Formulário de Atendimento Adulto

1º Consulta: / /

Dados gerais
Nome:
Endereço:
Data de nascimento: / / Idade:
Ocupação: Jornada de trabalho:

Anamnese Clínica
Motivo da Consulta: História da doe
______________
Sintomas diges
Atividade física (frequência/duração/horário):
Etilista:
( ) SIM ( ) NÃO
Tabagista:
( ) SIM ( ) NÃO

Exame Físico (cabeça, pescoço, abdômen,

MMII, MMSS, edema):
Avaliação Antropométrica
Peso usual: Peso teórico: Peso desejado:

Data / / / / / / / / / /

Peso (Kg)

Estatura (m)

IMC (Kg/m ) 2

Classificação IMC

CC (cm)

C. abd. (cm)

CB (cm)

DCB (mm)

DCT (mm)

DCSE (mm)

DCSI (mm)

GC (%)
Anamnese Alimentar

Refeição/horário Preparação (detalhamento) Quant. (medida caseira e/ou grama)

DESJEJUM
h

COLAÇÃO
h

ALMOÇO
h

LANCHE
h

JANTAR
h

CEIA
h

Ingestão hídrica:

Observações:

Preferências: Aversões:
 Exames Laboratoriais

Exame / / / / / / / / / / / /

Hematócrito

Hemoglobina

Eritrócitos

Linfócitos

Leucótitos

Plaquetas

Proteínas Totais

Albumina

Ferritina

Leptina

Transferrina

Proteína C-reativa

Glicemia de Jejum

Hemoglobina glicada

Colesterol total

HDL-c
VLDL-c

LDL-c

Triglicerídeos

Cálcio

Cloro

Cobre

Fósforo

Ferro

Magnésio

Manganês

Potássio

Selênio

Sódio

Zinco

TGO

TGP

Fosfatase Alcalina

Ativ. Protrombina

Ureia

Creatinina

Ácido úrico

T3
T4 livre TSH

Homocisteína

Insulina

Clearance de Creatinina

Testosterona Total

Testosterona Livre

Testosterona Disponível

Prolactina

Estradiol

FSH LH

Lipoproteína A

Cortisol

Bilirrubina Total

Diagnóstico Nutricional:
Cálculo do VET:
Características da dieta:
Parecer nutricional e evolução:
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