ANAMNESE NUTRICIONAL ADULTO-IDOSO

Prévia do material em texto

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): 
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________ 
 
 
MEDICAMENTOS/SUPLEMENTOS 
 
 
 
 
 
 
 
 
N
O
M
E
 
S
U
B
S
T
Â
N
C
IA
 
A
T
IV
A
 
IN
D
IC
A
Ç
Ã
O
 
E
F
E
IT
O
S
 
C
O
L
A
T
E
R
A
IS
 
IN
T
E
R
A
Ç
Ã
O
 D
R
O
G
A
 
X
 N
U
T
R
IE
N
T
E
 
D
O
S
E
 
H
O
R
Á
R
IO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ATIVIDADES DO DIA HORÁRIO FREQUÊNCIA TIPO DE TRABALHO 
Trabalho 
Cursos 
 
ATIVIDADE FÍSICA (qual?) FREQUÊNCIA HORÁRIO DURAÇÃO HÁ QUANTO TEMPO? 
 
 
 
 
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: ____________________________________________________________________________________ 
_______________________________________________________________________________________________ 
 
 
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? ______________________________________________ 
 
EXAMES BIOQUÍMICOS
DATA TIPO RESULTADO PARÂMETRO 
 
 
 
 
 
 
 
 
CÁLCULO DAS NECESSIDADES ENERGÉTICAS 
DATA DATA 
FAO 
 
 
 
 
 
EER 
 
 
 
 
 
 
 
 
Planejamento para estratégia e intervenção 
FAO 
 
 
 
 
 
EER 
 
 
 
 
 
 
 
 
Planejamento para estratégia de intervenção 
DADOS ANTROPOMÉTRICOS 
 
MEDIDAS 
DATA: DATA: 
1ª 2ª 3ª Média 
% 
Adequação 
1ª 2ª 3ª Média 
% 
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 
 
MEDIDAS 
DATA: DATA: 
1ª 2ª 3ª Média 
% 
Adequação 
1ª 2ª 3ª Média 
% 
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: 
Estatura estimada: 
Referência/data: 
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) 
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________