NUTRIO CLNICA FICHA DE ANAMNESE

ADULTO E IDOSO
Data: __/__/___ Hora:____________
INDENTIFICAO:
Nome:_________________________________________________ Data de Nascimento: _____________ Tel:_____________
Idade: _____ Sexo ( ) M ( ) F Estado civil: ________________________ Escolaridade: _____________________________
Profisso: __________________________Convnio:________________________E-mail:______________________________
HISTRIA CLNICA E NUTRICIONAL:
Motivo da consulta nutricional: ____________________________________________________________________________
J fez consulta nutricional? ( ) Sim ( ) No Antecedentes Patolgicos Familiares: __________________________________
Possui alguma patologia? _________________________________________________________________________________
Uso de medicamentos: ( ) Prescrio Mdica ( ) Venda Livre ( ) Suplemento Vitamnico e/ou Mineral
Quais? ________________________________________________________________________________________________
Alergias Alimentares: ( ) Sim ( ) No Quais alimentos?_________________________________________________________
Sente ansiedade? ( ) Sim ( ) No
De que forma isso interfere na sua rotina alimentar? ___________________________
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Apresenta sinais clnicos de desnutrio? ( ) Sim ( ) No
Quais: ___________________________________________
DADOS LABORATORIAIS:
Indicador/Unidade
Hematcrito
Hemoglobina (g/dL)
cido rico (mg/dL)
Uria (mg/dL)
Creatinina (mg/dL)
Glicemia Jejum (mg/dL)
Hemoglobina Glicada
Albumina (g/dL)
Ferro (g/dL)
Triglicerdeos (mg/dL)
LDL (mg/dL)
HDL (mg/dL)
Colesterol Total (mg/dL)

Valores
Normais*
M: 40 50%
F: 35 45%
M: 13,5 18
F: 12 16
M: 3,4 7
F: 2,4 6
10 45
M: 0,8 1,2
F: 0,6 1,0
70 100
3,6 5,3%
3,2 4,5
M: 49 181
F: 37 170
< 150
< 100

Valores obtidos
Data:__/___/___

Valores obtidos
Data:____/____/____

Valores obtidos
Data:____/____/____

> 40
< 200
21 a 54 anos:
0,4 4,2
TSH (u/L)
55 a 67 anos:
0,5 8,9
AST TGO (UI/L)
8 33
ALT TGP (UI/L)
4 36
* Manual de Nutrio Clnica, 2013.
Observaes:___________________________________________________________________________________________
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HBITOS DE VIDA:

Atividade Fsica: ( ) Sim ( ) No Freqncia/semana?_____________ Modalidade: __________________________________

Tabagista: ( ) Sim ( ) No Estilista: ( ) Sim ( ) No Ingesto de gua/dia: Copos ou Litros: _______________________
AVALIAO DO SISTEMA DIGESTRIO:
Esfago: ( ) Disfagia ( ) Odinofagia ( ) Regurgitao
Estmago: ( ) Nuseas ( ) Vmitos ( ) Dor ( ) Plenitude Gstrica ( ) Dispepsia
Intestino: ( ) Constipao ( ) Diarria ( ) Plenitude abdominal. Qual a frequncia de evacuao? _______________________

REGISTRO HABITUAL DE CONSUMO ALIMENTAR

Preparao

Refeio

Desjejum:
____hs

Lanche:
____hs

Almoo:
____hs

Lanche:
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Jantar:
____hs

Ceia:
____hs

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g/mL
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Quantidade
Medidas Caseiras
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Preferncias: ___________________________________________________________________________________________
Averses/Tabus:________________________________________________________________________________________

MEDIDAS ANTROPOMTRICAS:

Altura: ________(m)
Peso Ideal: _______(Kg)
Peso habitual: _______(Kg)
PARMETROS

1 consulta
Data:____/____/___

2 consulta
Data:____/____/____

3 consulta
Data:____/____/____

4 consulta
Data:____/____/____

Peso (Kg)
IMC (Kg/m)
C. Cintura (cm)
C. Quadril (cm)
C. Brao (cm)
CLASSIFICAO* CC:
SEXO
RISCO ELEVADO
MULHER
> 80 cm
HOMEN
> 94 cm
* OMS, 1998.

RISCO MUITO ELEVADO

> 88 cm
> 102 cm

META DE PERDA/GANHO DE PESO:

Quantos Kg? __________
Quanto tempo? _______________
EVOLUO NUTRICIONAL:
1 Consulta Data ______/_____/______
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1 Retorno Data ______/_____/______
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2 Retorno Data ______/_____/______
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3 Retorno Data ______/_____/_____
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