Hewan<o:p></o:p>
 </td>
 <td width="87" nowrap="" style="width:65.55pt;border-top:none;border-left:none;
 border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Nabati<o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:2;height:15.0pt">
 <td width="151" nowrap="" valign="bottom" style="width:113.35pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Sebelum Sakit<o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="65" nowrap="" valign="bottom" style="width:48.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="87" nowrap="" valign="bottom" style="width:65.55pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="67" nowrap="" valign="bottom" style="width:50.1pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:3;height:15.0pt">
 <td width="151" nowrap="" valign="bottom" style="width:113.35pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Selama Sakit …..hr<o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="65" nowrap="" valign="bottom" style="width:48.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="87" nowrap="" valign="bottom" style="width:65.55pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="67" nowrap="" valign="bottom" style="width:50.1pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:4;height:15.0pt">
 <td width="151" nowrap="" valign="bottom" style="width:113.35pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Selama Perawatan<o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="65" nowrap="" valign="bottom" style="width:48.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="87" nowrap="" valign="bottom" style="width:65.55pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="67" nowrap="" valign="bottom" style="width:50.1pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:5;height:15.0pt">
 <td width="151" nowrap="" valign="bottom" style="width:113.35pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Oral<o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="65" nowrap="" valign="bottom" style="width:48.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="87" nowrap="" valign="bottom" style="width:65.55pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="67" nowrap="" valign="bottom" style="width:50.1pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:6;height:15.0pt">
 <td width="151" nowrap="" valign="bottom" style="width:113.35pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Enteral<o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="65" nowrap="" valign="bottom" style="width:48.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="87" nowrap="" valign="bottom" style="width:65.55pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="67" nowrap="" valign="bottom" style="width:50.1pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:7;height:15.0pt">
 <td width="151" nowrap="" valign="bottom" style="width:113.35pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Parenteral<o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="65" nowrap="" valign="bottom" style="width:48.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="87" nowrap="" valign="bottom" style="width:65.55pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="67" nowrap="" valign="bottom" style="width:50.1pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow:8;mso-yfti-lastrow:yes;height:15.0pt">
 <td width="151" nowrap="" valign="bottom" style="width:113.35pt;border:solid windowtext 1.0pt;
 border-top:none;mso-border-left-alt:solid windowtext .5pt;mso-border-bottom-alt:
 solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;padding:
 0cm 5.4pt 0cm 5.4pt;height:15.0pt">
 Total<o:p></o:p>
 </td>
 <td width="66" nowrap="" valign="bottom" style="width:49.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="65" nowrap="" valign="bottom" style="width:48.95pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="87" nowrap="" valign="bottom" style="width:65.55pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="67" nowrap="" valign="bottom" style="width:50.1pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 <td width="62" nowrap="" valign="bottom" style="width:46.7pt;border-top:none;
 border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
 mso-border-bottom-alt:solid windowtext .5pt;mso-border-right-alt:solid windowtext .5pt;
 padding:0cm 5.4pt 0cm 5.4pt;height:15.0pt">
  <o:p></o:p>
 </td>
 </tr>
</tbody></table>

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