FICHA ESPELHO - Caderneta Do Idoso - Articuladores

MINISTRIO DA SADE CADERNETA DE SADE DA PESSOA IDOSA FICHA PRONTURIO ESPELHO (COLOQUE "S" PARA SIM E "N" PARA
NO) DATA: ______ / ______ / _______
Nome: __________________________________ Como conhecido:_____________________ Identificao N do Carto SUS:_____________________________ UBS referncia:___________________ Sexo: Mas. ( Endereo Telefone:__________________ Celular:__________________ Estado civil: casado ( ) solteiro ( ) vivo ( ) separado ( ) outros ( ) Escolaridade: analfabeto ( ) at 4 anos ( ) 4 a 8 anos ( ) 8 anos e + ( ) Aposentado:( ) Pensionista ( ) Ocupao antes de aposentar____________ Ocupao atual: ___________ Hbitos de vida: Fumo( ) frequentemente( ) raramente( ) parei de fumar( ) tipo:___________ quantidade:_____________ tempo de uso________ Bebida alcolica( ) frequentemente( ) raramente( ) parei de beber( ) tipo:______________ quantidade (N x / dia):________ tempo de uso____________ Realiza atividade fsica: ( ) Qual?_________________________________________________ frequentemente( ) raramente ( ) parei de fazer ( ). Frequenta alguma atividade social ou de lazer: ( ) Qual?______________________________ Realiza trabalhos voluntrios: ( ) Qual? ________________________________________ Come: frutas ( ) verduras ( ) legumes ( ) carne ( ) frituras ( ) acar ( ) sa l( ) Moram comigo ______ pessoas. Fica s a maior parte do dia? ( ) Pessoa que poderia cuidar caso precisasse:________________ Grau de vnculo: ___________ Esta pessoa mora prxima? ( ) Necessita de cuidados para o dia-a-dia? ( ) acamado? ( ) Usa cadeira de rodas? ( ) Andador? ( ) Endereo:_______________________________________ N:_______ CRA:______________ Bairro:____________________ Telefone:_______________ Celular:__________________ Minha sade : muito boa ( ) boa ( ) regular ( ) ruim ( ) muito ruim ( ) ) Fem. ( ) Data de nascimento:_____/_____/____ CRA:_____________
Endereo:____________________________________ N:_______ Bairro:________________
Escolaridade e ocupao
Alcool e Drogas
Atividade Fsica e Alimentao
Suporte de Cuidados e Dependncia
Endereo do Cuidador Auto Percepo
Doenas Crnicas
Quais os problemas de sade que acompanha?________________________________________ Tem osteoporose? ( ) Realizou densiometria no ltimo ano?( ) Doena pulmonar ( ) Doena renal ( ) Doena vascular ( ) Artrose ( ) Tem dor ( ) A dor : limitante ( ) frequentemente ( ) raramente ( ) Tem hipertenso arterial ( ) Tem diabetes ( )
Hipertenso/Diabetes
Medicamentos
Toma medicamentos diariamente ( ) Quais? (dosagem, n de vezes ao dia) _______ ____________________________________________________________________________________ __________________________________________________________________________ Para que? __________________________________________________________________ Usa medicamentos de alto custo: Demncia ( ) Parkinson ( ) Osteoartrose ( ) Dislipidemia ( ) Outros ( ) _____________________________________________________________ Foi internado no ltimo ano?______ Quantas vezes?______ Quando?______ Onde?_________ Porqu?______________________________________________ Quantos dias?__________ Sofreu queda nos ltimos 12 meses?__________ Quantas vezes?____________ Teve alguma fratura por causa dessas quedas?_____________________________ Recebeu vacina contra gripe na ltima campanha? ( ) Pneumococo? ( ) Teve gripe no ltimo ano? ( ) Ttano nos ltimos 10 anos? ( ) Teve pneumonia?( )
Programa Sade do Adulto/Idoso - Caapava
Internaes
Quedas Vacinao e Pneumonia
Assinatura do entrevistador:______________________________________________
CADERNETA DE SADE DA PESSOA IDOSA

