Roteiro de Anamnese

ID
NOME:_____________________________________________________________________
IDADE:________
SEXO: ( ) FEM ( )
MAS ETNIA_________________
ESTADO CIVIL:
( )Solteiro
( )Casado
( )Vivo
( )Separado
PROFISSO:_______________________________PROFISSO ANTERIOR:_________________________________
NATURALIDADE:________________________________RESIDENTE______________________________________
QP
O que te trouxe aqui
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HDA
Cronologia____________________________________________________________________________________
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Localizao___________________________________________________________________________________
Irradiao____________________________________________________________________________________
Frequncia____________________________________________________________________________________
Intensidade___________________________________________________________________________________
Fatores desencadeantes_________________________________________________________________________
Fatores que melhoram__________________________________________________________________________
Fatores associados_____________________________________________________________________________
Exames______________________________________________________________________________________
Tratamentos__________________________________________________________________________________
HPP
VIROSES E DOENAS COMUNS NA INFNCIA:
( )Sarampo
( )Caxumba
( )Rubola
( )Meningite
( )Catapora
( )Asma Brnquica
( )Coqueluche
ALERGIAS: ( )N ( )S Quais:___________________________________________________________________
INVESTIGAES E INFESTAES
( )Chagas
( )Hepatite
( )Dengue
( )Esquistossomose
( )Hansenase
( )TB
( )Malria
( )Ttano
( )Leishmaniose
OUTRAS DOENAS:
( )DM
( )Hrnias
( )HAS
( )Cardiopatias
( )Apendicite
( )Nefropatias
( )Derrame
( )Neuropatias
CIRURGIAS: ( )N ( )S
Tipo:_______________________________________________________________________________________
Data:__________________________
Anestesia:________________________
Complicaes: ( )N ( )S
Quais:___________________________________________________________________________________
TRANSFUSES: ( )N
( )S
DOAES SANGUNEAS: ( )N ( )S
TRAUMATISMOS: ( )N ( )S
Tipo:______________________________________________________________
Data:__________________
Sequelas: ( )N ( )S
VACINAS:____________________________________________________________________________________
DOENAS VENREAS: ( )N ( )S
Quais:________________________________________________________

