AVALIAÇÃO GERIÁTRICA AMPLA

Nome:_____________________________________________________________________________________
Idade:____________ Data:____/____/____

1. Queixa Principal / Motivo da Consulta e HDA:_________________________________________________

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2. ISDA / Revisão de Sistemas:

A) Geral:
- Perda de peso (Kg/tempo):_______________________ B) Pele e Anexos:
- Astenia - Xerose
- Febre - Prurido
- Sono:_________________________________________ - Lesões por pressão:_____________________________

D) Sistema Cardiovascular:
C) Sistema Respiratório:
- Palpitação
- Dispnéia
- Dor pré cordial
- Sibilos
- Ortopneia / DPN
- Tosse (caracterizar):_____________________________
- Edema MMII
E) Sistema Digestivo:
- Disfagia Sólidos Líquidos
F) Sistema Nervoso:
- Pirose
- Tremores (caracterizar):_________________________
- Náusea / Vômitos:
- Rigidez / Bradicinesia
- Dor epigástrica / Abdominal
- Tontura/ Lipotimia/ Sincope
(caracterizar):__________________________________
- Parestesia / Alteração de Sensibilidade
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- Paresia / Alteração de Força
- Hábito Intestinal:
- Alteração de Equilíbrio
Frequência e aspecto fezes:_______________________
- Convulsão
Alteração recente? Uso de laxantes?________________
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H) Sistema Musculoesquelético:
G) Psiquiátrico: - Atrofia Muscular
- Humor:________________________________________ - Dor / Artralgias / Rigidez Matinal
- Sintomas psicóticos - Deformidades Articulares _____________________

J) Aparelho Gênito-Urinário:
- Disúria
I) Sensorial (uso de próteses / última avaliação):
- Polaciúria / Nocturia
- Visão ________________________________________
- Incontinência urgência esforço mista
- Audição ______________________________________
- Prostatismo
- Olfato ________________________________________
- Queixas Climatéricas/ Sexualidade
- Última Avaliação Ginecologista: ___/___/___

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3. Medicamentos em uso ou que já usou (especificar porque parou e há quanto tempo):

Medicamento Dose Posologia Tempo de uso

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)

4. Hábitos:
- Etilismo: NÃO SIM Dose diária: ______________________________________________________
- Tabagismo: NÃO SIM _________maços / ano. Parou há quanto tempo? ______________________
- Atividade Física (Tipo e Frequência): _______________________________________________________

5. Antecedentes Familiares:
A. Câncer: Colo Retal Mama Próstata
B. Osteoporose Fraturas Fragilidade
C. Depressão
D. Demência
E. Outros ___________________________________________________________________________

6. Avaliação Funcional (Escalas Anexas):

A. Atividades Básicas de Vida Diária
B. Atividades Instrumentais de Vida Diária
C. Direção Veicular: SIM NÃO Por que parou? ___________________________________________

7. Avaliação da Motricidade:
A. Marcha
Sozinho Ajuda Frequente Andador Imobilidade (acamado)
Ajuda ocasional Muleta / Bengala Cadeira de rodas
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- “TIMED UP AND GO TEST”: ____segundos.
- “HAND GRIP TEST”: 1ª_____ 2ª ______ 3ª ______

B. Quedas
- Número de quedas no último ano: __________________ Nos últimos 6 meses: _____________________
- Causas / circunstâncias: __________________________________________________________________
- Consequências (Fraturas / TCE): ___________________________________________________________

8. Avaliação do Humor
A. Escala Geriátrica de Depressão (Yesavage): _______/15
B. DSM V: ______________________________________

9. Avaliação Cognitiva: (Esquecimento há quanto tempo? Vem piorando? Declínio funcional associado?)
A. MEEM: ________________________________________________________________________________
B. Teste de Fluência Verbal: ________________________________________________________________
C. Teste do Relógio: ______________________________________________________________________

10. Imunização (completar verso folha rostro):

- Tétano Data: ______________
- Influenza Data: ______________
- Pneumocócica Data: ______________
- COVID-19 Data: ______________
- Hepatite B Data: ______________
- Febre Amarela Data: ______________
- Dupla Adulto Data: ______________

11. Avaliação nutricional (MAN/ Risco Nutricional):

Peso: ___________ kg IMC: __________________________________
Altura: __________cm Circunferência da panturrilha: _____________cm

Observações da avaliação da nutrição: _______________________________________________________

12. Exame Físico:

Geral:___________________________________________________________________________________
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Cabeça / Pescoço:_________________________________________________________________________
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Cavidade Oral:___________________________________________________________________________
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Pulmonar:________________________________________________________________________________
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Cardíaca:_________________________________________________________________________________
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Abdômen:________________________________________________________________________________
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Extremidades:____________________________________________________________________________
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Pele:___________________________________________________________________________________
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13. Impressão Diagnóstica (ABVDs / Cognição / Mobilidade / Aspectos Sociais / Hipóteses Diagnósticas):
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14. PLANEJAMENTO DE CUIDADOS:
A. Orientações Gerais
Dieta (ingesta proteica, ingesta líquida, ingesta de cálcio, DRGE, laxativa): ________________________
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Atividade Física:__________________________________________________________________________
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Hábitos e Vícios: _________________________________________________________________________

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Higiene do Sono: _________________________________________________________________________

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Medidas Para Evitar Quedas: _______________________________________________________________

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Imunização: _____________________________________________________________________________
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Adesão Terapêutica: ______________________________________________________________________

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Cuidados Com a Pele: ____________________________________________________________________

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Enriquecer Ambiente / Vida Social:__________________________________________________________
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B. ENCAMINHAMENTOS: ___________________________________________________________________
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C. SOLICITAÇÃO DE EXAMES: _______________________________________________________________

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D. CONDUTA MEDICAMENTOSA (JUSTIFICAR): _________________________________________________

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E. RETORNO: ____________________________________________________________________________
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ALUNOS: ___________________________________ MÉDICO RESPONSÁVEL: ____________________

___________________________________ ENFERMEIRA RESPONSÁVEL: ________________
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