Ficha de Anamnese Nutricional

Enfermaria: _________

Leito: __________

Data de internao: ___/___/_____

1. Dados pessoais
Nome: ________________________________________________________________
Sexo:
Feminino ( )
Masculino ( )
Data de nascimento: ___/___/_____ Estado civil: ____________________________
Endereo: ______________________________________________________________
Bairro: ________________________ Complemento: ___________________________
CEP: ___________________ Cidade: _____________________________ UF: ______
Telefone: ___________________________Celular: ____________________________
Profisso: ______________________________________________________________
Escolaridade: ___________________________________________________________
2. Causa da internao:
______________________________________________________________________
3. Exame fsico:
______________________________________________________________________
4. Avaliao antropomtrica
Medida
Peso atual (kg)
Altura (m)
Peso habitual (kg)
CC (cm)
CB (cm)
DCT (mm)
CMB (cm)

Adequao/Risco DCV

DCV
CB (%)
DCT (%)
CMB (%)

5. Histrico social (HS)

5.1 Quantas pessoas moram na sua casa?
______________________________________________________________________
5.2 Quantas pessoas contribuem para a renda?
______________________________________________________________________
6. Histria patolgica pregressa (HPP)
6.1 Quando surgiu a doena?
______________________________________________________________________
7. Outras doenas/ Tabagismo/ Etilismo
Diabetes ( )
Hipertenso ( )

DCV ( )
Tabagismo ( )
Etilismo ( )

Quantidade/dia _______________________
Quantidade __________________________

8. Histria familiar (HF)

8.1 Pais/ irmos e familiares vivos.
______________________________________________________________________
______________________________________________________________________
8.2 Pais/ irmos e familiares mortos.
______________________________________________________________________
______________________________________________________________________
9. Histria Alimentar
Horrio/
Refeio

Alimento

Funo Intestinal
Mastigao
Alergias e/ou averses alimentares
Uso de temperos prontos/ embutidos/ etc

Quantidade

10. Histria da doena:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
11. Medicamentos usados antes da internao
______________________________________________________________________
______________________________________________________________________
12. Exames laboratoriais/ bioqumicos
Exame
Uria (mg/dL)
Creatinina (mg/dL)
Fsforo (mg/dL)
Clcio (mg/dL)
Magnsio (mg/dL)
Potssio (mEq/L)
Sdio (mEq/L)
Glicose (mg/dL)
Colesterol/
Triglicerdeos
(mg/dL)
Albumina (g/dL)
Bilirrubina Total
(mg/dL)
PTN Total (g/dL)
TGO (UL)
TGP (UL)
Hemoglobina (g/dL)
Hematcrito (%)

Data

Data

Referncia
Min./Max.
10-45
0,6-1,2
2,3-4,6
8,8-10,6
1,9-2,5
3,5-5,1
136-145
70-110
200/ 150
3,5-4,8
0,2-1,0
6,1-7,9
H: at 38 / M: at 32
H: at 41 / M: at 31
12-18
37-54