CONSOLIDADO DA FICHA PRONTURIO ESPELHO Itens Avaliados
60 a 65 anos 66 a 69 anos
Identificao
Idade Sexo 70 a 75 76 a 79 anos anos 80 a e+ masc fem Estado civil casado solteiro
UBS/ Unidade PSF Equipe 1 Equipe 2 Equipe 3 Equipe 4 Equipe 5 Equipe 6 Equipe 7 Equipe 8 Equipe 9 Equipe 10 Equipe 11 Equipe 12 Equipe 13 Equipe 14 Equipe 15 Equipe 16 Equipe 17 Equipe 18 Equipe 19 Equipe 20 Equipe 21 Equipe 22 Equipe 23 Equipe 24 Equipe 25 Equipe 26 Equipe 27 Equipe 28 Equipe 29 Equipe 30 Equipe 31 Equipe 32 Equipe 33 Equipe 34 Equipe 35 Equipe 36 Equipe 37 Equipe 38 Equipe 39
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Equipe 40 Total parcial Total Geral
0 0
0 0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0
DE SADE DA PESSOA IDOSA

Escolaridade e Ocupao
Estado civil vivo separado outros analfa beto Escolaridade at 4 anos 4a8 anos 8 anos e+ Aposentado S N Pensioniosta S N Ocupao S N No
DO DA FICHA PRONTURIO ESPELHO
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
lcool e Droga
Fumo Frequente raramente parei S N palha tipo charuto cigarro outro nmero de cigarros / dia at 10 11 a 20 21 a 30 31 e + tempo de uso ou parada / anos at 10
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0
lcool e Drogas
Bebida alcolica tempo de uso ou parada / anos 11 a 20 21 a 30 31 e + No Frequente raramente parei S N cerveja tipo vinho pinga outro nmero de vezes / dia 1 x dia
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0
Bebida alcolica nmero de vezes / dia tempo de uso ou parada / anos 2 x dia 3e+x/dia fim sem at 10 11 a 20 21 a 30 31 e + frequente mente
realiza atividade fsica raramente parei No caminhada
qual atividade hidro
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0
0 0 0

qual atividade ginastica outro S atividade social / lazer N trabalho voluntrio S N S frutas N verduras S N legumes S N come
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
S
come carne S N S frituras N S acar N S sal N n de pessoas que moram com ele mora s at 2 3a4 5a6 7 ou + fica s maior parte tempo S
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0

fica s maior parte tempo N quem poderia cuidar s/n filha(o) filhos esposa(o) vizinho no sabe outros ele mora proximo S N necessita cuidados diaria. S N acamado S
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
Auto Percepo
acamado N cad. Rodas S N andador S N muito boa boa sua sade regular ruim muito ruim diabetes S N hipertenso S N doena vascular S
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0
0 0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
Doenas Crnicas
doena vascular N doena cardaca S N doena pulmonar S N doena renal S N artrose S N S osteoporose N densiom. em1ano S N S outras N S tem dor
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
Medicamento
tem dor N limitante frequente raramente uso diario S N endcri nas medicaes cardacas neuro/ psiq. outros 1 nmero de medicamentos/dia 2 3 4 5
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0
0 0 0
0 0
0 0
0 0
0 0
0 0 0
0 0
0 0
Medicamento
medicao de alto custo demncia S N parkinson S N osteoart. S N dislipidemia S N S outros N 1x nmero de vezes ao dia 2a3x 4a6x 7x e + 6e+ S
Internaes
internado 2009
nmero de medicamentos/dia
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0
Internaes
internado 2009 N nmero de vezes 1x 2x 3X 4x + nos ltimos 12 meses S N 1x
Quedas
nmero de vezes 2x 3X 4x + fratura nestas quedas S N gripe S N
Vacinao e Pneu
ltima campanha/ ano
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0
0 0
0 0
0 0 0
0 0
0 0 0
0 0
Vacinao e Pneumonia
ltima campanha/ ano recebeu Pneumo S N ttano S N teve gripe S N teve pneumonia S N
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
0 0 0
0 0
CADERNETA DE S
Identificao
Idade Sexo 76 a 79 anos 80 a e+ masc fem 60 a 65 anos 66 a 69 anos 70 a 75 anos
CONSOLIDADO DA
Nome paciente
0 0
0 0
Total parcial Total Geral
0 0
0 0

