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anamnase feminina
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Anamnese Feminina Paciente: _____________________________________________________________________________________ Data de nascimento: _____/______/_____ Data consulta: ______/______/______ Retorno: ______/_____/_____ Motivo da Consulta: _____________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Dados Antropométricos: Peso: _______ Altura: ________ IMC:______ Circunferências C. Panturrilha: ________ C. Quadril: _______C. Cintura:________ C. Abdome:_______ C. Coxa: ________ C. Braço:_______. Dobras Cutâneas DTR (Tríceps): ________ DSB (subescapular): ________ DBI (bíceps): _______ DSI (supra ilíaca): _________ DCX (coxa): ________ DPM (panturrilha média): __________. Patologias: __________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Medicamentos: ______________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Histórico familiar de patologias: _________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Escala de Bristol: _____________ Urina: ____________. Desconforto abdominal: ____________ Hidratação: __________ Constipação: _____________ Náuseas: _______________ Obs: ______________________________________________ Alimentos que não consome de forma alguma: _____________________________________________________________ ___________________________________________________________________________________________________ Alimentos com consumo frequente: ______________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________________________________ Alterações nos exames: _______________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Ciclo menstrual: Data de Inicio: _________________ Data de fim ( caso esteja na menopausa): ______________________ Fluxo: ( ) Fraco - ( ) Moderado -( )Intenso Ciclo: ( ) regular - ( ) desregulado. Cólica: __________ Enxaqueca: ___________ náuseas: ___________ TPM: ____________ Vontade de doce: ___________ Conduta 1: ___________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ Conduta 2: ___________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ Suplementos indicados: ________________________________________________________________________________ ____________________________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ Orientações adicionais: _________________________________________________________________________________ ____________________________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ Rua: Antônio Vieira 472- Nova Iguaçu – RJ / CEP:26255-530 Contato: 21 2797-3655 / 21 9329-2895 Data 28 de outubro de 2023 image1.png Rua: Antônio Vieira 472 - Nova Iguaçu – RJ / CEP:26255 - 530 Contato: 21 2797 - 3655 / 21 9329 - 2895 Data 28 de outubro de 2023 Anamnese Feminina Paciente: ___________________________________________________________________________________ __ Data de nas cimento: __ ___/__ _ __ _/__ __ _ Da ta consulta: ___ ___/___ _ _ _/____ _ _ R etorno: ___ ___/__ ___/___ __ Motivo da Consulta: _____________________________________________________________________________ ___________________________________________________________________________________________ _______ ____________________________________________________________________________________ Dados Antropométricos: Peso: _______ Altura: ________ IMC:______ Circunferências C . P anturrilha : ________ C. Q uadril : _______ C . C intura :________ C . Abdome :_______ C. Coxa : ________ C. B raço :_______ . Dobras C utâneas DTR ( Tríceps ): ________ DSB ( subescapular ) : __ ______ DB I ( bíceps ) : _______ DSI ( s upra ilíaca ) : _________ DCX ( coxa ) : ________ DPM ( panturrilha média ) : __________ . Patologias: __ _____________________________ ____________________________ ________ _____________ ____ ______ _____________ ____________________________ __________________________________________________________ __ _______________________________________________________________________ __________________________ Medicamentos: __________________________________ _ ____________________ ________ _____________ ____ ______ ____________ ___________________________________ _ ___________________ ________ _____________ ____ ______ _ __ _____________ ______________________________________________________ ________ _____________ ____ _____ Históri co familiar de patologias: ________________________________________________ ______ _____ __ ____ ________ ______________________________________________________________________________ ______ ________ ____ ___ _______ ______________________________________________________________________ ______ ________ ____ ____ Esca la de B ristol: __________ _ __ Urina: ________ _ ___. Desconforto abdominal: ______ __ ____ Hidratação: __________ Constipação: _______ ___ ___ Náuseas : ______________ _ Obs: ____________________ __________________________Alimentos que não consome de forma alguma: ________________ _____ __ __________ _ ______ __________ __ _________ _______________________________________________________ _____ _ _ _________ _ ___________________________ Alimentos com consumo frequente: __________________________ _____ __________ _ _ ___________________________ ______________________ _______________________________ _____ __________ _ __ ____________________________ __ ________________________________________________________________________________ Alterações nos e xames: __________________ ____________________ _________ ________ _ __ _________ _ ___________ __ ________________________________________________________________________________ __ ________________________________________________________________________________ Rua: Antônio Vieira 472- Nova Iguaçu – RJ / CEP:26255-530 Contato: 21 2797-3655 / 21 9329-2895 Data 28 de outubro de 2023 Anamnese Feminina Paciente: _____________________________________________________________________________________ Data de nascimento: _____/______/_____ Data consulta: ______/______/______ Retorno: ______/_____/_____ Motivo da Consulta: _____________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Dados Antropométricos: Peso: _______ Altura: ________ IMC:______ Circunferências C. Panturrilha: ________ C. Quadril: _______C. Cintura:________ C. Abdome:_______ C. Coxa: ________ C. Braço:_______. Dobras Cutâneas DTR (Tríceps): ________ DSB (subescapular): ________ DBI (bíceps): _______ DSI (supra ilíaca): _________ DCX (coxa): ________ DPM (panturrilha média): __________. Patologias: __________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Medicamentos: ______________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Histórico familiar de patologias: _________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Escala de Bristol: _____________ Urina: ____________. Desconforto abdominal: ____________ Hidratação: __________ Constipação: _____________ Náuseas: _______________ Obs: ______________________________________________ Alimentos que não consome de forma alguma: _____________________________________________________________ ___________________________________________________________________________________________________ Alimentos com consumo frequente: ______________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________________________________ Alterações nos exames: _______________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
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