modelo de anamnese e exame fisico

Esta é uma pré-visualização de arquivo. Entre para ver o arquivo original

ANAMNESE E EXAME FÍSICO 
Data: ______/______/______.

 
1. Identificação

 
Nome:_____________________________________________________________________________________________________________________________ 
Idade: _________________

Sexo: ( ) Feminino ( ) Masculino Profissão: ________________________________Raça: ______________________________

 
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

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
Familiares ____________________________________________________________________________________________________________________________________________ 
____________________________________________________________________________________________________________________________________________ 
Tratamento regulares: 
Medicamento Dose Hora __________________________________________________
Cirurgias já realizadas: ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 
5. Necessidades Humanas Básicas
 
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
EXAME FÍSICO 
EXAME FÍSICO GERAL 
______________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
SSVV 
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
EXAME NEUROLÓGICO/ PSIQUICO 
______________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ 
CABEÇA E PESCOÇO 
______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ 
MAMAS 
______________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ 
APARELHO RESPIRATÓRIO 
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
SISTEMA CARDIOVASCULAR 
______________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ 
ABDOME 
______________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
______________________________________________________________________________________________________________________________________ 
GENITOURUNARIO 
______________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LOCOMOTOR 
______________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
PELE, MUCOSA E FÂNEROS - LESÕES 
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________