Pronturio Nutrio

Nome:
Sexo: (

Clnica:

Data da Consulta:
)M

( )F

Endereo:

Idade:

Data de Nascimento:

CEP:

Bairro:

Telefone:

Profisso:

Estado Civil: Solteiro (a) ( )

Casado (a) ( )

Vivo (a) ( )

Desquitado (a) ( ) Divorciado (a) ( )

Outros ______________________________________________________________________

Queixa principal:

HDA:

HPP:

Histria Familiar: ( ) Diabetes ______________________( ) H.A.S __________________

( ) Dislipidemias ___________________ ( ) Cardiopatias ___________________________
( ) Patologias renais _____________( ) Cncer gastrointestinais ______________________
( ) Outros__________________________________________________________________
Histria Social:

DUM:

Semana gestacional:

Data provvel do parto:

Sinais, sintomas, intercorrncias, desejos na gestao:

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Exame Fsico e Reviso de Sistemas

1 ) LOTE: ( ) S

( ) N Cabea e Pescoo: Cabelos: ( ) Com queda ( ) Quebradio ( ) Ressecado

( ) Despigmentado

Outras alteraes de cabea e pescoo: ________________________________________________________

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Colorao de Conjuntiva e Mucosas: ( ) Normo ( ) Hipo ( ) Hipercorado
( ) Normo ( ) Hipo ( ) Hiperhidratado
( ) Ictrico ( ) Anictrico ( ) Ciantico ( ) Aciantico
Hidratao: ( ) Normal ( ) Hipo ( ) Hiper-hidratado
Dentio prpria? ( ) S ( ) N Ausncia de peas dentrias: ( ) S ( ) N Prtese? ( ) S ( ) N
Estado de conservao bucal:
Aftas, Ulceraes e Inflamaes? ( ) S (
) N Xerostomia? ( ) S ( ) N Sialorreia? ( ) S ( ) N
2) Sistema Cardiorrespiratrio: Fr:__________ irpm Fc: _________ bpm
( ) Eupneico ( ) Dispneico ( ) Bradpneico ( ) Taqpneico
( ) Eucrdico ( ) Bradcrdico ( ) Taqcrdico
3) Pele: Turgor? ( ) S ( ) N

( ) Descamativa ( ) Petquias ( ) Hipohidratada

4) Esfago / Estmago:
Disfagia ( ) S ( ) N Slidos ( ) Lquidos ( )
Odinofagia ( ) S ( ) N Slidos ( ) Lquidos ( )
Aerofagia ( ) S ( ) N
Pirose ( ) S ( ) N
Dispepsia ( ) S ( ) N
Epigastralgia ( ) S ( ) N
Nuseas ( ) S ( ) N
Vmito ( ) S ( ) N
5) Intestinos: N. de evacuaes/dia _______ Consistncia das fezes: ____________
Odor: ____________ Colorao: ____________________________
Dor ou desconforto na evacuao: ( ) S ( ) N Flatulncia ( ) S ( ) N
Funcionamento intestinal: ( ) Normal ( ) Diarreico ( ) Constipado
6) Urina: Volume de 24 horas: ( ) Normal ( ) Poliria ( ) Oligria ( ) Anria
Hematria ( ) S ( ) N Nictria ( ) S ( ) N Polaciria ( ) S ( ) N
7) Abdmen: ( ) Simtrico ( ) Ascite
Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

8) Membros Superiores Alteraes ( ) S

9) Membros Inferiores Alteraes ( ) S

( ) N Quais: _______________________________
( ) N Quais: _______________________________

Atividade Fsica:

Frequncia e Tempo:

Cirurgias anteriores:

Acidente fsico:
Qual? ___________________________ Como? _______________________ Quando?_________________

Medicamentos:

Histria Sexual:
DST: ( ) S ( ) N Qual (is)? _______________________
Libido: ( ) Normal ( ) Aumentada ( ) Diminuda
Obs.:
Ciclo menstrual: ( ) Regular

( ) Irregular Obs.: ______________________________________________

TPM: ( ) Sim ( ) No
Sintomas:
Qualidade do sono:
Dorme bem? ( ) Sim ( ) No
Quantas horas por noite? ______________________
Tem pesadelos, insnia? ( ) Sim

( ) No

Obs.:

Histria Diettica:
Quantas e quais refeies faz por dia:
Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Temperatura das refeies: ( ) fria ( ) quente ( ) morna ( ) gelada

Consistncia:
Local onde faz as refeies: ( ) casa ( ) rua ( ) trabalho Ambiente ( ) calmo ( ) agitado
Alergias ou Averses alimentares: ( ) S ( ) N Quais? ___________________________________

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Recordatrio 24 horas

Refeio

Alimentos

Quantidade

DESJEJUM
Local:
Horrio:

COLAO
Local:
Horrio:

ALMOO
Local:
Horrio:

