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Nome:________________________________________________________________________
__________ Idade:________________________________
Profissão:_______________________________________ __
QD:_____________________________________________________________________
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HMA:________________________________________________________________________
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ISDA:_________________________________________________________________________
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__________________________________________________ Antecedentes Pessoais: ( )DÇS
CARDIOVASCULARES ( )DM ( )HAS ( )HEPATOPATIAS ( )ETILISMO ( )TABAGISMO (
)NEOPLASIAS ( )VARIZES ( )CIRURGIAS ( )ALERGIAS ( )DÇS COAGULAÇÃO ( )CIRURGIAS (
)OSTEOPOROSE ( )TRANFUSÕES SANGUÍNEAS ( )TRAUMATISMOS ( )MEDICAÇÃO (
)OUTROS ATIVIDADE
FÍSICA:_______________________________________________________________________
_ CIRURGIA PÓS
TRAUMA:___________________________________________________________________ (
)TABAGISTA ( )ETILISTA
Menarca:_____________________________
Sexarca:________________________________________ Ciclo de:____________________
dias Gestações: G_____P_____A_____ Fluxos de:___________________ dias
Tipos de partos:________________________________ DUM: __________________________
Complicações gestacionais:_________________________ Quantidade de
fluxo:______________ _______________________________________________
Data do último
parto:______________________________________________________________________
Calculo da Idade
Gestacional:________________________________________________________________
Data provável do
parto:____________________________________________________________________
Movimentos
fetais:________________________________________________________________________
Vida sexual ativa: ( )SIM ( )NÃO Parceiros: ( )MESMO ( )NOVO RELACIONAMENTO (
)ÚNICO ( )MAIS DE UM Uso de preservativos: ( )SIM ( )NÃO Dismenorréia: ( )SIM (
)NÃO
TPM:_________________________________________________________________________
_____________________________________________________________________________
____________________ Já realizou colpocitológico: ( )SIM ( )NÃO Data do último
exame:_________________________
Resultado:____________________________________________________________________
_____________________________________________________________________________
_____________________ Contracepção: ( )SIM ( )NÃO
______________________________________________________________ Corrimento: (
)SIM ( )NÃO ________________________________________________________________
Prurido vulvar: ( )SIM ( )NÃO Dispareunia: ( )SIM ( )NÃO ( )PENETRAÇÃO (
)PROFUNDIDADE Sinusorragia: ( )SIM ( )NÃO Cauterização prévia: ( )SIM ( )NÃO Infecção
pélvica: ( )SIM ( )NÃO
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AP.
RESPIRATÓRIO:________________________________________________________________
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AP.CARDÍACO:_________________________________________________________________
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ABDOMEN:____________________________________________________________________
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______________________________ EXAME GINECOLÓGICO MAMAS: Inspeção
Estática:___________________________________________
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________________________________________________ Inspeção
Dinâmica:_____________________________________________________________________
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____________________ Palpação
Axilar:________________________________________________________________________
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____________________ Palpação
Mama:_______________________________________________________________________
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Expressão:____________________________________________________________________
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