CONSOLIDADO DA FICHA PRONTURIO ESPELHO Escolaridade e Ocupao
Estado civil casado solteiro vivo 0 separado outros analfa beto 0 Escolaridade at 4 anos 4a8 anos 8 anos e+
0 0
0 0
Ocupao
Aposentado S N Pensioniosta S N S Ocupao N Fumo No Frequente raramente
0 0
0 0
0 0
0 0
parei S N palha charuto
tipo cigarro outro at 10
nmero de cigarros / dia 11 a 20 21 a 30
0 0
0 0
0 0
lcool e Drogas
Bebida alcolica tempo de uso ou parada / anos 31 e + at 10 11 a 20 21 a 30 31 e + No Frequente raramente parei S
e cigarros / dia
0 0
0 0
0 0
parei N cerveja vinho
tipo pinga outro 1 x dia
nmero de vezes / dia 2 x dia 3 e+ x / dia fim sem
0 0
0 0
realiza atividade fsica tempo de uso ou parada / anos at 10 11 a 20 21 a 30 31 e + frequente mente raramente parei No caminhada
qual atividade
0 0
0 0
0 0

qual atividade hidro ginastica outro S atividade social / lazer N trabalho voluntrio S N S frutas N
0 0
0 0
0 0
0 0
ca e Alimentao
come verduras S N S legumes N S carne N S frituras N S acar
0 0
0 0
0 0
0 0
0 0
n de pessoas que moram com ele acar N S sal N mora s at 2 3a4 5a6 7 ou +
fica s maior parte tempo S
0 0
0 0
0 0
0 0

fica s maior parte tempo N quem poderia cuidar s/n filha(o) filhos esposa(o) vizinho no sabe outros ele mora proximo S N
0 0
0 0
0 0
Auto Percep
necessita cuidados diaria. S N S acamado N S cad. Rodas N S andador N muito boa sua sade
0 0
0 0
0 0
0 0
0 0
Auto Percepo
sua sade boa regular ruim muito ruim S diabetes N S hipertenso N S doena vascular
0 0
0 0
0 0
0 0
Doenas Crnicas
doena vascular N S doena cardaca N S doena pulmonar N S doena renal N S artrose N
0 0
0 0
0 0
0 0
0 0
nicas
osteoporose S N densiom. em1ano S N S outras N S N tem dor limitante
0 0
0 0
0 0
0 0
0 0
tem dor frequente raramente S
uso diario N endcri nas
medicaes carda-cas neuro/ psiq. outras 1
nmero de me
0 0
0 0
0 0
Medicamento
nmero de medicamentos/dia 2 3 4 5 6e+ demncia S N S parkinson N medicao de alto custo
0 0
0 0
0 0
medicao de alto custo osteoart. S N S dislipidemia N S outros N 1x
nmero de vezes ao dia 2x 3x
0 0
0 0
0 0
0 0
Internaes
internado 2009 4x e + S N 1x nmero de vezes 2x 3X 4x + nos ltimos 12 meses S N
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
nmero de vezes 1x 2x 3X 4x + fratura nestas quedas S N gripe S N S Pneumo
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
ltima campanha/ ano recebeu Pneumo N S ttano N S teve gripe N teve pneumonia S N
0 0
0 0
0 0
0 0
CADERNETA DE SA
Identificao
Idade Sexo 76 a 79 anos 80 a e+ masc fem casado 60 a 65 anos 66 a 69 anos 70 a 75 anos
CONSOLIDADO DA FIC
Esta
Nome paciente
0 0
0 0

Estado civil solteiro vivo separado outros analfa beto Escolaridade at 4 anos 4a8 anos 8 anos e+ Aposentado S
0 0
0 0
0 0
Aposentado N
Pensioniosta S N S
Ocupao N
Fumo No Frequente raramente parei S
0 0
0 0
0 0
0 0
parei N palha charuto
nmero de cigarros / dia 11 a 20 21 a 30 31 e +
0 0
0 0
lcool e Drogas
Bebida alcolica tempo de uso ou parada / anos at 10 11 a 20 21 a 30 31 e + No Frequente raramente parei S N
0 0
0 0
tipo cerveja vinho pinga outro 1 x dia
nmero de vezes / dia 2 x dia 3 e+ x / dia fim sem at 10
tempo de uso ou parada / ano
0 0
0 0
0 0
realiza atividade fsica tempo de uso ou parada / anos 11 a 20 21 a 30 31 e + frequente mente raramente parei No caminhada
qual atividade hidro
0 0
0 0
0 0

qual atividade ginastica outro S atividade social / lazer N trabalho voluntrio S N S frutas N S verduras
0 0
0 0
0 0
0 0
0 0
ntao
come verduras N S legumes N S carne N S frituras N S acar N
0 0
0 0
0 0
0 0
0 0
n de pessoas que moram com ele sal S N mora s at 2 3a4 5a6 7 ou +
fica s maior parte tempo S N
0 0
0 0
0 0

