Pronturio Nutrio Clnica

Nome:

Data da Consulta:

Sexo: ( ) M

)F

Endereo:

Idade:

Data de Nascimento:

CEP:

Bairro:

Telefone:

Profisso:

Estado Civil: ( ) Solteiro(a)

) Casado(a)

( ) Vivo (a)

( ) Desquitado(a)

( ) Divorciado(a)

Outros ______________________________________________________________________

Queixa principal:

HDA:

HPP:

Histria Familiar:
( ) Diabetes: ___________________________ ( ) H.A.S: _________________________________
( ) Dislipidemias: _______________________ ( ) Cardiopatias: ____________________________
( ) Patologias renais: _____________________ ( ) Cncer gastrointestinais: ___________________
( ) Outros________________________________________________________________________
Histria Social:

Exame Fsico e Reviso de Sistemas

1 ) LOTE: ( ) S ( ) N
Cabea e Pescoo: Cabelos: ( ) Com queda ( ) Quebradio ( ) Ressecado

( ) Despigmentado

Outras alteraes de cabea e pescoo: ________________________________________________________

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Colorao de Conjuntiva e Mucosas: ( ) Normo ( ) Hipo ( ) Hipercorado
( ) Normo ( ) Hipo ( ) Hiperhidratado
Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

( ) Ictrico ( ) Anictrico ( ) Ciantico ( ) Aciantico

Hidratao: ( ) Normal ( ) Hipo ( ) Hiperhidratado
Exame Fsico e Reviso de Sistemas (continuao):
Dentio prpria? ( ) S ( ) N

Ausncia de peas dentrias: ( ) S ( ) N

Prtese? ( ) S ( ) N

Estado de conservao bucal: Aftas, Ulceraes e Inflamaes? ( ) S ( ) N

Xerostomia? ( ) S ( ) N
Sialorreia? ( ) S ( ) N
2) Sistema Cardiorrespiratrio: Fr:__________ irpm Fc: _________ bpm
( ) Eupneico ( ) Dispneico
( ) Bradpneico ( ) Taqpneico
( ) Eucrdico ( ) Bradcrdico ( ) Taqcrdico
3) Pele: Turgor? ( ) S ( ) N

( ) Descamativa ( ) Petquias ( ) Hipohidratada

4) Esfago / Estmago:
Disfagia ( ) S ( ) N Slidos ( ) Lquidos ( )
Odinofagia ( ) S ( ) N Slidos ( ) Lquidos ( )
Aerofagia ( ) S ( ) N
Pirose ( ) S ( ) N
Dispepsia ( ) S ( ) N
Epigastralgia ( ) S ( ) N
Nuseas ( ) S ( ) N
Vmito ( ) S ( ) N
5) Intestinos: N. de evacuaes/dia _______ Consistncia das fezes: ____________
Odor: ____________ Colorao: ____________________________
Dor ou desconforto na evacuao: ( ) S ( ) N Flatulncia ( ) S ( ) N
Funcionamento intestinal: ( ) Normal ( ) Diarreico ( ) Constipado
6) Urina: Volume de 24 horas: ( ) Normal ( ) Poliria ( ) Oligria ( ) Anria
Hematria ( ) S ( ) N
Nictria ( ) S ( ) N
Polaciria ( ) S ( ) N
7) Abdmen: ( ) Simtrico ( ) Ascite
8) Membros Superiores Alteraes ( ) S
9) Membros Inferiores Alteraes ( ) S

( ) N Quais: _______________________________
( ) N Quais: _______________________________

10) Estgios de Maturao Sexual (Diagrama de Tanner):

Genitlia: ________________
Pelos Pubianos: ________________

Atividade Fsica:

Idade Biolgica: _________________

Idade Biolgica: _________________

Frequncia e Tempo:

Cirurgias anteriores:

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Acidente fsico:
Qual? ___________________________ Como? _______________________ Quando?_________________

Medicamentos:
Histria Sexual:
J iniciou sua vida sexual: (

) Sim

( ) No

DST: ( ) S ( ) N Qual(is)? _______________________

Libido: ( ) Normal ( ) Aumentada ( ) Diminuda
Obs.:
Ciclo menstrual: ( ) Regular

( ) Irregular Obs.: ______________________________________________

TPM: ( ) Sim ( ) No
Sintomas:
Qualidade do sono:
Dorme bem? ( ) Sim ( ) No
Quantas horas por noite? ______________________
Tem pesadelos, insnia? ( ) Sim

( ) No

Obs.:

Histria Diettica:
Quantas e quais refeies faz por dia:

