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9.

2 MODELO PROTOCOLO CONSULTA DIETOTERPICA


CONSULTA DIETOTERPICA SERVIO DE NUTRIO PROGRAMA DE PROMOO DE
SADE NA INFNCIA
1
2

Nome da criana: ____________________________________________________________________


2. Sexo: ( ) M ( ) F
3. Categoria: ( ) Comercirio/Dependente
4.

( ) Conveniado ( ) Usurio

Nmero

da

matrcula:

__________________________________________________________________
5. Data de nascimento: ___/___/___ 6. Idade: __________________
7. Nome dos pais: ______________________________________________________________________
8. Endereo: __________________________________________________________________________
_____________________________________________________________________________________
9. Telefones de contato: ________________________________________________________________
10. E-mail: ___________________________________________________________________________
11. Histria Patolgica Pregressa: (

) HAS

) Diabetes

) Anemia

Hipercolesterolemia
(

)Hipertrigliceridemia

) Doena Celaca

) Intolerncia Lactose

) Outros

) Outros

___________
12. Histrico familiar: (

) HAS

) Diabetes

) Cncer

) Obesidade

______
12.1.

Quem?

____________________________________________________________________________
13. Atividade fsica: (

) Sim

) No

13.1. Qual?

_____________________________________
13.2.

Frequncia:

_________________________________________________________________________
14.

Mastigao:

__________________________________________________________________________
15.

Ingesto

hdrica:

______________________________________________________________________
16.

Frequncia

de

evacuao:

______________________________________________________________
17. Faz uso de suplemento nutricional?

) Sim

) No

Qual?

________________________
SESC-SC
DPS - Programa Sade
Educao em Sade

18. Uso de medicamentos:


Medicao

Concentrao

Quantidade

Freqncia

Data: ___/___/___

Data: ___/___/___

Data: ___/___/___

19. Exames:
Tipo
Colesterol total
HDL
LDL
Triglicerdeos
Glicemia
Outros

20. Nmero de pessoas na residncia: ______________________________________________________


21. Onde realiza as refeies? ____________________________________________________________
22.

Tem

alguma

intolerncia/restrio

alimentar?

____________________________________________
23. Avaliao Antropomtrica:
Data

Peso (kg)

Altura (m)

IMC/Curva

Diagnstico Nutricional

24. Plano alimentar inicial:


VCT:

____________________

CHO:

_______________

PTN:

________________

LIP:

_______________
Fibras:
________________________________________________________________________________
Vitaminas:___________________________________________________________________________
Minerais:____________________________________________________________________________
RECORDATRIO 24 HORAS
Refeio/Lanche

Alimentos

Medida Caseira

Desjejum
Lanche da manh
Almoo
SESC-SC
DPS - Programa Sade
Educao em Sade

Lanche da tarde
Jantar
Ceia
Evoluo:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________________

9.3 MODELO PLANO ALIMENTAR


PLANO ALIMENTAR PROGRAMA DE PROMOO DE SADE NA INFNCIA
Nome da criana: _______________________________________________________________
Nome do responsvel: ___________________________________________________________
Descrio do Plano:______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
SESC-SC
DPS - Programa Sade
Educao em Sade

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

______________________________________________
Nutricionista responsvel

SESC-SC
DPS - Programa Sade
Educao em Sade