quem poderia cuidar s/n filha(o) filhos esposa(o) vizinho no sabe outros ele mora proximo S N necessita cuidados diaria. S
0 0
0 0
0 0
Auto Percepo
necessita cuidados diaria. N S acamado N S cad. Rodas N S andador N muito boa boa sua sade
0 0
0 0
0 0
0 0
0 0
Auto Percepo
sua sade regular ruim muito ruim S diabetes N S hipertenso N S doena vascular N
0 0
0 0
0 0
0 0
Doenas Crnicas
doena cardaca S N S doena pulmonar N S doena renal N S artrose N S osteoporose
0 0
0 0
0 0
0 0
0 0
osteoporose N densiom. em1ano S N S
outras N
tem dor S N limitante frequente
0 0
0 0
0 0
0 0
0 0
uso diario raramente S N endcri nas
medicaes carda-cas neuro/ psiq. outras 1 2
nmero de medicamentos/dia
0 0
0 0
0 0
0 0
Medicamento
nmero de medicamentos/dia 3 4 5 6e+ demncia S N S parkinson N S medicao de alto custo osteoart.
0 0
0 0
0 0
0 0
medicao de alto custo osteoart. N S dislipidemia N S outros N 1x
nmero de vezes ao dia 2x 3x 4x e +
0 0
0 0
0 0
0 0
Internaes
internado 2009 S N 1x nmero de vezes 2x 3X 4x + nos ltimos 12 meses S N 1x
Quedas
nmero de vezes
0 0
0 0
0 0
0 0
Quedas
nmero de vezes 2x 3X 4x + fratura nestas quedas S N gripe S N S Pneumo N
Vacinao e Pneumoni
ltima campanha/ ano recebe
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
ltima campanha/ ano recebeu ttano S N S teve gripe N teve pneumonia S N
0 0
0 0
0 0
CADERNETA DE S
CONSOLIDADO DA Identificao
Nome paciente
0 0
0 0

Estado civil casado solteiro vivo separado outros analfa beto Escolaridade at 4 anos 4a8 anos 8 anos e+
0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
osteoporose S N densiom. em1ano S N S outras N tem dor S N limitante
0 0
0 0
0 0
0 0
0 0
uso diario frequente raramente S N endcri nas
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE S
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE S
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE S
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA D
Identificao
Idade Sexo 76 a 79 anos 80 a e+ masc 60 a 65 anos 66 a 69 anos 70 a 75 anos
CONSOLIDADO
Nome paciente
0 0
0 0

Sexo fem casado solteiro Estado civil vivo separado outros analfa beto Escolaridade at 4 anos 4a8 anos
0 0
0 0
0 0
aridade e Ocupao
Aposentado 8 anos e+ S N Pensioniosta S N S Ocupao N Fumo No Frequente
olaridade
0 0
0 0
0 0
0 0
0 0
raramente
nmero de cigarros / dia 11 a 20
0 0
0 0
0 0
lcool e Drogas
Bebida alcolica nmero de cigarros / dia 21 a 30 31 e + at 10 tempo de uso ou parada / anos 11 a 20 21 a 30 31 e + No Frequente raramente
0 0
0 0
0 0
parei S N cerveja vinho
nmero de vezes / dia 2 x dia 3 e+ x / dia
0 0
0 0
0 0
realiza atividade fsica tempo de uso ou parada / anos fim sem at 10 11 a 20 21 a 30 31 e + frequente mente raramente parei No
de vezes / dia
0 0
0 0
0 0

qual atividade caminhada hidro ginastica outro S atividade social / lazer N trabalho voluntrio S N S frutas
0 0
0 0
0 0
0 0
vidade Fsica e Alimentao

come frutas N S verduras N S legumes N S carne N S frituras N
0 0
0 0
0 0
0 0
0 0
n de pessoas que moram com ele acar S N S sal N mora s at 2 3a4 5a6 7 ou +
0 0
0 0
0 0

