FICHA DE AVALIAÇÃO

Nome.:_______________________________________________________________________
Data de nascimento.: ____/_______/______
Sexo.: F( ) M( )
Altura.: _______________________________________
Raça.: ________________________________________
Naturalidade.: _________________________________
Estado.: __________________________________ País.: ___-
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Local de nascimento.: ___________________________________________________________
Horário do
nascimento:__________________________________________________________
Id. Cronológica.: ___________________________ Id. Corrigida.: ________________________
Peso ao Nascer.: ___________________________ Peso atual.: _________________________
Apgar.: 1ºmin_____ 5º_____

Nome da mãe.:_________________________________
Tabagista: _____________________________________
Drogas: _______________________________________
Naturalidade.:__________________________________
Estado civil.:___________________________________
Profissão.:_____________________________________
Religião.:______________________________________
Escolaridade.:__________________________________
Data de nascimento.:____________________________
Idade.:________________________________________
Contato.:______________________________________
Endereço.:_____________________________________
Data da avaliação.:______________________________

ANAMNESE
GESTAÇÃO: ( )sem complicação ( )com complicação Qual?
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PARTO: ( )sem complicação ( )com complicação. Qual?

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ACOMPANHAMENTO MÉDICO? ( )sim ( )não. Qual?

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MEDICAMENTOS: ( )sim ( )não. Qual?
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PATOLOGIAS ASSOCIADAS: ( )sim ( )não. Qual?

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EXAMES COMPLEMENTARES:_____________________________________________________
OUTRAS OBSERVAÇÕES:_________________________________________________________

QP (QUEIXA PRINCIPAL).:
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HDA(HISTÓRIA DA DOENÇA ATUAL).:

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HPP (HISTÓRIA PATOLÓGICA PREGRESSA) História Fisiológica, Familiar e Social.:

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HISTÓRIA DO PARTO, GESTAÇÃO E PÓS PARTO.:

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HISTÓRIA DO DESENVOLVIMENTO.:
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ALIMENTAÇÃO.:
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EXAME FÍSICO
SINAIS VITAIS.:______ PA(mmHg).:______
FR(ipm) .:__________ FC(bpm) .:______
Temperatura.:______

INSPEÇÃO ESTÁTICA.:______ INSPEÇÃO DINAMICA.:______

ADM.:______ TONUS.:______
FORÇA.:______ PALPAÇÃO.:______
SENSIBILIDADE.:______ EQUILIBRIO.:______
CORDENAÇÃO.:______ MARCHA.:______