Ficha Anamnese

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ROTEIRO PARA ANAMNESE
Identificação:
Nome: _________________________________________________________________
Idade: ___________________________ Sexo: Feminino ( ) Masculino ( )
Cor∕Etnia: Branca ( ) Parda ( ) Preta ( ) Indígena ( ) Asiático ( )
Estado Civil: Casado ( ) Solteiro ( ) Divorciado ( ) Viúvo ( ) Outros ( )
Profissão: ______________________________________________________________
Local de Trabalho: ________________________________________________________
Naturalidade: ____________________ Procedência: ____________________________
Residência: _____________________________________________________________
Nome da Mãe: __________________________________________________________
Nome do responsável∕ cuidador∕ acompanhante: _______________________________________________________________________
Religião: _________________________ Plano de Saúde: ________________________
Queixa Principal:
______________________________________________________________________________________________________________________________________________
História da Doença Atual:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Interrogatório Sintomatológico:
Estado Geral:____________________________________________________________
_______________________________________________________________________
Pele e fâneros: __________________________________________________________
_______________________________________________________________________
Cabeça: ________________________________________________________________
_______________________________________________________________________
Olhos: _________________________________________________________________
_______________________________________________________________________
Ouvidos: _______________________________________________________________
_______________________________________________________________________
Nariz e cavidades paranasais: ______________________________________________
_______________________________________________________________________
Cavidade Bucal e anexos: __________________________________________________
_______________________________________________________________________
Faringe: ________________________________________________________________
_______________________________________________________________________
Laringe: ________________________________________________________________
_______________________________________________________________________
Vasos e linfonodos: ______________________________________________________
_______________________________________________________________________
Mamas: ________________________________________________________________
_______________________________________________________________________
Sistema Respiratório: _____________________________________________________
_______________________________________________________________________
Sistema Cardiovascular: ___________________________________________________
_______________________________________________________________________
Sistema Digestório: ______________________________________________________
_______________________________________________________________________
Sistema Urinário: ________________________________________________________
_______________________________________________________________________
Sistema Genital Masculino: ________________________________________________
_______________________________________________________________________
Sistema Genital Feminino: _________________________________________________
_______________________________________________________________________
Sistema Hemolinfopoético: ________________________________________________
_______________________________________________________________________
Sistema Endócrino: _______________________________________________________
_______________________________________________________________________
Sistema Osteoarticular: ___________________________________________________
_______________________________________________________________________
Sistema Nervoso: ________________________________________________________
_______________________________________________________________________
Exame psíquico e condições emocionais: _____________________________________
_______________________________________________________________________
Antecedentes Pessoais:
Gestação e Nascimento: __________________________________________________
_______________________________________________________________________
Desenvolvimento Psicomotor e Neural: ______________________________________
______________________________________________________________________
Desenvolvimento Sexual: __________________________________________________
_______________________________________________________________________
Doenças da Infância: _____________________________________________________
_______________________________________________________________________
Traumas∕acidentes: ______________________________________________________
Doenças graves e∕ou crônicas: ______________________________________________
_______________________________________________________________________
Cirurgias: _______________________________________________________________
Paternidade: ____________________________________________________________
Imunizações: ____________________________________________________________
Alergias: _______________________________________________________________
Medicamentos em uso atual: ______________________________________________
Antecedentes Familiares: _________________________________________________
______________________________________________________________________________________________________________________________________________
Hábitos de Vida:
Alimentação: ___________________________________________________________
_______________________________________________________________________
Viagens recentes: ________________________________________________________
Atividades físicas diárias e regulares: ________________________________________
_______________________________________________________________________
Atividade Sexual: ________________________________________________________
Manutenção de peso: ____________________________________________________
Consumo de bebidas alcoólicas∕ tabaco ∕ drogas ilícitas: _________________________
_______________________________________________________________________
Condições socioeconômicas (moradia, saneamento básico, rendimento mensal, etc): _______________________________________________________________________
_______________________________________________________________________
Vida conjugal: __________________________________________________________