NOME:___________________________________________________ SEXO: F ( ); M ( ) IDADE:_________

DOENAS DO PACIENTE:_____________________________________________________________________
CASOS DE DOENAS NA FAMLIA:____________________________________________________________
PESO:_________ ALTURA:_________ IMC:__________ SU( ); N(

); SO( ); OB1( ); OB2( ); OB3(

ATIVIDADES FSICAS PRATICADAS:___________________________________________________________

FREQUNCIA DA ATIVIDADE FSICA PRATICADA: _____________________________________________
TIPO DE ALIMENTAO:_____________________________________________________________________
TEM HORRIO P/ AS REFEIES:___________ QUANTIDADE DE COMIDA:________________________
PRESSO ARTERIAL:____________
BAIXA(

); NORMAL(

); ALTA(

GLICEMIA:_____________
)

BAIXA(

); NORMAL(

); ALTA(

RESULTADO:_______________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
OBSERVAES:_____________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________