H. FIS
DURANTE GESTAO:
Me: Fumante ( )S ( )N
Etilista ( )S ( )N
Acidentes ( )S ( )N
Doenas ( )S ( )N
TIPO DE PARTO:
( )Domiciliar
( )Hospitalar
( )Prematuro
( ) termo
QUANDO COMEOU A ANDAR:____________________QUANDO COMEOU A FALAR:______________________
PUBERDADE:___________________________________
MENOPAUSA: ( )S ( )N
GESTAES: _______________________
ABORTOS: ( )S ( )N
HISTRIA SOCIAL
ESCOLARIDADE:________________________________________________________________________________
ALIMENTAO:________________________________________________________________________________
DORME BEM: ( )S ( )N
ETILISTA: ( )S ( )N
TABAGISTA: ( )S ( )N
DROGAS ILCITAS: ( )S ( )N
MEDICAMENTOS_______________________________________________________________________________
Doses dirias:_______________________________________________________________________________
ESPORTES:____________________________________________________________________________________
HABITAO
Tipo de casa:________________________________________________________________________________
Luz eltrica: ( )S ( )N
Abastecimento de gua:
( )Domicilio ligado rede
( )Ponto de gua coletivo
( )Outro
( )Domiclio com gua de poo
( )Ponto de gua fora
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Esgoto:
( )Ligado a rede de esgoto
( )A cu aberto
( )Fossa negra ou sptica
( )Outro _____________________________
BEBE GUA FILTRADA: ( )S ( )N
LIXO DA RESIDNCIA:
( )Coletado
( )Queimado
( )Enterrado
( )Jogado ao ar livre
QUANTAS PESSOAS VIVEM NA CASA:_________________
QUANTOS CMODOS:__________________
RENDA MENSAL:_________________
ANIMAIS DOMSTICOS: ( )S ( )N
Quais:______________________________________________________
Vacinados:___________________________________________________
TOMA BANHO DE RIO: ( )S ( )N
VIAJOU RECENTEMENTE: ( )S ( )N
Aonde:_____________________________________________________
HISTRIA FAMILIAR E FAMILIAL
DOENAS NA FAMLIA:__________________________________________________________________________
FILHOS:______________________________________________________________________________________
IRMOS:_____________________________________________________________________________________
MORTE:
Me:_____________________________________________________________________________________
Pai:______________________________________________________________________________________
OBS.:
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INTERROGATRIO SINTOMATOLGICO
ESTADO GERAL
( )Astenia
( )Febre
( )Emagrecimento
( )Cianoese
( )Adinamia
( )Calafrios
( )Sudorese
( )Ictercia
PELE/ALTERES
Colorao:__________________________________________________________________
Textura:____________________________________________________________________
Umidade:___________________________________________________________________
Leses:_____________________________________________________________________
Fneros:____________________________________________________________________
CABEA
( )Cefalias
( )Tonturas
( )Alopcia
OLHOS
( )Escotoma
Modificao da cor da esclera: ( )S ( )N ________________________
Queixas visuais:_______________________________________________________________________________
Dor:________________________________________________________________________________________
Infalmaes:_________________________________________________________________________________
OUVIDOS
Queixas auditivas:_____________________________________________________________________________
Dor:________________________________________________________________________________________
Inflamaes:_________________________________________________________________________________
( )Zumbido
( )Surdez
( )Vertigem
NARIZ E SEIOS PARANASAIS
( )Rinorria
( )Obstruo
( )Dor na face
( )Epistaxe
( )Prurido
CAVIDADE BUCAL
( )Sialorria
( )Leses
( )Halitose
( )Disfonia
( )Sangramento
( )Aftas
( )Dor
( )Alteraes da voz
( )Prtese
Estado dos dentes:______________________________________________________
PESCOO
( )Dor
( )Limitaes de movimento
( )Tumoraes
( )Pulsaes anormais
GLNGLIOS LINFTICOS (cervicais, axilares, inguinais, epitrocleanos)
Dor:________________________________________________________________________________________
Aumento de tamanho:_________________________________________________________________________
MAMAS
( )Ndulos
( )Dor________________________________________________________
( )Secreo
( )Galactorria
APARELHO RESPIRATRIO
( )Dor torcica
( )Hemoptise
( )de esforo
( )Tosse
( )Chiado
( )Dispnia
( )Expectorao
( )Estridor
( )sem esforo
APARELHO CARDIOVASCULAR
( )Dor torcica
( )Desconforto precordial
( )Palpitaes
( )Edema
( )Ortopnia
( )Dispnia paroxstica noturna
( )Cianose
APARELHO GASTRINTESTINAL
( )Tenesmo
( )Melema
( )Ictercia
( )Acolia
( )Enterorragia
( )Prurido anal
APARELHO URINRIO
Cor da urina:______________________________ Odor da urina:_________________________________
( )Clica nefrtica
( )Nictria
( )Enurese noturna
( )Incontinncia urinria
( )Estrangria
( )Disria
( )Reteno urinria
( )Hematria
( )Polaciria
( )Oligria
( )Urgncias miccionais
( )Piria
( )Poliria
( )Anria
( )Gotejamento
( )Edema facial

APARELHO GENITAL
Fluxo menstrual:_____________________________________________________________________________
( )Sangramento intermenstrual
( )Prurido
( )Secura vaginal
( )Dispareunina
( )Infeces
( )Sinusiorragia
( )Leucorria
MEMBROS/MARCHA
( )Dor
( )Artrite
( )Parestesia
( )Flogose
( )Dificuldades
( )Varizes
( )micoses
( )Fraturas
( )Claudicao
( )Flebite
( )Edema
( )Atrofia muscular
( )Artralgia
( )Tremor
COLUNA
( )Dor
( )Rigidez
( )Limitaes do movimento
( )Lombociatalgia
SISTEMA HEMATOPOITICO
( )Sangramentos
( )Anemias
( )Infeces
SISTEMA ENDCRINO
( )Intolerncia ao calor
( )Intolerncia ao frio
( )Alteraes na pele
Relao apetite/peso:________________________________________________________________________
( )Nervosismo
( )Voz rouca
( )Polidipsia
( )Apatia
( )Tremores
( )Polifagia
( )Depresso
( )Poliria
( )Hirsuitismo
SISTEMA NERVOSO
( )Sncope
( )Convulses
( )Perda da conscincia
( )Alterao da fala
Estado emocional:___________________________________________________________________________
( )Distrbios de orientao
( )Incoordenao dos movimentos
( )Distrbios de memria
( )Paralisias
( )Alteraes do sono
( )Parestesias
( )Tremores
( )Cefalias

OBS.:________________________________________________________________________________________
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