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ANAMNESE 
Data de avaliação: ____/____/____ 
 
Procedência: 
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QP: 
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HISTÓRIA DA DOENÇA ATUAL – HDA 
Sinais e sintomas: ____________________________________________________ 
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Início e evolução:_____________________________________________________ 
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Características: ______________________________________________________ 
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NOME:____________________________________________________________ 
SEXO:__________________ NATURALIDADE: ____________________ 
COR:______________RELIGIÃO:__________________ ETNIA:______________ 
PROFISSÃO:__________________ ESCOLARIDADE:______________________ 
DATA DE NASCIMENTO: ____/____/_____ IDADE:_____ 
ESTADO CIVIL: □ SOLTEIRO □ CASADO □ DIVORCIADO □ VIÚVO 
TEM FILHOS: □ SIM □ NÃO SE SIM, QUANTOS? ____________ 
TEL/PACIENTE: (__)_______________ TEL/FAMILIAR: (__)________________ 
ENDEREÇO:_______________________________________________________ 
Nº:______ BAIRRO: ___________________ CIDADE: ___________________ 
 
 
 
O que agrava: ______________________________________________________ 
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O que alivia: ________________________________________________________ 
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Tratamentos realizados: _______________________________________________ 
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Observações:________________________________________________________
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HISTÓRIA DA DOENÇA PREGRESSA – HDP 
DESCRIÇÃO: 
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CIRURGIAS: □ SIM □ NÃO Se sim, qual:___________________________ 
INTERNAÇÃO: □ SIM □ NÃO Se sim, quando e a causa:______________ 
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TRANFUSÕES SANGUÍNEAS: □ SIM □ NÃO Quant: ________________ 
 
ANTECEDENTES PATOLÓGICOS:______________________________________ 
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HISTÓRICO FAMILIAR: 
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HÁBITOS ALIMENTARES: 
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REALIZA ATIVIDADES: 
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FÁRMACOS: 
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ALERGIAS: 
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EXAMES COMPLEMENTARES E LABORATORIAIS: 
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EXAME FÍSICO GERAL: 
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OBSERVAÇÕES: 
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