LANCHE
Local:
Horrio:

JANTAR
Local:
Horrio:

CEIA
Local:
Horrio:
Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Obs.:

Frequncia Alimentar
Forma de preparao Frequncia
Alimentos

Quantidade/vez

< 1x/sem

1-3x/sem

4-6x/sem

Leite
Derivados
lcteos
Carne vermelha
Carnes brancas
Vsceras
Ovos
Leguminosas
Cereais
Frutas
Hortalias A
Hortalias B
Hortalias C
Oleaginosas
Embutidos
Enlatados
Defumados/
Salgados
Acar
Doces
Infusos
Refrigerantes
Bebidas
Alcolicas
Sucos
industrializados
Adoantes
Gorduras
Condimentos
Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

> 6x/sem

Raramente/
Nunca

Temperos
prontos
Fast-food
Legenda: V = Vapor
F = Frito

Gt=Gratinado
Gr= Grelhado

D= Defumado
E = Enlatado

C = Cozido
A = Assado

Avaliao Nutricional
DUM:

Peso Terico:

Peso pr-gravdico:

IMC pr-gravdico:

Peso atual:

IMC atual:

Estatura:

IMC terico:

Data da
consulta
pr-natal

Ordem da
consulta

Idade
gestacional
(semanas)

Pesos
medidos
(Kg)

Ganho
ponderal em
relao ao
peso prgestacional
(Kg)

Ganho em relao ao
peso anterior (Kg)

TOTAL

SEMANAL

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

IMC
(Kg/m)

Data
CB
DCT
CMB
Presso Arterial

Diagnstico Nutricional:

DN

Ganho
Ganho
Ganho
Ganho
Ganho
previsto no 1 efetivo no previsto no 2 efetivo no efetivo no
tri
1 tri
e 3 tri
2 tri
3 tri

Ganho total
previsto na
gestao

Ganho efetivo
total na gestao

Obs.:
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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Exames Laboratoriais
Data
Hemcias
Hemoglobina
Hematcrito
VCM
HCM
CHCM
RDW
Plaquetas
Leuccitos
Linfcitos
Glicose
Ureia
Creatinina
cido rico
Protena Total
Albumina
Globulina
TGO
TGP
GT
Fosfatase
Alcalina
Bilirrubina Total
Bilirrubina
Direta
Bilirrubina
Indireta
c. Glicurnico
Amilase
Lipase
Sdio
Potssio
Clcio
Ferro
Zinco
Magnsio
Lipdeos Totais
Colesterol Total
LDL
HDL
VLDL
Triglicerdeos
cido Flico
Vit. B12
Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Retinol srico
TSH ultrasens.
T3
T4 livre

EAS:
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Parasitolgico (MIF de 3):
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Outros exames:
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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Clculos e caractersticas da dieta

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Prescrio Dietoterpica

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Clculo da dieta em equivalentes

Nutrientes Desjejum
PTNA.
CHO S
CHO C
LIP P
LIP M
LIP S

Colao

Almoo

Lanche

Jantar

Ceia

Clculo da dieta
Alimento

PTNA.

CHO.

LIP

Modificaes na conduta dietoterpica:

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

EVOLUO
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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Questionrio de Personalidade
(Para prescrio de Florais)
1 Voc se denomina uma pessoa que sempre influenciada pela opinio alheia ou aceita a opinio alheia, mas reflete e age de
acordo com a sua opinio ou gosta que sempre a sua opinio prevalea?
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2 Qual a melhor poca de sua vida (passado, presente, futuro)?

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3 Caso se atenha ao passado, porque essa escolha?
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4 Voc se acha uma pessoa lutadora ou tem receio e procura se esconder frente vida?
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5 Voc ama sem grandes preocupaes?
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6 Como est sua vida amorosa? Suas relaes afetivas? Tem ou j teve grandes decepes? Isso ainda te incomoda? Ainda existem
mgoas?
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7 Voc muito punitiva diante das falhas ou no se preocupa quando as comete?

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8 Voc tem frequentemente extremos de sentimentos (raiva, angstia, tristeza, amor, dio)?

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

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9 Como voc acha que est sua qualidade de raciocnio consegue se concentrar nas tarefas que desempenha, desatenta, demora
para perceber as coisas?
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10 Essa gravidez foi esperada ou acidental?

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11 - Seu cnjuge, companheiro ou namorado est feliz com a gravidez? Qual a expectativa dele para o filho?
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12 Voc j ama os eu filho incondicionalmente?

(

) Sim

( ) No

Porque?
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13 Quais as suas expectativas para esse filho?

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14 Voc feliz?
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Como voc se define:

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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Como eu defino a pessoa:

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Floral (is) que a pessoa se identificou durante a dinmica:

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Floral (is) que a pessoa no se identificou durante a dinmica:

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Floral (is) indicados:

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Ncleos:

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Observaes:

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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.