Roteiro de Anamnese Ginecológica e obstétrica

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Ficha Ginecológica 
Paula Dumas Figueiredo – Turma XXI 
 
Data: ___________________________________________________________________________________ 
Nome:__________________________________________________________________________________ 
Idade:________________________________ Profissão:_________________________________________ 
QD:____________________________________________________________________________________ 
 
HMA:___________________________________________________________________________________
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ISDA:___________________________________________________________________________________
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Antecedentes Pessoais: 
( )DÇS CARDIOVASCULARES ( )DM ( )HAS ( )HEPATOPATIAS ( )ETILISMO ( )TABAGISMO 
( )NEOPLASIAS ( )VARIZES ( )CIRURGIAS ( )ALERGIAS ( )DÇS COAGULAÇÃO ( )CIRURGIAS 
( )OSTEOPOROSE ( )TRANFUSÕES SANGUÍNEAS ( )TRAUMATISMOS ( )MEDICAÇÃO ( )OUTROS 
ATIVIDADE FÍSICA:________________________________________________________________________ 
CIRURGIA PÓS TRAUMA:___________________________________________________________________ 
( )TABAGISTA ( )ETILISTA 
Antecedentes Ginecológicos e Obstétricos 
Menarca:_____________________________ Sexarca:________________________________________ 
 
Ciclo de:____________________ dias Gestações: G_____P_____A_____ 
Fluxos de:___________________ dias Tipos de partos:________________________________ 
DUM: __________________________ Complicações gestacionais:_________________________ 
Quantidade de fluxo:______________ _______________________________________________ 
Data do último parto:______________________________________________________________________ 
Calculo da Idade Gestacional:________________________________________________________________ 
Data provável do parto:____________________________________________________________________ 
Movimentos fetais:________________________________________________________________________ 
Vida sexual ativa: ( )SIM ( )NÃO 
Parceiros: ( )MESMO ( )NOVO RELACIONAMENTO ( )ÚNICO ( )MAIS DE UM 
Uso de preservativos: ( )SIM ( )NÃO 
Dismenorréia: ( )SIM ( )NÃO 
TPM:___________________________________________________________________________________
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Já realizou colpocitológico: ( )SIM ( )NÃO Data do último exame:_________________________ 
Resultado:_______________________________________________________________________________
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Contracepção: ( )SIM ( )NÃO ______________________________________________________________ 
Corrimento: ( )SIM ( )NÃO ________________________________________________________________ 
Prurido vulvar: ( )SIM ( )NÃO 
Dispareunia: ( )SIM ( )NÃO ( )PENETRAÇÃO ( )PROFUNDIDADE 
Sinusorragia: ( )SIM ( )NÃO 
Cauterização prévia: ( )SIM ( )NÃO 
Infecção pélvica: ( )SIM ( )NÃO 
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Sintomas Climatério: 
( )FOGACHOS ( )SUDORESE ( )NERVOSISMO ( )IRRITABILIDADE ( )INSÔNIA ( )CEFALÉIA 
( )ARTRALGIAS ( )DISPAREUNIA ( )SECURA VAGINAL ( )PERDA DE URINA ( )PERDA DE LIBIDO 
( )ALTERAÇÕES CUTÂNEAS ( )HORMONOTERAPIA 
Antecedentes mamários: 
( )DERRAME PAPILAR ( )NÓDULOS ( )MASTALGIA ( )MASTODINIA ( )INGURGITAMENTO MAMÁRIO 
MMG: ( )SIM ( )NÃO 
RESULTADO:_____________________________________________________________________________
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HIST. DE CA DE MAMA: ( )SIM ( )NÃO 
AMAMENTAÇÃO: ( )SIM ( )NÃO 
 
Queixas Urinárias: 
( )INCONTINÊNCIA ( )DISÚRIA ( )OLIGÚRIA ( )ANÚRIA ( )POLACIÚRIA ( )URGÊNCIA ( )NICTÚRIA 
( )HEMATÚRIA ( )HESITAÇÃO ( )RETENÇÃO ( )EDEMA ( )FEBRE E CALAFRIOS 
( )DOR HIPOGÁSTRICA ( )SENSAÇÃO DE PROLAPSO 
 
Resultados de Exames: 
USG PÉLVICA ( ) USTV ( ) MMG ( ) COLPOSCOPIA ( ) COLPOCITOLOGIA ( ) OUTROS ( ) 
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EXAME FÍSICO 
Ectoscopia:______________________________________________________________________________
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PA:______X_______mmHg FC:_______bpm Pulso:______bpm Peso:_______Kg ALT:______m 
IMC:_________ 
AP. 
RESPIRATÓRIO:___________________________________________________________________________
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AP.CARDÍACO:____________________________________________________________________________
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ABDOMEN:______________________________________________________________________________
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EXAME GINECOLÓGICO 
MAMAS: 
Inspeção 
Estática:_________________________________________________________________________________
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Inspeção 
Dinâmica:_______________________________________________________________________________
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Palpação 
Axilar:__________________________________________________________________________________
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Mama:__________________________________________________________________________________
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Expressão:_______________________________________________________________________________
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D E 
 
 
 
 
 
OGE(órgãos genitais externos): 
PILIFICAÇÃO:_____________________________________________________________________________ 
LÁBIOS:_________________________________________________________________________________ 
CLITÓRIS:________________________________________________________________________________ 
URETRA:________________________________ HÍMEN:_________________________________. 
GL. BARTHOLIN:____________________ GL. SKENE:_____________________________________ 
PAREDE VAGINAL ANTERIOR:________________________________________________________________ 
PAREDE VAGINAL POSTERIOR:_______________________________________________________________ 
PERDA URINÁRIA: ( )SIM ( )NÃO 
EXAME REGIÃO ANAL: _____________________________________________________________________ 
 
OGI (órgãos genitais internos) – EXAME ESPECULAR: 
VAGINA:__________________________________________________________ TESTE DE SCHILLER: 
COLO:_____________________________________________________________ ( ) POSITIVO 
CONTEUDO VAGINAL:________________________________________________ ( )POSITIVO 
OBS:_______________________________________________________________ ( ) IODO CLARO 
 
 TOQUE: 
VAGINA;________________________________________________________________________________ 
ÚTERO:_________________________________________________________________________________ 
ANEXO DIREITO:__________________________________________________________________________ 
ANEXO ESQUERDO:_______________________________________________________________________ 
PARAMÉTRIOS:___________________________________________________________________________ 
 
DIAGNÓSTICO:___________________________________________________________________________
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CONDUTA:_______________________________________________________________________________
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