1.

IDENTIFICAÇÃO

NOME:___________________________________________
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SEXO:___________________________________________
IDADE:__________
COR: branca/parda/preta
ESTADO CIVIL:__________________________________
PROFISSÃO:______________________________________
NATURAL DE:____________________________________
PROCEDENTE ____________________________________
2. QUEIXA PRINCIPAL E DURAÇÃO
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3.

HISTÓRIA DA DOENÇA ATUAL (HDA)
(duração total, início, curso, características,
sintomas associados, efeitos de tratamentos,
progressão, repercussões sobre a vida do paciente,
ordem cronológica, sintomas associados)
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4.

INTERROGATÓRIO SINTOMATOLÓGICO

Sintomas gerais: alterações do peso (em quanto tempo),
febre, calafrios, astenia, sudorese noturna , anorexia
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Pele e fâneros: prurido, lesões cutâneas (localização),
alopecia, alterações da pigmentação, anormalidades nos pêlos
e na aparência ungueal
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Cabeça e pescoço: cefaléia, cervicalgia, limitação da
movimentação do pescoço, tumorações cervicais
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Olhos: dor ocular, acuidade visual, diplopia, fotofobia,
lacrimejamento, secreção conjuntival, escotomas visuais,
visão turva, correção com óculos ou lentes de contato
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Ouvidos, nariz e seios da face: otalgia, algias faciais,
congestão periorbitária, epistaxe, otorréia, rinorréia,
obstrução nasal, espirros freqüentes, gota pós-nasal,
zumbidos, acuidade auditiva, vertigem
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Cavidade Oral: odontalgia, gengivorragias, ulcerações da
mucosa, queimação ou ardência da língua, odinofagia,
sialose, dor em ATM
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Mamas: mastalgia, descarga mamilar, nódulos palpáveis.
Ginecomastia no homem
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Respiratório: tosse, expectoração (aspecto e quantidade),
rouquidão, hemoptise, dor torácica, dispnéia, chiado no tórax
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Cardiovascular: precordialgia, palpitações, dispnéia de
esforço, noturna e de decúbito, síncope, edema, cianose,
claudicação intermitente, veias varicosas, úlceras de perna
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Gastrintestinal: disfagia, pirose, intolerância alimentar,
eructações, empachamento, regurgitação, epigastralgia,
cólicas, icterícia, náuseas e vômitos, hematêmese, hábito

intestinal (n0 de evacuações diárias, aspecto das fezes - cor e
consistência -, presença elementos anormais - sangue, muco
e/ou pus), tenesmo evacuatório, dor e prurido retal,
enterorragia, melena, meteorismo, cólicas, flatulência,
obstipação intestinal
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Urinário: dor (lombar, no flanco, vesical), disúria, alterações
miccionais, estrangúria, polaciúria, alterações da cor e odor
da urina, nictúria, enurese, oligúria, poliúria, incontinência
urinária de esforço (mulher), gotejamento terminal e força do
jato urinário (homem), eliminação de cálculos durante a
micção
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Genital: homem (corrimento uretral, lesões genitais,
disfunções
sexuais);
mulher
(leucorréia,
prurido
vulvovaginal, sangramento intermenstrual, dor pélvica,
dispareunia)
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Osteoarticular: artralgias, rigidez matinal, edema articular,
limitação de movimentos, deformidades, lombalgia
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Hematopoiético:
palidez,
tendências
hemorrágicas,
linfadenomegalias, esplenomegalia, hepatomegalia

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Endócrino: intolerância ao frio ou ao calor, poliúria, polifagia
e polidipsia, hirsutismo
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Nervoso: paresias (paralisia moderada), paralisias,
parestesias, atrofias musculares, tremores, convulsões,
ausências, perturbações da memória (amnésia transitória ou
permanente)
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Psiquismo:
insônia,
nervosismo,
choro
freqüente,
irritabilidade, tristeza, sentimento de culpa, perda de interesse
e prazer no trabalho e no lazer
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5.

ANTECEDENTES PESSOAIS FISIOLÓGICOS

Condições de gestação e nascimento:__________________
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Desenvolvimento neuropsicomotor: __________________
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Imunizações (BCG, DTP, anti-polio, hepatite viral, antitetanica, gripe ) ____________________________________
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Adolescência: (puberdade, surgimentos dos caracteres
secundários)_______________________________________
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Atividade sexual e vida reprodutiva (primeiro contato,
parceiros,
freqüência
de
relações,
camisinha,
emnstruação(fluxo,
ciclo),
gestações,
partos)
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Climatério: (idade da mennopausa, ondas de calor,
ressecamento vaginal) _______________________________
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Senectude: ( como o paciente se sente no ambiente familiar,
solidão, viuvez, pensão, aposentadoria, atividades diárias)
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6.

ANTECEDENTES PESSOAIS PATOLÓGICOS

Doenças da infância (sarampo, catapora, rubéola,
caxumba):_________________________________________
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Doenças apresentadas na vida adulta ( tuberculose, DST,
hepatite, diabetes, hieprtensão arterial, cardiopatias,
epilepsias, febre reumática, asma, aborto espontâneo ou não,
disfunção
sexual)
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Antecedentes de alergia: ____________________________
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Cirurgias:_________________________________________
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Hospitalizações:____________________________________
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Traumatismos:_____________________________________
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Hemotransfusões:___________________________________
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Uso de drogas injetáveis:____________________________
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Medicações de uso prolongado:______________________
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7. ANTECEDENTES FAMILIARES
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8.

ANTECEDENTES SOCIAIS

Condições de habitação e higiene: ____________________
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Condições de alimentação: __________________________
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Nível de instrução: ________________________________
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História Ocupacional: ______________________________
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Religião: _________________________________________
Renda familiar mensal: ____________________________
Relações interpessoais:
( se existe problema de
relacionamento na família – se o paciente tem amigos – sente
solidão
tem
ressentimento
)
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Problemas psicossociais: ( maior preocupação do paciente -o
que lhe estressava antes da internação - sofreu alguma perda
importante no passado - sente-se realizado – se houve
expectativas frustradas)_____________________________
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Hábitos e costumes: tabagismo (duração, tipo de cigarro, nº
de cigarros consumidos por dia), consumo de álcool
(duração, tipo de bebida, quantidade consumida), banhos de
rios açudes e lagoas (localidade e época), contato com o
triatomíneo, contato com animais domésticos, prática regular
de exercícios físicos (tipo e freqüência), sono, lazer, viagens,
uso de drogas ilícitas
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