fica s maior parte tempo S N quem poderia cuidar s/n filha(o) filhos esposa(o) vizinho no sabe outros ele mora proximo S
0 0
0 0
0 0
ncia
ele mora proximo N necessita cuidados diaria. S N S acamado N S cad. Rodas N S andador N
0 0
0 0
0 0
0 0
0 0
Auto Percepo
sua sade muito boa boa regular ruim muito ruim S diabetes N S hipertenso N
0 0
0 0
0 0
Doenas Crnicas
doena vascular S N S doena cardaca N S doena pulmonar N S doena renal N S artrose
0 0
0 0
0 0
0 0
0 0
oenas Crnicas
artrose N S N osteoporose densiom. em1ano S N S outras N tem dor S N
0 0
0 0
0 0
0 0
0 0
uso diario limitante frequente raramente S N endcri nas
medicaes carda-cas neuro/ psiq. outras
0 0
0 0
0 0
Medicamento
nmero de medicamentos/dia 1 2 3 4 5 6e+ demncia S N S parkinson
medicao d
0 0
0 0
0 0
medicao de alto custo parkinson N S osteoart. N S dislipidemia N S outros N 1x
nmero de vezes ao dia 2x
0 0
0 0
0 0
0 0
0 0
Internaes
nmero de vezes ao dia 3x 4x e + internado 2009 S N 1x nmero de vezes 2x 3X 4x + nos ltimos 12 meses S
0 0
0 0
0 0
0 0
Quedas
nos ltimos 12 meses N 1x nmero de vezes 2x 3X 4x + fratura nestas quedas S N gripe S N
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
ltima campanha/ ano recebeu Pneumo S N S ttano N S teve gripe N teve pneumonia S N
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE S
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA D
Identificao
Idade Sexo 76 a 79 anos 80 a e+ masc 60 a 65 anos 66 a 69 anos 70 a 75 anos
CONSOLIDADO
Nome paciente
0 0
0 0

Sexo fem casado solteiro Estado civil vivo separado outros analfa beto Escolaridade at 4 anos 4a8 anos
0 0
0 0
0 0
aridade e Ocupao
Aposentado 8 anos e+ S N Pensioniosta S N S Ocupao N Fumo No Frequente
olaridade
0 0
0 0
0 0
0 0
0 0
raramente
nmero de cigarros / dia 11 a 20
0 0
0 0
0 0
lcool e Drogas
Bebida alcolica nmero de cigarros / dia 21 a 30 31 e + at 10 tempo de uso ou parada / anos 11 a 20 21 a 30 31 e + No Frequente raramente
0 0
0 0
0 0
parei S N cerveja vinho
nmero de vezes / dia 2 x dia 3 e+ x / dia
0 0
0 0
0 0
realiza atividade fsica tempo de uso ou parada / anos fim sem at 10 11 a 20 21 a 30 31 e + frequente mente raramente parei No
de vezes / dia
0 0
0 0
0 0

qual atividade caminhada hidro ginastica outro S atividade social / lazer N trabalho voluntrio S N S frutas
0 0
0 0
0 0
0 0
vidade Fsica e Alimentao

come frutas N S verduras N S legumes N S carne N S frituras N
0 0
0 0
0 0
0 0
0 0
n de pessoas que moram com ele acar S N S sal N mora s at 2 3a4 5a6 7 ou +
0 0
0 0
0 0

fica s maior parte tempo S N quem poderia cuidar s/n filha(o) filhos esposa(o) vizinho no sabe outros ele mora proximo S
0 0
0 0
0 0
ncia
ele mora proximo N necessita cuidados diaria. S N S acamado N S cad. Rodas N S andador N
0 0
0 0
0 0
0 0
0 0
Auto Percepo
sua sade muito boa boa regular ruim muito ruim S diabetes N S hipertenso N
0 0
0 0
0 0
Doenas Crnicas
doena vascular S N S doena cardaca N S doena pulmonar N S doena renal N S artrose
0 0
0 0
0 0
0 0
0 0
oenas Crnicas
artrose N S N osteoporose densiom. em1ano S N S outras N tem dor S N
0 0
0 0
0 0
0 0
0 0
uso diario limitante frequente raramente S N endcri nas
medicaes carda-cas neuro/ psiq. outras
0 0
0 0
0 0
Medicamento
nmero de medicamentos/dia 1 2 3 4 5 6e+ demncia S N S parkinson
medicao d
0 0
0 0
0 0
medicao de alto custo parkinson N S osteoart. N S dislipidemia N S outros N 1x
nmero de vezes ao dia 2x
0 0
0 0
0 0
0 0
0 0
Internaes
nmero de vezes ao dia 3x 4x e + internado 2009 S N 1x nmero de vezes 2x 3X 4x + nos ltimos 12 meses S
0 0
0 0
0 0
0 0
Quedas
nos ltimos 12 meses N 1x nmero de vezes 2x 3X 4x + fratura nestas quedas S N gripe S N
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
ltima campanha/ ano recebeu Pneumo S N S ttano N S teve gripe N teve pneumonia S N
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE S
CONSOLIDADO DA Identificao
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE S
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE S
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO DA
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
CONSOLIDADO Identificao
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
nmero de vezes / dia 2 x dia 3e+x/dia fim sem
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
Identificao
CONSOLIDADO D
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0
CADERNETA DE
CONSOLIDADO D Identificao
Nome paciente
0 0
0 0