Temperatura das refeies: ( ) fria ( ) quente ( ) morna ( ) gelada

Consistncia:
Local onde faz as refeies: ( ) casa ( ) rua ( ) trabalho Ambiente ( ) calmo ( ) agitado
Alergias ou Averses alimentares: ( ) S ( ) N Quais? ___________________________________

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Recordatrio de 24 horas
Refeio

Alimentos

Quantidade

DESJEJUM
Local:
Horrio:

COLAO
Local:
Horrio:
ALMOO
Local:
Horrio:

LANCHE
Local:
Horrio:

JANTAR
Local:
Horrio:

CEIA
Local:
Horrio:

Obs.:

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Frequncia Alimentar
Forma de preparao Frequncia
Alimentos

Quantidade/vez

< 1x/sem

1-3x/sem

4-6x/sem

Leite
Derivados
lcteos
Carne vermelha
Carnes brancas
Vsceras
Ovos
Leguminosas
Cereais
Frutas
Hortalias A
Hortalias B
Hortalias C
Oleaginosas
Embutidos
Enlatados
Defumados/
Salgados
Acar
Doces
Infusos
Refrigerantes
Bebidas
Alcolicas
Sucos
industrializados
Adoantes
Gorduras
Condimentos
Temperos
prontos
Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

> 6x/sem

Raramente/
Nunca

Fast-food
Legenda: V = Vapor
F = Frito

Gt = Gratinado
Gr = Grelhado

D = Defumado
E = Enlatado

C = Cozido
A = Assado

Anlise do Peso
Peso atual:

Peso Terico:

Estatura:

Peso Ideal:

IMC atual:

IMC mdio:

Avaliao Nutricional
Data
Peso atual
Estatura
IMC atual
ndice IMC/Idade
ndice Est/Idade
CB
DCT
% de gordura
CMB
Cintura
Quadril
Relao C/Q
Presso Arterial

Diagnstico Nutricional:

Exames Laboratoriais
Data
Hemcias
Hemoglobina
Hematcrito
VCM
HCM
CHCM
RDW
Plaquetas
Leuccitos
Linfcitos
Glicose
Ureia
Creatinina
cido rico
Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Protena Total
Albumina
Globulina
TGO
TGP
GT
Fosfatase
Alcalina
Bilirrubina Total
Bilirrubina
Direta
Bilirrubina
Indireta
c. Glicurnico
Amilase
Lipase
Sdio
Potssio
Clcio
Ferro
Zinco
Magnsio
Lipdeos Totais
Colesterol Total
LDL
HDL
VLDL
Triglicerdeos
cido Flico
Vit. B12
Retinol srico
TSH ultrasens.
T3
T4 livre

EAS:
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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Parasitolgico (MIF de 3):

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Outros exames:
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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Clculos e caractersticas da dieta

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Prescrio Dietoterpica

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Clculo da dieta em equivalentes

Nutrientes Desjejum Colao Almoo Lanche Jantar
PTNA.
CHO S
CHO C
LIP P
LIP M
LIP S

Ceia

TOTAL

Obs.: Os lipdeos mono, poli-insaturados e saturados esto em maior quantidade do que o exposto e calculado
devido a estarem intrnsecos nos alimentos.

Clculo da dieta
Alimento

Quant.
(g/ml)

Ptna. (g)

Gil. (g)

Lip. (g)

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

Total
Kcal

EVOLUO
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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

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Questionrio de Personalidade
(Para prescrio de Florais)
1 Voc se denomina uma pessoa que sempre influenciada pela opinio alheia ou aceita a opinio alheia, mas reflete e age de
acordo com a sua opinio ou gosta que sempre a sua opinio prevalea?
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2 Qual a melhor poca de sua vida (passado, presente, futuro)?

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3 Caso se atenha ao passado, porque essa escolha?
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4 Voc se acha uma pessoa lutadora ou tem receio e procura se esconder frente vida?
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5 Voc ama sem grandes preocupaes?
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6 Como est sua vida amorosa? Suas relaes afetivas? Tem ou j teve grandes decepes? Isso ainda te incomoda? Ainda existem
mgoas?
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7 Voc muito punitiva diante das falhas ou no se preocupa quando as comete?

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

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8 Voc tem frequentemente extremos de sentimentos (raiva, angstia, tristeza, amor, dio)?
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9 Como voc acha que est sua qualidade de raciocnio consegue se concentrar nas tarefas que desempenha, desatenta, demora
para perceber as coisas?
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10 Voc feliz?
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Como voc se define:

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Como eu defino a pessoa:

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Floral(is) que pessoa se identificou durante a dinmica:

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Floral(is) que pessoa no se identificou durante a dinmica:

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Floral(is) indicados:

Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.

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Ncleos

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Observaes:

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Copyright, 2015. Mariana Braga Neves. Todos os direitos reservados.