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IDENTIFICAÇÃO _________________________________________________
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NOME:___________________________________________ _________________________________________________
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SEXO:___________________________________________ _________________________________________________
IDADE:__________ COR: branca/parda/preta _________________________________________________
ESTADO CIVIL:__________________________________ _________________________________________________
PROFISSÃO:______________________________________ _________________________________________________
NATURAL DE:____________________________________ _________________________________________________
PROCEDENTE ____________________________________ _________________________________________________
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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
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_________________________________________________ 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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_________________________________________________ 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,
Ouvidos, nariz e seios da face: otalgia, algias faciais, enterorragia, melena, meteorismo, cólicas, flatulência,
congestão periorbitária, epistaxe, otorréia, rinorréia, obstipação intestinal
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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_________________________________________________ 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
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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_________________________________________________ Genital: homem (corrimento uretral, lesões genitais,
_________________________________________________ disfunções sexuais); mulher (leucorréia, prurido
_________________________________________________ vulvovaginal, sangramento intermenstrual, dor pélvica,
_________________________________________________ dispareunia)
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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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_________________________________________________ Osteoarticular: artralgias, rigidez matinal, edema articular,
_________________________________________________ limitação de movimentos, deformidades, lombalgia
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Gastrintestinal: disfagia, pirose, intolerância alimentar, Hematopoiético: palidez, tendências hemorrágicas,


eructações, empachamento, regurgitação, epigastralgia, linfadenomegalias, esplenomegalia, hepatomegalia
cólicas, icterícia, náuseas e vômitos, hematêmese, hábito
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Endócrino: intolerância ao frio ou ao calor, poliúria, polifagia _________________________________________________
e polidipsia, hirsutismo _________________________________________________
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_________________________________________________ Climatério: (idade da mennopausa, ondas de calor,
_________________________________________________ ressecamento vaginal) _______________________________
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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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_________________________________________________ Senectude: ( como o paciente se sente no ambiente familiar,
_________________________________________________ solidão, viuvez, pensão, aposentadoria, atividades diárias)
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Psiquismo: insônia, nervosismo, choro freqüente, _________________________________________________
irritabilidade, tristeza, sentimento de culpa, perda de interesse _________________________________________________
e prazer no trabalho e no lazer
_________________________________________________ 6. ANTECEDENTES PESSOAIS PATOLÓGICOS
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_________________________________________________ Doenças da infância (sarampo, catapora, rubéola,
_________________________________________________ caxumba):_________________________________________
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5. ANTECEDENTES PESSOAIS FISIOLÓGICOS _________________________________________________

Condições de gestação e nascimento:__________________ 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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Desenvolvimento neuropsicomotor: __________________ _________________________________________________
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Antecedentes de alergia: ____________________________
Imunizações (BCG, DTP, anti-polio, hepatite viral, anti- _________________________________________________
tetanica, gripe ) ____________________________________ _________________________________________________
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_________________________________________________ Cirurgias:_________________________________________
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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)
_________________________________________________ Hospitalizações:____________________________________
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_________________________________________________ Nível de instrução: ________________________________
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_________________________________________________ História Ocupacional: ______________________________
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Traumatismos:_____________________________________ _________________________________________________
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_________________________________________________ Religião: _________________________________________
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_________________________________________________ Renda familiar mensal: ____________________________
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Relações interpessoais: ( se existe problema de
Hemotransfusões:___________________________________ relacionamento na família – se o paciente tem amigos – sente
_________________________________________________ solidão - tem ressentimento )
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Uso de drogas injetáveis:____________________________ _________________________________________________
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Medicações de uso prolongado:______________________ _________________________________________________
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Problemas psicossociais: ( maior preocupação do paciente -o
7. ANTECEDENTES FAMILIARES 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,
8. ANTECEDENTES SOCIAIS uso de drogas ilícitas
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Condições de habitação e higiene: ____________________ _________________________________________________
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Condições de alimentação: __________________________ _________________________________________________
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