Anamnese Médica

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ANAMNESE
DADOS DE IDENTIFICAÇÃO:
DATA DA INTERNAÇÃO: _______________________ DATA DA CONSULTA: _________________________
NOME COMPLETO: ____________________________________________________________________________
IDADE: _______ COR: _________________ SEXO: __________________ ESTADO CIVIL: ________________
NATURALIDADE: __________________________ PROCEDÊNCIA: ____________________________________
ENDEREÇO: ___________________________________________________________________________________
OCUPAÇÃO ATUAL: _________________________ OCUPAÇÃO ANTERIOR: ___________________________
FONTE DE ANAMNESE: ___________________________ CONFIABILIDADE: ___________________________
RELIGIÃO: ___________________________ ENCAMINHAMENTO: ____________________________________
QUEIXA PRINCIPAL:
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HISTÓRIA DA DOENÇA ATUAL:
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MEDICAÇÕES ATUAIS:
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ALERGIAS:
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HISTÓRIA PATOLÓGICA PREGRESSA:
DOENÇAS DA INFÂNCIA: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DOENÇAS DO ADULTO: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*CIRURGIAS: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*ANTECEDENTES GINECOLÓGICOS/ OBSTÉTRICOS: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*ANTECEDENTES PSIQUIÁTRICOS: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CONDIÇÕES DE SAÚDE:
*DIETA E ATIVIDADE FISICA: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*IMUNIZAÇÃO: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*ÁLCOOL E DROGAS ILÍCITAS: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
*TABACO: ______________________________________________________________________________________________________________________________________________________________________________________________
*EXAMES DE RASTREAMENTO (Papanicolaou, mamografia, exame de próstata, ...): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HISTÓRIA FAMILIAR: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HISTÓRIA PSICOSSOCIAL: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________REVISÃO DE SISTEMAS:
GERAL: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PELE E ANEXOS: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CABEÇA: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OLHOS: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OUVIDOS: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
NARIZ E SEIOS DA FACE: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
BOCA E GARGANTA: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PESCOÇO: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MAMAS: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
RESPIRATÓRIO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CARDIOVASCULAR: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DIGESTÓRIO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
URINÁRIO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
GENITAL: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
VASCULAR PERIFÉRICO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MÚSCULO ESQUELÉTICO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
NEUROLÓGICO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HEMATOLÓGICO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ENDOCRINOLÓGICO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PSIQUIÁTRICO: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________