FICHA DE ANAMNESE NUTRICIONAL PARA NUTRIÇÃO CLINICA

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FICHA DE ANAMNESE NUTRICIONAL 
 
DATA: ____/____/ ____ 
1.DADOS PESSOAIS: 
Nome: _________________________________________________________________ Idade: ________ 
Sexo: F ( ) M ( ) Estado civil: ____________________________ Data de Nascimento: ____/____/____ 
Bairro: _______________________ Cidade: ________________________ Contato: _________________ 
OBJETIVO OU QUEIXA: __________________________________________________________________ 
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2. DADOS SOCIOECONÔMICOS: 
Escolaridade: __________________________________________________________________________ 
Profissão: _________________________________________________ Exerce a mesma? Sim( ) Não ( ) 
Se não, quais / qual atividade exerce: _______________________________________________________ 
Mora com: ( ) Pais/Familiares ( ) Cônjuge ( ) Amigos ( ) Sozinho 
Total de moradores na residência: ________________ Renda familiar: ____________________________ 
Com que frequência vai ao supermercado: __________________________________________________ 
Quem faz as compras? __________________________________________________________________ 
 
3. HISTÓRICO CLÍNICO: 
Funcionamento do intestino (consistência/nº de evacuações): __________________________________ 
Hidratação e Diurese (cor): _______________________ Sono: __________________________________ 
Cirurgias: _____________________________________________________________________________ 
Uso de medicamentos: __________________________________________________________________ 
Tabagismo: Sim ( ) Não ( ) Bebida alcoólica: _______________________________________________ 
Outros sintomas (pirose, gases intestinais, distensão): _________________________________________ 
OBS: _________________________________________________________________________________ 
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Patologias: ____________________________________________________________________________ 
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Histórico familiar (Obesidade, diabetes, hipertensão, DCV ou problemas circulatórios, dislipidemias, 
hipertrigliceridemia, gastrite/refluxo/úlceras, hipertireoidismo ou hipotireoidismo, depressão, câncer): 
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Identificou alguma condição psicológica (estresse/ ansiedade/ possível transtorno alimentar)? 
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4. AVALIAÇÃO DIETÉTICA: 
História alimentar 
a) Quantas refeições costuma fazer por dia: _________________________________________________ 
b) Quem prepara as refeições: ____________________________________________________________ 
c) Possui tempo livre para fazer as refeições? ________________________________________________ 
d) O apetite está normal: ________________________________________________________________ 
e) Costuma tomar líquido junto as refeições? ( ) Sim ( ) Não. Quantidade? _______________________ 
f) Quanto litros de água consome por dia? _________________________________________________ 
g) Costuma se alimentar em frente a TV ou com o celular? ( ) Sim ( ) Não 
h) Mastigação: ( ) Lenta ( ) Normal ( ) Rápida Deglutição? _________________________________ 
i) Alimentos preferidos: ________________________________________________________________ 
j) Alimentos que não gosta de ingerir: _____________________________________________________ 
k) Alergias ou Intolerâncias: _____________________________________________________________ 
K) Com que frequência administra os seguintes alimentos: 
 
( N ) não usa ( P ) usa pouco ( F ) usa frequentemente 
Sal ( ) Shoyo ( ) Caldo concentrado ( ) Azeite ( ) Óleo ( ) Limão ( ) Vinagre ( ) 
Margarina ( ) Manteiga ( ) Maionese ( ) Açúcar 
( ) Molho de Tomate industrializado ( ) 
 
5. CONSUMO ALIMENTAR (pesquisar o modo de preparação dos alimentos): 
5.1 Desjejum:(____:____)_Local: _________________________________________________________ 
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5.2-Lanche: ( ___:___) Local: _____________________________________________________________ 
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5.3-Almoço: (___:___) Local: _____________________________________________________________ 
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5.4-Lanche:(___:___) Local: ______________________________________________________________ 
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5.5-Jantar(___:___) Local: _______________________________________________________________ 
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5.6-Ceia (__:___) Local: _________________________________________________________________ 
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Total calorias: ___________________________ 
Utiliza suplemento alimentar? ____________________________________________________________ 
Já fez ou faz alguma dieta? ______________________________________________________________ 
Aceita a introdução de alimentos não consumidos habitualmente? ______________________________ 
Qual seria sua maior dificuldade? _________________________________________________________ 
OBS:_________________________________________________________________________________
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6. AVALIAÇÃO ANTROPOMÉTRICA 
 
Apresentou perda de peso? __________ Em qnt tempo? ___________ Intencional? ________________ 
 
6.1 Pratica atividade física ( ) Não ( ) Sim, Qual? ___________________________________________ 
Com que frequência, quantas vezes, qual a duração? _________________________________________ 
 
 
7. EXAME FÍSICO/CLÍNICO 
7.1 Cabelo: ____________________________________________________________________ 
7.2 Face: ______________________________________________________________________ 
7.3 Olhos: _____________________________________________________________________ 
7.4 Boca (gengiva, dentes): ______________________________________________________ 
7.5 Pescoço/tórax/dorso: ________________________________________________________ 
7.6 Membros superiores e inferiores: _______________________________________________ 
7.7 Reserva de tecido adiposo subcutâneo/ massa muscular: ____________________________ 
7.8 Abdômen: __________________________________________________________________ 
7.9 Pele/ Unhas: ________________________________________________________________ 
7.10 Presença de edema/ascite: ____________________________________________________ 
 
8. EXAMES LABORATORIAIS: _______________________________________________________________________________________________________________________________________________
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9. DIAGNÓSTICO NUTRICIONAL: _________________________________________________________ 
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MEDIDA 
DATA EVOLUÇÃO 
__/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ 
Peso usual (kg) 
Peso atual (kg) 
Altura (m) 
IMC (kg/m²) 
CB | ADEQUAÇÃO 
CC 
CQ 
CP 
Altura do Joelho 
PCT 
PCB 
PCSE 
PCSI 
% GORDURA 
 
10. CONDUTA NUTRICIONAL: ___________________________________________________________ 
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11. ACOMPANHAMENTO: ______________________________________________________________ 
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