modelo de anamnese e exame fisico

modelo de anamnese e exame fisico


DisciplinaPráticas de Saúde e Enfermagem II42 materiais126 seguidores
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ANAMNESE E EXAME FÍSICO 
Data: ______/______/______.\u2028\u2028 
1. Identificação\u2028\u2028 
Nome:_____________________________________________________________________________________________________________________________ 
Idade: _________________\u2028\u2028Sexo: ( ) Feminino ( ) Masculino Profissão: ________________________________Raça: ______________________________\u2028\u2028 
Estado Civil: __________ Naturalidade: __________ 
4. HDA ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
5. Interrogatório sintomatológico 
a. Sintomas gerais ____________________________________________________________________________________________________________________________________________ 
b. Pele e fâneros ____________________________________________________________________________________________________________________________________________ 
c. Cabeça e pescoço ___________________________________________________________________________________________________________________________________________ 
d. SN e mental/emocional ___________________________________________________________________________________________________________________________________________ 
e. S Locomotor ___________________________________________________________________________________________________________________ ________________________
f. Tórax ____________________________________________________________________________________________________________________________________________ 
g. Abdome ____________________________________________________________________________________________________________________________________________ 
h. S Genitourinario ___________________________________________________________________________________________________________________________________________ 
i. S Hemolinfopoético ____________________________________________________________________________________________________________________________________________ 
j. S Endocrino ____________________________________________________________________________________________________________________________________________ 
6. Antecedentes clínicos: 
Pessoais\u2028\u2028________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
Familiares ____________________________________________________________________________________________________________________________________________ 
____________________________________________________________________________________________________________________________________________ 
Tratamento regulares: 
Medicamento Dose Hora __________________________________________________
Cirurgias já realizadas: ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 
5. Necessidades Humanas Básicas\u2028 \u2028_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
EXAME FÍSICO 
EXAME FÍSICO GERAL 
______________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
SSVV 
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
EXAME NEUROLÓGICO/ PSIQUICO 
______________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ 
CABEÇA E PESCOÇO 
______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ 
MAMAS 
______________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ 
APARELHO RESPIRATÓRIO 
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
SISTEMA CARDIOVASCULAR 
______________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ 
ABDOME 
______________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
______________________________________________________________________________________________________________________________________ 
GENITOURUNARIO 
______________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________