FICHA DE ANAMNESE NUTRICIONAL

1. DADOS PESSOAIS:
1.1.Nome:
______________________________________________________________________
1.2. Sexo: Feminino ( ) Masculino ( )
1.3. Data de nascimento: ____/____/______. Idade: ____________________________
1.4. Estado civil: ________________________________________________________
1.5. Endereo: __________________________________________________________
Bairro: _________________________________ Complemento: __________________
CEP:________________________. Cidade: ____________________________ UF: __
1.6. Telefone residencial: ____________________ Celular: ______________________
1.7. E-mail: ____________________________________________________________
DADOS ANTROPOMTRICOS
Peso_________kg Altura___________cm
Peso almeijado_________
2. DADOS SOCIOECONMICOS:
2.1. Escolaridade:________________________________________________________
2.2. Mora com___________________________________________________________
2.8. Renda familiar: ( ) 1 a 3 salrios mnimos ( ) 4 a 7 salrios mnimos
2.9. Quantas vezes ao ms vai ao supermercado: ______________________________
3. HISTRICO CLINICO
3.1. Funcionamento do intestino: ___________________________________________
3.2. Diurese: ___________________________________________________________
3.3. Sono (horas por dia): _________________________________________________
3.4. Alergias: ___________________________________________________________
3.5.Cirurgias: ___________________________________________________________
3.6. Uso de medicamentos: ________________________________________________
3.7 Tabagismo:__________________________________________________________
3.8: Bebidas alcolicas:___________________________________________________
3.9: Patologias:__________________________________________________________
Patologia Indivduo Me Pai Irmo Avs
OBS:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
4. AVALIAO DIETTICA
A) Historia alimentar
4.1. Quantas refeies faz por dia: __________________________________________
4.2. Horrios das refeies: ________________________________________________
4.3. Onde se alimenta: ____________________________________________________
4.4. Quem prepara: ______________________________________________________
4.6. Toma liquido junto s refeies:Sim ( ) No ( )
4.7. Se alimenta em frente a TV? Sim ( ) No ( )
4.8. Mastigao: Normal ( ) Lenta ( ) Rpida ( )
4.9. Problemas de deglutio: Sim ( ) No ( )

4.10. Alimentos preferidos: ________________________________________________

4.11. Alimentos que no gosta de ingerir: _____________________________________
4.12. Intolerncias: ______________________________________________________
4.13. Como, onde usa e com que freqncia administra os seguintes itens:
Sal: _______________________________________________________________
leo: ______________________________________________________________
Shoyo: _____________________________________________________________
Ajinomoto: _________________________________________________________
Caldo concentrado: ___________________________________________________
Azeite: ____________________________________________________________
Limo: _____________________________________________________________
Vinagre: ____________________________________________________________
Margarina: __________________________________________________________
Manteiga: ___________________________________________________________
Maionese: __________________________________________________________
Acar: ____________________________________________________________
5. Freqncia de atividade fsica: ( ) vezes/semana ( )horas/dia
OBS:__________________________________________________________________
______________________________________________________________________
6. EXAME FSICO/CLINICO
6.1. Estado de:
Unha Quebradia: Sim ( ) No ( )
Queda de cabelo: Sim ( ) No ( )
Boca (gengiva, dentio): ___________________________________________
Face: ____________________________________________________________
Olhos: ___________________________________________________________
Pele: ____________________________________________________________
Nariz:____________________________________________________________
Mucosa: _________________________________________________________
Hematomas: ______________________________________________________
Abdmen: ________________________________________________________
Musculatura: _______________________________________________________
Presena de Edemas: _______________________________________________
Depresso: ________________________________________________________
Agitao: _________________________________________________________
Aparncia geral: ___________________________________________________

RECORDATRIO 24 HORAS
Refeio Horrio Alimento/preparao Quantidade e (final de semana)
Obs.:________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________