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ROTEIRO ANAMNESE GINECOLÓGICA + EXAME FÍSICO

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Exame Clínico Ginecológico 
 
DATA:__________________ HORÁRIO:___________ 
NOME:_________________________________________________________________PRONTUÁRIO:____________ 
IDADE__________ DATA NASCIMENTO________________ SEXO:________________ COR:___________________ 
ESTADO CIVIL:__________ RELIGIÃO_______________ESCOLARIDADE:___________________ GS:_____________ 
PROFISSÃO: __________________ NATURALIDADE:_______________ RESIDÊNCIA ATUAL:___________________ 
ENDEREÇO:_____________________________________________________________________________________ 
 
Queixa Principal:_________________________________________________________________________________ 
 
História da Doença Atual: 
(Checklist: O quê; Início; Fator desencadeante; Tipo; Intensidade; Duração; Localização; Irradiação; Fator melhora/piora; Sintomas associados; 
Medicações; Situação atual do sintoma) 
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Sintomatológico: 
Estado Geral: 
Pele e fâneros: 
Cabeça: 
Olhos: 
Ouvidos: 
Cavidade bucal e anexos: 
Faringe: 
Laringe: 
Vasos e Linfonodos: 
Mama: 
Respiratório: 
Cardiovascular: 
Digestório: 
Urinário: 
Genital Feminino: 
Hemolinfopoietico: 
Osteoarticular: 
Nervoso: 
 
 
 
 
 
 
História Patológica Pregressa: 
PATOLOGIAS PRÉVIAS OU ATUAIS: __________________________________________________________________ 
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MEDICAMENTOS EM USO: _________________________________________________________________________ 
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CIRURGIAS:_____________________________________________________________________________________ 
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ALERGIAS:______________________________________________________________________________________ 
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TRANSFUSÕES:__________________________________________________________________________________ 
 
ACIDENTES:_____________________________________________________________________________________ 
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VACINAS:_______________________________________________________________________________________ 
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História Gineco-Obstétrica 
MENARCA:__________________ SEXARCA:__________________ DUM:_______________________ 
CICLOS MENSTRUAIS: _____________________________________________________________________________ 
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CONTRACEPÇÃO:_________________________________________________________________________________ 
VIDA SEXUAL:___________________________________________________________________________________ 
ANTECEDENTES OBSTÉTRICOS: _____________________________________________________________________ 
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História Social: 
CONDIÇÕES DE MORADIA:________________________________________________________________________ 
 
 
ALIMENTAÇÃO:_________________________________________________________________________________ 
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CONTATO COM ANIMAIS:_________________________________________________________________________ 
USO DE ÁLCOOL, FUMO OU DROGAS ILÍCITAS:________________________________________________________ 
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ATIVIDADE FÍSICA:______________________________________________________________________________ 
BANHO DE RIO:________________________________________________________________________________ 
História Familiar: 
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Exame físico ginecológico 
Exame Físico Geral 
(Checklist: Ectoscopia, Marcha, Fáscies, Sinais Vitais, Mucosas, Peso E Altura, Tireóide, Ausculta Cardiaca, Ausculta Respiratória, Mmii) 
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Exame Das Mamas 
(Checklist: Inspeção, Palpação, Axilas E Fossas Supraclaviculares, Complexo Areolo-Papilar) 
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Exame do Abdome: 
(Checklist: Inspeção, Ausculta, Percussão, Palpação) 
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GENITÁLIA EXTERNA: 
(Checklist: Inspeção, Distopias) 
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EXAME ESPECULAR: 
(Checklist: Inspeção, Coleta dupla) 
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