ANAMNESE E AVALIA TERAPUTICA

ALUNO: FONE:
DISCIPLINA: DATA:
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CADASTRO PESSOAL

PACIENTE (NOME FICTCIO): ______________________________________________________

DATA DE NASCIMENTO: ____________________ SEXO: M( ) F ( )

ESCOLARIDADE: ( ) 1 GRAU ( ) 2 GRAU ( ) 3 GRAU

PESO: ______________________________ ALTURA: ________________________

PROFISSO: ___________________________________________________________________

NVEL SOCIOECONMICO: _________________________

ESTRUTURA FAMILIAR (COM QUEM MORA?) ________________________________________

SINTOMAS

1) QUAIS AS MAIORES QUEIXAS? ____________________________________________

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2) QUANTO TEMPO TEM SENTIDO ESSAS QUEIXAS? _____________________________
3) POSSUI DIAGNSTICO MDICO? ___________________________________________
4) QUEM MAIS SOFRE DO MESMO PROBLEMA NA FAMLIA?
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5) QUAIS OS TRATAMENTOS J UTILIZADOS? MEDICAMENTOS?
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6) COM QUE REGULARIDADE VAI AO MDICO?
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 ESTILO DE VIDA

1) QUANTOS COPOS DE GUA AO DIA ? _____________

2) QUANTAS HORAS DE REPOUSO A NOITE? _______ DEITAR?______ ACORDAR?_______
3) PRATICA EXERCCIOS FSICOS REGULARMENTE? QUAL?_________________________
3X/SEMANA ( ) 2X/SEMANA ( ) TODOS OS DIAS ( ) NO FAZ ( )
4) QUANTIDADE DE TEMPO AO SOL TODOS OS DIAS? ____________________________
5) PROCURA FAZER EXERCCIOS DE RESPIRAO PROFUNDA? _____________________
6) COMO CONTROLA O EQUILBRIO ENTRE TRABALHO, FAMLIA E LAZER?
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7) COMO EST SUA F? CONFIA EM DEUS? VIVE A RELIGIO?
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8) FUMANTE? _______________ FAZ USO DE BEBIDAS ALCOLICAS? ______________
9) ALIMENTAO
a) QUANTAS REFEIES FAZ AO DIA, INCLUINDO OS LANCHINHOS? ____________
b) EM QUE MOMENTO DO DIA VOC MELHOR SE ALIMENTA?

MANH ( ) TARDE ( ) NOITE ( )

c) FAZ USO DE LQUIDOS COM AS REFEIES? ____________________

d) QUAL O INTERVALO ENTRE AS PRINCIPAIS REFEIES?_____________________
e) DESCREVA O CARDPIO DE 1 DIA:

DESJEJUM:
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ALMOO:
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JANTAR
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 f) QUAIS DESSES ARTIGOS VOC FAZ USO NA ALIMENTAO?

REFRIGERANTE, ACAR BRANCO, LEITE E DERIVADOS (MANTEIGA, IOGURTE, NATA,

REQUEIJO...), CARNES, INDUSTRIALIZADOS (SALGADINHOS, BOLACHAS, SORVETES, SUCOS,
GELATINAS), FARINHA BRANCA, DOCES, ALIMENTOS PROCESSADOS (SALSICHAS, EMBUTIDOS,
MOLHOS PRONTOS), ARROZ BRANCO, CHOCOLATE, CH MATE, CAF, TEMPEROS PRONTOS
(SAZOM, CALDOS DE LEGUMES, ANJINOMOTO, SAL TEMPERADO...)

g) QUAL A PORCENTAGEM DE ALIMENTOS QUE VOC UTILIZA EM SUAS REFEIES:

________% CRU

________% COZIDO

OBSERVAES COMPLEMENTARES:
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POSSVEIS TRATAMENTOS (idias principais)

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