Ambulatório Integrado de Saúde

Ambulatório de Nutrição

ANAMNESE NUTRICIONAL Data: ____/____/___________

ADULTO ( ) IDOSO ( )
Intervenção nutricional: cardápio ( ) plano alimentar ( ) prato modelo ( )
IDENTIFICAÇÃO DO PACIENTE
Nome: _____________________________________________________ E-mail: _________________________________
RG: __________________________________________ CPF: _______________________________________________
Telefones: Res. _______ Comercial _____ Cel. __________________
Data de nascimento: / / Idade: anos Sexo: ( ) feminino ( ) masculino
Profissão: ________
Escolaridade: ______________________________________________________________________________________

OBJETIVO DO TRATAMENTO

ACOMPANHAMENTO ( ) Medicina - Especialidade: _______________________________________________________

( ) Enfermagem ( ) Farmácia ( ) Fisioterapia ( ) Psicologia ( ) Odontologia ( ) Nenhum

HISTÓRICO MÉDICO E FAMILIAR

Tabagista: ( ) Não ( ) Sim Quantos cigarros por dia? _______________________________
Ex-tabagista: ( ) Não ( ) Sim Há quanto tempo? ______________________________________
Patologias Atuais: _________________________________________________________________________________
CID: ___________________________________________________________________________________________
Antecedentes familiares (condições de saúde dos pais, irmãos, avós e tios 1ª geração - se falecidos, citar idade e
causa da morte):
_______________________________________________________________________________________________
__
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Histórico Médico (saúde na infância, hospitalizações e cirurgias – com datas e motivos, gestações, história de
alergia, traumatismos etc):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
 SUBSTÂNCIA EFEITOS INTERAÇÃO DROGA DOSE HORÁRIO
NOME INDICAÇÃO
ATIVA COLATERAIS X NUTRIENTE
MEDICAMENTOS/SUPLEMENTOS
 Alterações Gastrointestinais : ( ) Pirose ( ) Constipação intestinal ( ) Diarreia
( ) Distensão ( ) Flatulência ( ) Outros _______________________
Evacuações: ( ) Diária ( ) Alternada ( ) 2 Dias sem evacuar ( ) > 3 dias sem evacuar
Consistência das Fezes: ( ) ressecada ( ) pastosa ( ) líquida
Edema: ( )Não ( ) Sim Onde? ______________________________________________

PERFIL PSICOLÓGICO/COMPORTAMENTO ALIMENTAR

Já realizou algum tipo de dieta? ( )Não ( ) Sim Qual? _____________________________________________
______________________________________________________________________________________________________
Houve alteração de peso recente? ( ) Não ( ) Sim ( ) Aumentou ( ) Diminuiu
Motivo: ____________
Apetite: ( ) Normal ( ) Inapetência ( ) Aumentado
Alteração do Hábito Alimentar: ( ) Normal ( ) Inapetência Há quanto tempo? __________________________
Motivo: _________________________________________________________________________________________
_______________________________________________________________________________________________
Quando fica ansioso ( ) come mais ( ) come menos ( ) não come ( ) sem alteração
Dentição: ( ) Completa ( ) Incompleta ( ) Prótese/Aparelho
Como é sua mastigação? ( ) Lenta ( ) Normal ( ) Rápida
Costuma fazer alguma outra atividade durante as refeições? ( ) Não ( ) Sim? Qual? ______________________
_______________________________________________________________________________________________
Durante a refeição você costuma ingerir líquidos? ( ) Sim ( ) Não
Qual/Quantidade? ____________________________________
Usa adoçante? ( ) Sim ( ) Não Qual/Quantidade? ________________________
Etilismo: ( ) Sim ( ) Não Qual/Quantidade? ________________________
Preferências alimentares: ____________________________________________________________________________
_________________________________________________________________________________________________
Aversões alimentares: __________________________________________________________________________________
_____________________________________________________________________________________________________
Alergias alimentares: __________________________________________________________________________________
___________________________________________________________________________________________________
Ingestão de água: ____________________________________________________________________________________
Observações: ____________________________________________________________________________________
_______________________________________________________________________________________________

ATIVIDADES DO DIA HORÁRIO FREQUÊNCIA TIPO DE TRABALHO

Trabalho
Cursos

ATIVIDADE FÍSICA (qual?) FREQUÊNCIA HORÁRIO DURAÇÃO HÁ QUANTO TEMPO?

EXAMES BIOQUÍMICOS

DATA TIPO RESULTADO PARÂMETRO

CÁLCULO DAS NECESSIDADES ENERGÉTICAS

DATA DATA
FAO FAO

EER EER

Planejamento para estratégia e intervenção Planejamento para estratégia de intervenção

 DADOS ANTROPOMÉTRICOS
DATA: DATA:
MEDIDAS
% %
1ª 2ª 3ª Média 1ª 2ª 3ª Média
Adequação Adequação
DCT
DCB
DCSI
DCSE
Circunf. Braço
Circunf. Cintura
Circunf. Pescoço
Circunf. Panturrilha
∑ Dobras
% Gordura (Dobras)
% Gordura (BIA) Res= Reac= %G= Res= Reac= %G=

DIAGNÓSTICO NUTRICIONAL

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
 DADOS ANTROPOMÉTRICOS
DATA: DATA:
MEDIDAS
% %
1ª 2ª 3ª Média 1ª 2ª 3ª Média
Adequação Adequação
DCT
DCB
DCSI
DCSE
Circunf. Braço
Circunf. Cintura
Circunf. Pescoço
Circunf. Panturrilha
∑ Dobras
% Gordura (Dobras)
% Gordura (BIA) Res= Reac= %G= Res= Reac= %G=

DIAGNÓSTICO NUTRICIONAL

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Altura (m): __________________ h2 (m2): _________________
Data Peso (kg) IMC (kg⁄m2) Classificação

Peso estimado: Referência/data:

Estatura estimada: Referência/data:

Observações: _______________________________________________________________________________________
___________________________________________________________________________________________________

BARREIRAS REFERIDAS COMO LIMITANTES PARA A ADESÃO AO TRATAMENTO NUTRICIONAL:

Data Descrever dificuldades relatadas pelo paciente
RECORDATÓRIO DE 24 HORAS - 1º inquérito alimentar

Data da Entrevista: _____/_____/_______ Dia da semana avaliado: ___________________________________________

Hora que acordou:

Refeição/Horário Alimento Quantidade

Ingestão hídrica:
Hora que dormiu:
RECORDATÓRIO DE 24 HORAS - 2º inquérito alimentar

Data da Entrevista: _____/_____/_______ Dia da semana avaliado: ___________________________________________

Hora que acordou:

Refeição/Horário Alimento Quantidade

Ingestão hídrica:
Hora que dormiu:
 EVOLUÇÃO DAS CONSULTAS
(colocar data da consulta e nome do estagiário que realizou o atendimento)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
 EVOLUÇÃO DAS CONSULTAS
(colocar data da consulta e nome do estagiário que realizou o atendimento)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________