0 0
0 0
Ocupao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
lcool e Drogas
e cigarros / dia
0 0
0 0
0 0
0 0
0 0
qual atividade
0 0
0 0
0 0

0 0
0 0
0 0
0 0
ca e Alimentao
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
Auto Percep
0 0
0 0
0 0
0 0
0 0
Auto Percepo
0 0
0 0
0 0
0 0
Doenas Crnicas
0 0
0 0
0 0
0 0
0 0
nicas
0 0
0 0
0 0
0 0
0 0
nmero de me
0 0
0 0
0 0
Medicamento
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Internaes
Que
e vezes ao dia
0 0
0 0
0 0
0 0
Quedas
Vacinao e
ltima campanh
0 0
0 0
0 0
0 0
Vacinao e Pneumonia
0 0
0 0
0 0
0 0

FICHA ESPELHO - Caderneta Do Idoso - Articuladores

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FICHA ESPELHO - Caderneta Do Idoso - Articuladores

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MINISTRIO DA SADE CADERNETA DE SADE DA PESSOA IDOSA FICHA PRONTURIO ESPELHO (COLOQUE "S" PARA SIM E "N" PARA

NO) DATA: ______ / ______ / _______

Endereo:____________________________________ N:_______ Bairro:________________

Atividade Fsica e Alimentao

Suporte de Cuidados e Dependncia

Endereo do Cuidador Auto Percepo

Quedas Vacinao e Pneumonia

CADERNETA DE SADE DA PESSOA IDOSA

Equipe 40 Total parcial Total Geral

DE SADE DA PESSOA IDOSA

DO DA FICHA PRONTURIO ESPELHO

realiza atividade fsica raramente parei No caminhada

qual atividade hidro

Atividade Fsica e Alimentao

Suporte de Cuidados e Dependncia

ltima campanha/ ano

Total parcial Total Geral

CADERNETA DE SADE DA PESSOA IDOSA

parei S N palha charuto

tipo cigarro outro at 10

nmero de cigarros / dia 11 a 20 21 a 30

parei N cerveja vinho

tipo pinga outro 1 x dia

nmero de vezes / dia 2 x dia 3 e+ x / dia fim sem

Atividade Fsica e Alimentao

fica s maior parte tempo S

Suporte de Cuidados e Dependncia

tem dor frequente raramente S

uso diario N endcri nas

medicaes carda-cas neuro/ psiq. outras 1

medicao de alto custo osteoart. S N S dislipidemia N S outros N 1x

nmero de vezes ao dia 2x 3x

Total parcial Total Geral

CADERNETA DE SADE DA PESSOA IDOSA

Fumo No Frequente raramente parei S

parei N palha charuto

tipo cigarro outro at 10

nmero de cigarros / dia 11 a 20 21 a 30 31 e +

tipo cerveja vinho pinga outro 1 x dia

nmero de vezes / dia 2 x dia 3 e+ x / dia fim sem at 10

tempo de uso ou parada / ano

qual atividade hidro

Atividade Fsica e Alimentao

n de pessoas que moram com ele sal S N mora s at 2 3a4 5a6 7 ou +

fica s maior parte tempo S N

Suporte de Cuidados e Dependncia

osteoporose N densiom. em1ano S N S

tem dor S N limitante frequente

uso diario raramente S N endcri nas

medicaes carda-cas neuro/ psiq. outras 1 2

medicao de alto custo osteoart. N S dislipidemia N S outros N 1x

nmero de vezes ao dia 2x 3x 4x e +

ltima campanha/ ano recebe

Total parcial Total Geral

CADERNETA DE SADE DA PESSOA IDOSA

parei S N palha charuto

tipo cigarro outro at 10

nmero de cigarros / dia 11 a 20 21 a 30

parei N cerveja vinho

tipo pinga outro 1 x dia

nmero de vezes / dia 2 x dia 3 e+ x / dia fim sem

Atividade Fsica e Alimentao

NO) DATA: / / ___

Endereo:________________________________ N:_ Bairro:______________