1.

IDENTIFICAO

NOME:___________________________________________
_________________________________________________
SEXO:___________________________________________
IDADE:__________
COR: branca/parda/preta
ESTADO CIVIL:__________________________________
PROFISSO:______________________________________
NATURAL DE:____________________________________
PROCEDENTE ____________________________________
2. QUEIXA PRINCIPAL E DURAO
_________________________________________________
_________________________________________________
_________________________________________________
3.

HISTRIA DA DOENA ATUAL (HDA)

(durao total, incio, curso, caractersticas,
sintomas associados, efeitos de tratamentos,
progresso, repercusses sobre a vida do paciente,
ordem cronolgica, sintomas associados)
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
4.

REVISO DOS SISTEMAS

Sintomas gerais: alteraes do peso (em quanto tempo),

febre, calafrios, astenia, sudorese noturna , anorexia
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Pele e fneros: prurido, leses cutneas (localizao),
alopecia, alteraes da pigmentao, anormalidades nos plos
e na aparncia ungueal
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Cabea e pescoo: cefalia, cervicalgia, limitao da
movimentao do pescoo, tumoraes cervicais
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Olhos: dor ocular, acuidade visual, diplopia, fotofobia,
lacrimejamento, secreo conjuntival, escotomas visuais,
viso turva, correo com culos ou lentes de contato
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________

_________________________________________________
_________________________________________________
Ouvidos, nariz e seios da face: otalgia, algias faciais,
congesto periorbitria, epistaxe, otorria, rinorria,
obstruo nasal, espirros freqentes, gota ps-nasal,
zumbidos, acuidade auditiva, vertigem
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Cavidade Oral: odontalgia, gengivorragias, ulceraes da
mucosa, queimao ou ardncia da lngua, odinofagia,
sialose, dor em ATM
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Mamas: mastalgia, descarga mamilar, ndulos palpveis.
Ginecomastia no homem
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Respiratrio: tosse, expectorao (aspecto e quantidade),
rouquido, hemoptise, dor torcica, dispnia, chiado no trax
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Cardiovascular: precordialgia, palpitaes, dispnia de
esforo, noturna e de decbito, sncope, edema, cianose,
claudicao intermitente, veias varicosas, lceras de perna
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Gastrintestinal: disfagia, pirose, intolerncia alimentar,
eructaes, empachamento, regurgitao, epigastralgia,
clicas, ictercia, nuseas e vmitos, hematmese, hbito

intestinal (n0 de evacuaes dirias, aspecto das fezes - cor e

consistncia -, presena elementos anormais - sangue, muco
e/ou pus), tenesmo evacuatrio, dor e prurido retal,
enterorragia, melena, meteorismo, clicas, flatulncia,
obstipao intestinal
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Urinrio: dor (lombar, no flanco, vesical), disria, alteraes
miccionais, estrangria, polaciria, alteraes da cor e odor
da urina, nictria, enurese, oligria, poliria, incontinncia
urinria de esforo (mulher), gotejamento terminal e fora do
jato urinrio (homem), eliminao de clculos durante a
mico
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Genital: homem (corrimento uretral, leses genitais,
disfunes
sexuais);
mulher
(leucorria,
prurido
vulvovaginal, sangramento intermenstrual, dor plvica,
dispareunia)
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Osteoarticular: artralgias, rigidez matinal, edema articular,
limitao de movimentos, deformidades, lombalgia
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Hematopoitico:
palidez,
tendncias
hemorrgicas,
linfadenomegalias, esplenomegalia, hepatomegalia

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Endcrino: intolerncia ao frio ou ao calor, poliria, polifagia
e polidipsia, hirsutismo
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Nervoso: paresias (paralisia moderada), paralisias,
parestesias, atrofias musculares, tremores, convulses,
ausncias, perturbaes da memria (amnsia transitria ou
permanente)
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Psiquismo:
insnia,
nervosismo,
choro
freqente,
irritabilidade, tristeza, sentimento de culpa, perda de interesse
e prazer no trabalho e no lazer
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
5.

ANTECEDENTES PESSOAIS FISIOLGICOS

Condies de gestao e nascimento:__________________

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Desenvolvimento neuropsicomotor: __________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Imunizaes (BCG, DTP, anti-polio, hepatite viral, antitetanica, gripe ) ____________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Adolescncia: (puberdade, surgimentos dos caracteres
secundrios)_______________________________________
_________________________________________________
_________________________________________________
_________________________________________________
________________________________________________
Atividade sexual e vida reprodutiva (primeiro contato,
parceiros,
freqncia
de
relaes,
camisinha,
emnstruao(fluxo,
ciclo),
gestaes,
partos)
_________________________________________________
_________________________________________________
_________________________________________________

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Climatrio: (idade da mennopausa, ondas de calor,
ressecamento vaginal) _______________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Senectude: ( como o paciente se sente no ambiente familiar,
solido, viuvez, penso, aposentadoria, atividades dirias)
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
6.

HISTORIA PATOLOGICA PREGRESSA

Doenas da infncia (sarampo, catapora, rubola,

caxumba):_________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Doenas apresentadas na vida adulta ( tuberculose, DST,
hepatite, diabetes, hieprtenso arterial, cardiopatias,
epilepsias, febre reumtica, asma, aborto espontneo ou no,
disfuno
sexual)
:
___________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Antecedentes de alergia: ____________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Cirurgias:_________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Hospitalizaes:____________________________________
_________________________________________________

_________________________________________________
________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Traumatismos:_____________________________________
_________________________________________________
_________________________________________________
________________________________________________
_________________________________________________
_________________________________________________
Hemotransfuses:___________________________________
_________________________________________________
________________________________________________
Uso de drogas injetveis:____________________________
_________________________________________________
_________________________________________________
Medicaes de uso prolongado:______________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
7. HISTORIA FAMILIAR
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
8.

HISTORIA SOCIAL

Condies de habitao e higiene: ____________________

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Condies de alimentao: __________________________
_________________________________________________
_________________________________________________
_________________________________________________

_________________________________________________
_________________________________________________
Nvel de instruo: ________________________________
_________________________________________________
Histria Ocupacional: ______________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Religio: _________________________________________
Renda familiar mensal: ____________________________
Relaes interpessoais:
( se existe problema de
relacionamento na famlia se o paciente tem amigos sente
solido
tem
ressentimento
)
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Problemas psicossociais: ( maior preocupao do paciente -o
que lhe estressava antes da internao - sofreu alguma perda
importante no passado - sente-se realizado se houve
expectativas frustradas)_____________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Hbitos e costumes: tabagismo (durao, tipo de cigarro, n
de cigarros consumidos por dia), consumo de lcool
(durao, tipo de bebida, quantidade consumida), banhos de
rios audes e lagoas (localidade e poca), contato com o
triatomneo, contato com animais domsticos, prtica regular
de exerccios fsicos (tipo e freqncia), sono, lazer, viagens,
uso de drogas ilcitas
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________