Escolar Documentos
Profissional Documentos
Cultura Documentos
ALUNO(S):
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FICHA DE ANAMNESE
1. IDENTIFICAO
NOME:_____________________________________________________________________________________________
SEXO: __________________________________________
DATA DE NASCIMENTO: ____/____/______ IDADE ______________ COR: branca/parda/preta
TIPO SANGUNEO: _______________________________
ESTADO CIVIL:____________________________________ ESCOLARIDADE: ___________________________________
PROFISSO:______________________________________ RELIGIO: ________________________________________
NATURAL DE:_____________________________________ PROCEDENTE _____________________________________
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)
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4. INTERROGATRIO SINTOMATOLGICO
Sintomas gerais: alteraes do peso (em quanto tempo), febre, calafrios, astenia, sudorese noturna, anorexia
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Pele e fneros: prurido, leses cutneas (localizao), alopecia, alteraes da pigmentao, anormalidades
nos plos e na aparncia ungueal
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Olhos: dor ocular, acuidade visual, diplopia, fotofobia, lacrimejamento, secreo conjuntival, escotomas
visuais, viso turva, correo com culos ou lentes de contato
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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
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Respiratrio: tosse, expectorao (aspecto e quantidade), rouquido, hemoptise, dor torcica, dispnia,
chiado no trax
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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
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Genital: homem (corrimento uretral, leses genitais, disfunes sexuais); mulher (leucorria, prurido
vulvovaginal, sangramento intermenstrual, dor plvica, dispareunia)
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Osteoarticular: artralgias, rigidez matinal, edema articular, limitao de movimentos, deformidades, lombalgia
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Nervoso: paresias (paralisia moderada), paralisias, parestesias, atrofias musculares, tremores, convulses,
ausncias, perturbaes da memria (amnsia transitria ou permanente)
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Psiquismo: insnia, nervosismo, choro freqente, irritabilidade, tristeza, sentimento de culpa, perda de interesse
e prazer no trabalho e no lazer
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5. ANTECEDENTES PESSOAIS FISIOLGICOS
Desenvolvimento neuropsicomotor:
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Atividade sexual e vida reprodutiva (primeiro contato, parceiros, freqncia de relaes, camisinha,
menstruao(fluxo, ciclo), gestaes, partos)
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Doenas apresentadas na vida adulta ( tuberculose, DST, hepatite, diabetes, hipertenso arterial,
cardiopatias, epilepsias, febre reumtica, asma, aborto espontneo ou no, disfuno sexual):
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Antecedentes de alergia:
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Cirurgias:
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Hospitalizaes:____________________________________________________________________________________________
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Traumatismos:______________________________________________________________________________________________
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Hemotransfuses:___________________________________________________________________________________________
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8. ANTECEDENTES SOCIAIS
Condies de alimentao:
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Histria Ocupacional:
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Relaes interpessoais: ( se existe problema de relacionamento na famlia se o paciente tem amigos sente
solido - tem ressentimento )
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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)
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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
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Exame fsico
Altura _______ Peso__________ Circunferncia abdominal__________ IMC___________
Membros inferiores: unhas, dor, edema, pulsos pediosos e leses; articulaes (capacidade de flexo,
extenso, limitaes de mobilidade, edemas); ps (bolhas, sensibilidade, ferimentos, calosidades e corte das
unhas).
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Abordar/orientar sobre:
Sinais de hipoglicemia e hiperglicemia e orientaes sobre como agir diante dessas situaes;
Motivao para modificar hbitos de vida no saudveis (fumo, estresse, bebida alcolica e
sedentarismo);
Avaliar com a pessoa e a famlia o quanto as metas de cuidados foram alcanadas e o seu grau de
satisfao em relao ao tratamento.
Percepo de presena de complicaes; A doena e o processo de envelhecimento;
Insulina:30 minutos antes das refeies 1 3x/dia. A aplicao subcutnea pode ser realizada nos
braos, abdmen, coxas e ndegas.
recomendada a monitorizao da glicemia capilar trs ou mais vezes ao dia a todas as pessoas
com DM tipo 1 ou tipo 2 em uso de insulina em doses mltiplas
Estabelecer metas de controle de peso e sobre exerccio fsico.
Avaliar o conhecimento sobre os cuidados com os ps e as unhas (complicaes agudas e crnicas
de fcil identificao);Avaliar o comportamento do paciente com relao aos seus ps; Avaliar o
cuidado executado pela pessoa;
Realize 5 a 6 refeies dirias, evitando beliscar alimentos entre as refeies e permanecer longos
perodos sem se alimentar. Evite o consumo de alimentos ricos em acar.
Consuma frutas diariamente. O ideal so trs pores dirias (uma poro = 1 ma mdia ou 1
banana ou 1 fatia mdia de mamo ou 1 laranja mdia). Para evitar o aumento da glicemia, prefira
consumir as frutas acompanhadas com leite, aveia, linhaa, granola diet ou como sobremesa aps as
refeies, sendo preferencialmente com casca ou bagao, por possurem maiores quantidades de
fibras.
Evite consumir alimentos ricos em sal como embutidos. Diminua o consumo de alimentos ricos em
gordura.