Modelo-para-anamnese

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1. IDENTIFICAÇÃO
NOME:___________________________________________
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SEXO:___________________________________________
IDADE:__________ COR: branca/parda/preta
ESTADO CIVIL:__________________________________
PROFISSÃO:______________________________________
NATURAL DE:____________________________________
PROCEDENTE ____________________________________
2. QUEIXA PRINCIPAL E DURAÇÃO
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3. HISTÓRIA DA DOENÇA ATUAL (HDA) 
(duração total, início, curso, características, 
sintomas associados, efeitos de tratamentos, 
progressão, repercussões sobre a vida do paciente, 
ordem cronológica, sintomas associados)
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4. INTERROGATÓRIO SINTOMATOLÓGICO
Sintomas gerais: alterações do peso (em quanto tempo), 
febre, calafrios, astenia, sudorese noturna , anorexia
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Pele e fâneros: prurido, lesões cutâneas (localização), 
alopecia, alterações da pigmentação, anormalidades nos pêlos 
e na aparência ungueal
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Cabeça e pescoço: cefaléia, cervicalgia, limitação da 
movimentação do pescoço, tumorações cervicais
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Olhos: dor ocular, acuidade visual, diplopia, fotofobia, 
lacrimejamento, secreção conjuntival, escotomas visuais, 
visão turva, correção com óculos ou lentes de contato
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Ouvidos, nariz e seios da face: otalgia, algias faciais, 
congestão periorbitária, epistaxe, otorréia, rinorréia, 
obstrução nasal, espirros freqüentes, gota pós-nasal, 
zumbidos, acuidade auditiva, vertigem
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Cavidade Oral: odontalgia, gengivorragias, ulcerações da 
mucosa, queimação ou ardência da língua, odinofagia, 
sialose, dor em ATM
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Mamas: mastalgia, descarga mamilar,nódulos palpáveis. 
Ginecomastia no homem
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Respiratório: tosse, expectoração (aspecto e quantidade), 
rouquidão, hemoptise, dor torácica, dispnéia, chiado no tórax
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Cardiovascular: precordialgia, palpitações, dispnéia de 
esforço, noturna e de decúbito, síncope, edema, cianose, 
claudicação intermitente, veias varicosas, úlceras de perna
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Gastrintestinal: disfagia, pirose, intolerância alimentar, 
eructações, empachamento, regurgitação, epigastralgia, 
cólicas, icterícia, náuseas e vômitos, hematêmese, hábito 
intestinal (n0 de evacuações diárias, aspecto das fezes - cor e 
consistência -, presença elementos anormais - sangue, muco 
e/ou pus), tenesmo evacuatório, dor e prurido retal, 
enterorragia, melena, meteorismo, cólicas, flatulência, 
obstipação intestinal
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Urinário: dor (lombar, no flanco, vesical), disúria, alterações 
miccionais, estrangúria, polaciúria, alterações da cor e odor 
da urina, nictúria, enurese, oligúria, poliúria, incontinência 
urinária de esforço (mulher), gotejamento terminal e força do 
jato urinário (homem), eliminação de cálculos durante a 
micção
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Genital: homem (corrimento uretral, lesões genitais, 
disfunções sexuais); mulher (leucorréia, prurido 
vulvovaginal, sangramento intermenstrual, dor pélvica, 
dispareunia)
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Osteoarticular: artralgias, rigidez matinal, edema articular, 
limitação de movimentos, deformidades, lombalgia
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Hematopoiético: palidez, tendências hemorrágicas, 
linfadenomegalias, esplenomegalia, hepatomegalia
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Endócrino: intolerância ao frio ou ao calor, poliúria, polifagia 
e polidipsia, hirsutismo
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Nervoso: paresias (paralisia moderada), paralisias, 
parestesias, atrofias musculares, tremores, convulsões, 
ausências, perturbações da memória (amnésia transitória ou 
permanente)
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Psiquismo: insônia, nervosismo, choro freqüente, 
irritabilidade, tristeza, sentimento de culpa, perda de interesse 
e prazer no trabalho e no lazer
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5. ANTECEDENTES PESSOAIS FISIOLÓGICOS
Condições de gestação e nascimento:__________________ 
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Desenvolvimento neuropsicomotor: __________________ 
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Imunizações (BCG, DTP, anti-polio, hepatite viral, anti-
tetanica, gripe ) ____________________________________
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Adolescência: (puberdade, surgimentos dos caracteres 
secundários)________________________________________________________________________________________
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Atividade sexual e vida reprodutiva (primeiro contato, 
parceiros, freqüência de relações, camisinha, 
emnstruação(fluxo, ciclo), gestações, partos) 
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Climatério: (idade da mennopausa, ondas de calor, 
ressecamento vaginal) _______________________________
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Senectude: ( como o paciente se sente no ambiente familiar, 
solidão, viuvez, pensão, aposentadoria, atividades diárias) 
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6. ANTECEDENTES PESSOAIS PATOLÓGICOS
Doenças da infância (sarampo, catapora, rubéola, 
caxumba):_________________________________________ 
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Doenças apresentadas na vida adulta ( tuberculose, DST, 
hepatite, diabetes, hieprtensão arterial, cardiopatias, 
epilepsias, febre reumática, asma, aborto espontâneo ou não, 
disfunção sexual) : ___________________ 
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Antecedentes de alergia: ____________________________ 
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Cirurgias:_________________________________________
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Hospitalizações:____________________________________
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Traumatismos:_____________________________________
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Hemotransfusões:___________________________________
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Uso de drogas injetáveis:____________________________
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Medicações de uso prolongado:______________________ 
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7. ANTECEDENTES FAMILIARES
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8. ANTECEDENTES SOCIAIS
Condições de habitação e higiene: ____________________ 
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Condições de alimentação: __________________________ 
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Nível de instrução: ________________________________
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História Ocupacional: ______________________________ 
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Religião: _________________________________________
Renda familiar mensal: ____________________________
Relações interpessoais: ( se existe problema de 
relacionamento na família – se o paciente tem amigos – sente 
solidão - tem ressentimento ) 
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Problemas psicossociais: ( maior preocupação do paciente -o 
que lhe estressava antes da internação - sofreu alguma perda 
importante no passado - sente-se realizado – se houve 
expectativas frustradas)_____________________________ 
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Hábitos e costumes: tabagismo (duração, tipo de cigarro, nº 
de cigarros consumidos por dia), consumo de álcool 
(duração, tipo de bebida, quantidade consumida), banhos de 
rios açudes e lagoas (localidade e época), contato com o 
triatomíneo, contato com animais domésticos, prática regular 
de exercícios físicos (tipo e freqüência), sono, lazer, viagens, 
uso de drogas ilícitas
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