ANAMNESE DO PACIENTE

Número do prontuário: ____________ Data do atendimento:____________________

Nome:__________________________________________________________________________
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Data de nascimento: ____/____/_____ Gênero: [ ] M [ ] F [ ] ________________________

Endereço:_______________________________________________________________________
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Escolaridade:____________________________________________________________________

Profissão:_______________________________________________________________________

Peso: __________________________________ Altura: _______________________________

Alergia:_________________________________________________________________________

Pratica atividade física? Quantas vezes por semana?

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Avaliação nutricional do paciente:

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Quando você afere sua pressão, quanto acostuma ser:

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Patologia Pré-existente:
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Histórico patológico da família:
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Uso de medicações diárias:

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Faz uso de medicamento controlado? Quais medicamentos?

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Câncer? Se sim, em que local. Explique, também, se fez uso de algum uso de radioterapia,
quimioterapia ou imunoterapia.

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Realizou alguma cirurgia? Se sim, em que local.

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Consome álcool? Qual a frequência?

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Consome drogas? Qual a frequência?

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Tabagismo? Qual a frequência?

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