ANAMNESE NUTRICIONAL - GESTANTES

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Avaliação Nutricional de Gestantes
___ Consulta
Data: ___/___/___.
1) Dados Pessoais:
Nome: ____________________________________________________
Idade: ___________ Data de nascimento: ___/___/___
Profissão/ocupação: _________________________________________
Bairro: _________________________ Telefone: ___________________
2) Objetivo: __________________________________________________
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3) História Gestacional:
Antecedentes obstétricos:
Gesta: _________ Para:_________ Aborto:_________
Partos vaginais: _______ Cesáreas: _______ Fórceps: _______
Filhos: A termo: _______ Prematuros: _______
Nativivos: > 2500g: _______ < 2500g: _______ Natimortos: _______
Data do último parto: ____/____/____ Tipo: ( ) VG ( ) CS
Data do último aborto: ____/____/____
Gestação Atual:
D.U.M.: ____/____/____ D.P.P.: ____/____/____
IG: __________ semanas
Risco gestacional (intercorrências): _____________________________
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4) História - alterações corporais:
Estado Nutricional: _______________________________________
Atividade física:____________ Freqüência:________ Tempo: ________
Tabagismo: ( ) Sim ( ) Não
Etilismo: ( ) Sim ( ) Não
Pressão arterial: ___________________
5) História clínica
História familiar: ( ) DM ( ) Eclampsia ( ) HAS ( ) Pré-eclampsia
( ) Gemelar ( ) Outras: ______________________________________
História pregressa: __________________________________________
História atual: ______________________________________________
Medicações e/ou suplementos nutricionais: _______________________
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6) Alimentação pregressa:
Dietas realizadas: ___________________________________________
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7) Anamnese alimentar:
Aversões: _________________________________________________
Preferências: _______________________________________________
Responsável pela compra dos alimentos: _________________________
Responsável pela preparação dos alimentos: _____________________
Alergia Alimentar:____________________________________________
Função intestinal: ___________________________________________
Ingestão Hídrica:____________________________________________
8) Avaliação laboratorial:
Data
Hemácias
Hemoglobina
Hematócrito
Linfócitos
Leucócitos
Plaquetas
Albumina
Colesterol Total
HDL-colesterol
LDL-colesterol
VLDL - colesterol
Triglicerídeos
Glicose
Uréia
Creatinina
Ácido úrico
Sódio
Potássio
Cálcio
Magnésio
Ficha de Acompanhamento de Gestantes
___ Consulta
Data: ___/___/___.
Nome: ______________________________________________________Idade: ____________
Peso Atual: _______Kg Altura: _______m IMC Gestacional: _______Kg/m²
(Classificação: _______________)
Peso utilizado:
( ) Peso Pré Gestacional (PPG): _____Kg
( ) Peso Desejável (PD): ______Kg (IMC médio 20,8Kg/m²)
TMB: ______________Kcal/dia
VET: ______________ Kcal/dia F.A. utilizado: ____________
Ganho: ________Kg em 1 semana +________ Kcal/dia VET final: ___________Kcal/dia
 % Kcal G g/Kg/dia
Proteínas 
Glicídios 
Lipídios 
Anamnese: Exames, Queixas, Intercorrências, Recordatório Alimentar, Conduta.
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9) Ingestão Habitual:
Desjejum : Horário : ___________ Local: ____________________
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Colação : Horário : ___________ Local: ____________________
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Almoço : Horário : ___________ Local: ____________________
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Lanche : Horário : ___________ Local: ____________________
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Jantar : Horário : ___________ Local: ____________________
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Ceia : Horário : ___________ Local: ____________________
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10) Dados Antropométricos:
Peso Pré Gestacional: _______Kg Altura: _______m IMC Pré Gestacional: ______Kg/m²
(Classificação: _______________)
Peso Atual: _____Kg IMC Gestacional: _______Kg/m² (Classificação: _______________)
11) Cálculo para estimativa de ganho de peso durante a gestação:
12) Prescrição:
Peso utilizado:
( ) Peso Pré Gestacional (PPG): _____Kg
( ) Peso Desejável (PD): ______Kg (IMC médio 20,8Kg/m²)
TMB: ______________Kcal/dia
VET: ______________ Kcal/dia F.A. utilizado: ____________
Ganho: ________Kg em 1 semana +________ Kcal/dia VET final: ___________Kcal/dia
 % Kcal g g/Kg/dia
Proteínas 
Glicídios 
Lipídios 
13) Conduta :
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14) Observações:
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PLANEJAMENTO DIETÉTICO PARA GESTANTE
Paciente: ______________________________________ Data da consulta: ___/___/___
Peso:_______ Altura: _______ Idade: _______ Motivo da consulta: _______________
Ganho de _____ kg por semana IMC: ________ kg/m²
Desjejum : Horário : ___________
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Colação : Horário : ___________
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Almoço : Horário : ___________
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Lanche : Horário : ___________
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Jantar : Horário : ___________
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Ceia : Horário : ___________
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