Avaliação Nutricional de Gestantes

___ Consulta

Data: ___/___/___.
1)Dados Pessoais:

Nome: ____________________________________________________

Idade: ___________ Data de nascimento: ___/___/___

Profissão/ocupação: _________________________________________

Bairro: _________________________ Telefone: ___________________

2)Objetivo: __________________________________________________

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3)História Gestacional:

➢Antecedentes obstétricos:
Gesta: _________ Para:_________ Aborto:_________
Partos vaginais: _______ Cesáreas: _______ Fórceps: _______
Filhos: A termo: _______ Prematuros: _______
Nativivos: > 2500g: _______ < 2500g: _______ Natimortos: _______
Data do último parto: ____/____/____ Tipo: ( ) VG ( ) CS
Data do último aborto: ____/____/____

➢Gestação Atual:
D.U.M.: ____/____/____ → D.P.P.: ____/____/____
IG: __________ semanas
Risco gestacional (intercorrências): _____________________________
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4)História - alterações corporais:

Estado Nutricional: _______________________________________

Atividade física:____________ Freqüência:________ Tempo: ________

Tabagismo: ( ) Sim ( ) Não

Etilismo: ( ) Sim ( ) Não
Pressão arterial: ___________________

5)História clínica

História familiar: ( ) DM ( ) Eclampsia ( ) HAS ( ) Pré-eclampsia

( ) Gemelar ( ) Outras: ______________________________________
História pregressa: __________________________________________
História atual: ______________________________________________
Medicações e/ou suplementos nutricionais: _______________________
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6)Alimentação pregressa:
Dietas realizadas: ___________________________________________

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Aversões: alimentar:
7)Anamnese _________________________________________________
Preferências: _______________________________________________
Responsável pela compra dos alimentos: _________________________
Responsável pela preparação dos alimentos: _____________________
Alergia Alimentar:____________________________________________
Função intestinal: ___________________________________________
Ingestão Hídrica:____________________________________________

8)Avaliação laboratorial:

Data
Hemácias

Hemoglobina

Hematócrito

Linfócitos

Leucócitos

Plaquetas

Albumina

Colesterol Total

HDL-colesterol

LDL-colesterol

VLDL - colesterol

Triglicerídeos

Glicose
Uréia
Creatinina
Ácido úrico
Sódio
Potássio
Cálcio
Magnésio
 Ficha de Acompanhamento de Gestantes

___ Consulta
Data:
___/___/___.

Nome: ______________________________________________________Idade: ____________

Peso Atual: _______Kg Altura: _______m IMC Gestacional: _______Kg/m²

(Classificação: _______________)

Peso utilizado:
( ) Peso Pré Gestacional (PPG): _____Kg
( ) Peso Desejável (PD): ______Kg (IMC médio 20,8Kg/m²)
TMB: ______________Kcal/dia
VET: ______________ Kcal/dia F.A. utilizado: ____________
Ganho: ________Kg em 1 semana +________ Kcal/dia VET final: ___________Kcal/dia

% Kcal G g/Kg/dia
Proteínas
Glicídios
Lipídios

Anamnese: Exames, Queixas, Intercorrências, Recordatório Alimentar, Conduta.

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9) Ingestão Habitual:

Desjejum : Horário : ___________ Local: ____________________

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Colação : Horário : ___________ Local: ____________________

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Almoço : Horário : ___________ Local: ____________________

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Lanche : Horário : ___________ Local: ____________________

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Jantar : Horário : ___________ Local: ____________________

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Ceia : Horário : ___________ Local: ____________________
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10) Dados Antropométricos:

Peso Pré Gestacional: _______Kg Altura: _______m IMC Pré Gestacional: ______Kg/m²
(Classificação: _______________)
Peso Atual: _____Kg IMC Gestacional: _______Kg/m² (Classificação: _______________)

11) Cálculo para estimativa de ganho de peso durante a gestação:

12) Prescrição:
Peso utilizado:
( ) Peso Pré Gestacional (PPG): _____Kg
( ) Peso Desejável (PD): ______Kg (IMC médio 20,8Kg/m²)
TMB: ______________Kcal/dia
VET: ______________ Kcal/dia F.A. utilizado: ____________
Ganho: ________Kg em 1 semana +________ Kcal/dia VET final: ___________Kcal/dia
 % Kcal g g/Kg/dia
Proteínas
Glicídios
Lipídios

13) Conduta :

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14) Observações:
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PLANEJAMENTO DIETÉTICO PARA GESTANTE

Paciente: ______________________________________ Data da consulta: ___/___/___

Peso:_______ Altura: _______ Idade: _______ Motivo da consulta: _______________
Ganho de _____ kg por semana IMC: ________ kg/m²

Desjejum : Horário : ___________

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Colação : Horário : ___________
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Almoço : Horário : ___________
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Lanche : Horário : ___________

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Jantar : Horário : ___________
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Ceia : Horário : ___________

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