Ana Paula Camargo

ananutri1204@gmail.com Goiânia-GO

CRN: CRN/1-15200 Fone: 6499964-9585

Anamnese
Nome:
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Caso Clínico/ Objetivo:

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Hábitos de vida
Refeições
Refeições fora de casa

Geralmente aonde são realizadas essas refeições fora de casa?

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Geralmente consome quais alimentos fora de casa?

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Vegetariano
Não
Vegetariano(a)
Vegano(a)

Álcool
Ingestão de bebida alcoólica
Frequência ____________________________________________________________________

Tabagismo
Fumante
Frequência ____________________________________________________________________
Mora com quantas pessoas? _________________________________ Quem prepara as refeições? ____________________________
Quem realiza as compras da ____________________________________________________________________
casa?
Onde realiza as compras? ____________________________________________________________________

Quantas vezes por mês? ____________________________________________________________________

Quais tipos de frutas geralmente são comprados?

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Quais tipos de legumes, vegetais e hortaliças, geralmente são comprados?

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Quais tipos de carnes geralmente são comprados (bovina, frango, suína, peixes)?
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Litros de óleo utilizados por mês? ____________________________________________________________________

Kg de sal utilizado por mês? ____________________________________________________________________

Sono
Dorme bem
Dorme mal
Quantas horas? ____________________________________________________________________

Observações do Sono ____________________________________________________________________

Exercícios Físicos ____________________________________________________________________

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Observação ____________________________________________________________________
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Patologias
Diabetes
Osteoporose
Endócrino
Hipertensão
Cardíaco
RGE
Circulatório
Rinite/Sinusite
Dor de cabeça
Dislipidemia
Colite
Irritabilidade
Câncer
Hipoglicemia
Ansiedade
Renal
Herpes
Depressão
Hepatite
Gastrite
Hipotireoidismo
Anemia
Colesterol

Outras patologias?
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Medicamentos?
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Exames?
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Histórico familiar:
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Avaliação Clínica

Apetite
Normal
Aumentado
Diminuído
Mastigação
Normal
Rápida
Lenta
Hábito Intestinal
Normal
Constipante
Diarréico
Variado

Frequência Evacuação:
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Laxante
Faz uso
Hábito Urinário?
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Ingestão Hídrica?
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Alterações recentes de peso?

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Dietas anteriores?
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Hábitos Alimentares
Suplementos alimentares?
Alergia alimentar?
Intolerâncias alimentares?
Aversão alimentares?
Observação:
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 RECORDATÓRIO DE 24 HORAS

Refeição Hora Local Alimento Quantidade

Desjejum

Colação

Almoço

Lanche

Jantar

Ceia

Dia da semana investigado:

Este dia está na média do cosumo da semana?

Quais os dias da semana em que você consome maior quantidade?

Quais os dias da semana em que você consome menor quantidade?

 FREQUÊNCIA ALIMENTAR

Alimento Diariamente 3a4 1a2 Quinzenal Mensal Raramente

x/semana x/semana
Leite

Derivados do leite

Frutas

Verduras

Leguminosas

Massas

Doces

Frituras

Refrigerante

Suco natural

Suco artificial

Salgados

Quitandas

Salgadinho/Bolacha
(pacote)

Café

Observações: