Roteiro para Anamnese | MAYARA FARIA TXXVII B

IDENTIFICAÇÃO
Nome:________________________________________________________________________________________
Idade:______ Sexo/Gênero:____ Cor/Etnia: Branca( ) Parda( ) Indígena( ) Asiático( ) Estado Civil: Casado( )
Solteiro( ) Viúvo( ) Outros:____________________________________
Natural De: __________________________________________
Procedente De:___________________________________________________
Residência (Rua, Número, Bairro, Cidade, Uf):_________________________________________________________
Religião:________________________ Plano De Saúde( )
Nome Da Mãe__________________________________________________________________________________
Escolaridade:__________________________________________
Nome Do Cuidador (Responsável/Cuidador/Acompanhante): _____________________________________________
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Profissão: ___________________________________ Local De Trabalho: ___________________________________

QUEIXA PRINCIPAL OU MOTIVO DA DOENÇA

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HISTÓRIA ATUAL DA DOENÇA

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Como avaliar o sintoma:
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1. Início
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2. Intensidade (1 a 10)
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3. Localização
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4. Características (duração, e
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tipo – pontada,
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formigamento...)
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5. Concomitantes
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6. Irradiação
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7. Atenuantes
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8. Agravantes
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9. Frequência
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10. Está sentindo agora?
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INTERROGATÓRIO SINTOMATOLÓGIGO
 Sintomas Gerais
Febre( ) Astenia( )
Alteração Do Peso – Quanto, Quando E Motivo__________________________________________________
Sudorese – Generalizada Ou Localizada_______________________________________________________
Calafrios – Relacionado Ou Não Com A Febre___________________________________________________
 Roteiro para Anamnese | MAYARA FARIA TXXVII B
Obs.:___________________________________________________________________________________
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 Pele E Fâneros
Alterações Na Pele – Cor, Textura, Umidade, Temperatura, Sensibilidade, Prurido, Lesões________________
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Queda De Cabelo( ) Pelos Nos Rosto – F( ) Alterações Nas Unhas___________________________________
Exposição Solar – Hora, Com Ou Sem Uso De Protetor____________________________________________
Obs.:___________________________________________________________________________________
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 Crânio, Face E Pescoço
Dor____________________________________________________________________________________
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Alterações_______________________________________________________________________________
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 Olhos
Dor Ocular( ) Cefaleia relacionada( ) Sensação De Corpo Estranho( ) Prurido( ) Queimação Ou Ardência( )
Lacrimejamento( ) Ressecamento( ) Xantopsia – Amarelo( ) Iantopsia – Violeta( ) Doropsia – Verde( )
Diminuição Ou Perda Da Visão – Uni Ou Bilateral, Súbita Ou Gradual, Relação Com A Luz, Visão Noturna,
Correção________________________________________________________________________________
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Diplopia( ) Fotofobia( ) Nistagmo – Movimento( ) Estocomas – Manchas No Campo Visual( ) Secreção( )
Vermelhidão( ) Alucinações Visuais( ) Uso De Óculos Ou Lentes( )
Visita Ao Oftalmologista_____________________________
Obs.:___________________________________________________________________________________
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 Ouvidos
Dor____________________________________________________________________________________
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Otorreia( ) Otorragia( ) Zumbidos( ) Vertigem( ) Tontura( )
Transtornos De Acuidade___________________________________________________________________
Uso De Aparelhos Auditivos( ) Poluição Sonora( )
Obs.:___________________________________________________________________________________
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 Nariz E Cavidades Paranasais
Prurido( ) Dor( ) Obstrução Nasal( ) Epistaxe( ) Alterações Olfatórias( ) Alteração Na Fonação( )
Espirros – Isolados Ou Crise E Fatores Desencadeantes___________________________________________
Rinorréia – Aspecto E Odor _________________________________________________________________
Obs.:___________________________________________________________________________________
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 Cavidade Bucal E Anexos
Sialose( ) Halitose( )
Dor - Dente, Glândulas Salivares, Glossalgia, Na Articulação _______________________________________
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Ulcerações/Sangramento___________________________________________________________________
Visita Ao Odontólogo__________________________________________
Obs.:___________________________________________________________________________________
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 Faringe
Dor De Garganta – Espontânea Ou Na Deglutição________________________________________________
Pigarro( ) Ronco( )
 Roteiro para Anamnese | MAYARA FARIA TXXVII B
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 Laringe
Alteração Na Voz – Disfonia, Afonia, Voz Lenta E Monótona, Fanhosa Ou Anasalada_____________________
Obs.:___________________________________________________________________________________
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 Tireoide E Paratireoides
Dor – Espontânea Ou Na Deglutição___________________________________________________________
Nódulo( ) Bócio( ) Rouquidão( )
Obs.:___________________________________________________________________________________
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 Vasos E Linfonodos
Dor____________________________________________________________________________________
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Adenomegalias___________________________________________________________________________
Pulsações Ou Turgência Jugular ( )
Obs.:___________________________________________________________________________________
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 Mamas
Dor____________________________________________________________________________________
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Nódulos_________________________________________________________________________________
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Secreção – Uni Ou Bilateral, Espontânea Ou Provocada E Aspecto___________________________________
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Autoexame( ) Última Mamografia_______________ Último Ultrassom____________________
Obs.:___________________________________________________________________________________
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 Sistema Respiratório
Dor____________________________________________________________________________________
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Alteração Da Forma Torácica( ) Compressão( ) Tiragem – Aumentos Dos Espaços Intercostais( )
Dispneia E Com O Que Está Relacionada_______________________________________________________
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Tosse – Seca Ou Com Expectoração, Frequência, Intensidade, Tonalidade, Relação Com O Decúbito, Período
De Predominância_________________________________________________________________________
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Expectoração____________________________________________________________________________
Hemoptise( ) Vômica – Eliminação De Pus Ou Liquido Mucoide Ou Seroso( ) Chieira( ) Cornagem/Estritor( )
Soluços – Isolados Ou Em Crise ______________________________________________________________
Exposição A Alergênicos____________________________________ Última Radiografia Do Tórax_________
Obs.:___________________________________________________________________________________
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 Sistema Cardiovascular
Dor____________________________________________________________________________________
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Palpitações – Tipo De Sensação, Horário, Modo De Instalação E Desaparecimento, Relação Com Esforço Ou
Outros Fatores___________________________________________________________________________
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Intolerância Aos Esforços( ) Desmaio( ) Síncope( ) Cianose( ) Astenia( ) Sudorese Fria( )
Alterações No Sono_______________________________________________________________________
Edema__________________________________________________________________________________
Exposição A Fatores Estressantes( ) Último Check-Up Cardiológico_____________________________
Obs.:___________________________________________________________________________________
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 Roteiro para Anamnese | MAYARA FARIA TXXVII B
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 Sistema Digestório
Dor____________________________________________________________________________________
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Disfagia( ) Onidofagia – Dor Retroesternal Ao Deglutir( ) Dor Não Associada À Deglutição( ) Pirose( )
Regurgitação( ) Eructação( ) Soluço( ) Hematêmese( ) Sialose( ) Vômito( )
Alterações No Apetite______________________________________________________________________
Diarréia_________________________________________________________________________________
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Enterorragia – Hemorragia Intestinal( ) Epigastralgia( ) Esteatorreia( ) Flatulências( ) Melena( )
Incontinência Fecal( ) Náuseas( ) Prurido Anal( ) Regurgitações( ) Sangramento Anal( )
Uso De Antiácidos E Laxantes( ) Icterícia – Relacionada A Bilirrubina( )
Ritmo Intestinal___________________________________________________________________________
Obs.:___________________________________________________________________________________
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 Sistema Urinário
Dor____________________________________________________________________________________
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Alterações Miccionais______________________________________________________________________
Volume E Ritmo Urinário____________________________________________________________________
Cor Da Urina _____________________________________________________________________________
Edema__________________________________________________________________________________
Febre___________________________________________________________________________________
Obs.:___________________________________________________________________________________
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 Sistema Genital Masculino
Dor____________________________________________________________________________________
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Lesões Penianas__________________________________________________________________________
Nódulos No Testículo( ) Priapismo( ) Hemospermia( ) Corrimento____________________________________
Disfunções Sexuais_____________________________________________________________________
Autoexame( ) Último Exame Prostático___________________________ Preservativos( )
Obs.:___________________________________________________________________________________
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 Sistema Genital Feminino
Ciclo Menstrual – Menarca E Duração Dos Ciclos_________________________________________________
Distúrbios Menstruais______________________________________________________________________
TPM( ) Hemorragias( ) Corrimento____________________________________________________________
Prurido( ) Disfunção Sexual__________________________________________________________________
Menopausa E Climatério____________________________________________________________________
Último Exame Ginecológico___________________________ Preservativos( ) Reposição Hormonal( )
Obs.:___________________________________________________________________________________
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 Sistema Hemolinfopoético
Adenomegalias( ) Esplenomegalia( ) Hepatomegalia( )
Obs.:___________________________________________________________________________________
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 Sistema Endócrino
Dor____________________________________________________________________________________
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Alterações No Desenvolvimento Físico_________________________________________________________
Alterações No Desenvolvimento Sexual________________________________________________________
Alterações Na Tireoide( ) Nódulo( ) Bócio( ) Sintomas De Hiperfunção Ou Hipofunção( ) Gônadas( )
Obs.:___________________________________________________________________________________
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 Roteiro para Anamnese | MAYARA FARIA TXXVII B

 Sistema Osteoarticular E Muscular

Dor____________________________________________________________________________________
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Cãibra( ) Astenia( ) Mialgia( ) Atrofia( ) Deformidades Ósseas( ) Deformidades Articulares( ) Edema( )
Sinais De Inflamação( ) Espasmos( ) Limitação( ) Rigidez( )
Obs.:___________________________________________________________________________________
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 Sistema Nervoso
Dor____________________________________________________________________________________
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Distúrbios De Consciência( ) Tontura/Vertigem( ) Convulsões( ) Traumatismos( ) Automatismo( )
Distúrbios De Marcha( ) Distúrbios De Motricidade Voluntária( ) Distúrbios De Sensibilidade( )
Distúrbios Esfincterianos( ) Disfunção De Funções Cerebrais________________________________________
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Andadores, Bengala Ou Cadeira De Rodas( ) Fisioterapia( )
Obs.:___________________________________________________________________________________
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 Exame Psíquico E Condições Emocionais
Alucinações( ) Angústia( ) Ansiedade( ) Atos Compulsivos( ) Claustrofobia( ) Agorafobia( )
Consciência E Atenção_____________________________________________________________________
Tricofagia( ) Onicofagia( ) Sensação De Medo Constante( ) Toques( ) Vômitos Induzidos( )
Humor_______________________________ Orientação_______________________________________
Memória_______________________________ Ordem De Pensamento____________________________
Obs.:___________________________________________________________________________________
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ANTECEDENTES PESSOAIS FISIOLÓGICOS

Pré-Natal( ) Condições De Parto__________________________________________________________
Quantidade De Irmãos__________ Ordem De Nascimento___________ Aproveitamento Escolar_________________
Desenvolvimento Físico____________________________ Dentição_______________________________________
Engatinhar__________ Andar_________________ Falar______________ Controle Dos Esfíncteres_____________
Menarca_________________ Menopausa______________ Orientação Sexual__________________________
Sexarca____________ Desenvolvimento Sexual_______________
Vida Sexual___________________________________________________________________________
Obs.:_________________________________________________________________________________________
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ANTECEDENTES PESSOAIS PATOLÓGICOS

Doenças Da Infância_____________________________________________________________________________
Traumatismos E Acidentes________________________________________________________________________
Doenças Graves E/Ou Crônicas____________________________________________________________________
Cirurgias E/Ou Internações________________________________________________________________________
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Transfusões Sanguíneas__________________________________________________________________________
História Obstétrica: Gesta____ Para____ Aborto ____(Espontâneo Ou Provocado) Prematuro ____ Cesariana____
Vacinas_______________________________________________________________________________________
Alergias_______________________________________________________________________________________
Medicamentos__________________________________________________________________________________
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Viagens Recentes_______________________________________________________________________________
Obs.:_________________________________________________________________________________________
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 Roteiro para Anamnese | MAYARA FARIA TXXVII B

ANTECEDENTES FAMILIARES
Avós_________________________________________________________________________________________
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Cônjuge_______________________________________________________________________________________
Filhos_________________________________________________________________________________________
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Mãe__________________________________________________________________________________________
Pai___________________________________________________________________________________________
Tios__________________________________________________________________________________________
Primos________________________________________________________________________________________
Obs.:_________________________________________________________________________________________
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HÁBITOS DE VIDA
Alimentação____________________________________________________________________________________
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Atividade Física_________________________________________________________________________________
Tabagismo – Cigarros Dia/20 X Anos________________________________________________________________
Etilismo_______________________________________________________________________________________
Uso De Drogas Ilícitas____________________________________________________________________________
Anabolizante___________________________________________________________________________________
Obs.:_________________________________________________________________________________________
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CONDIÇÕES SOCIOECONÔMICAS E CULTURAIS

Quantidade De Cômodos___________ Tipo De Construção____________________________ Saneamento Básico( )
Coleta De Lixo( ) Tipo De Água_______________________________
Condições Econômicas___________________________________________________________________________
Animais De Estimação E Sua Vacinação_____________________________________________________
Contato Com Pessoas E/Ou Animais Doentes_________________________________________________
Vida Conjugal E Convívio Familiar___________________________________________________________________
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Lazer_________________________________________________________________________________________
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Obs.:_________________________________________________________________________________________
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