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Avaliação Nutricional de Gestantes ___ Consulta Data: ___/___/___. 1) Dados Pessoais: Nome: ____________________________________________________ Idade: ___________ Data de nascimento: ___/___/___ Profissão/ocupação: _________________________________________ Bairro: _________________________ Telefone: ___________________ 2) Objetivo: __________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ 3) História Gestacional: Antecedentes obstétricos: Gesta: _________ Para:_________ Aborto:_________ Partos vaginais: _______ Cesáreas: _______ Fórceps: _______ Filhos: A termo: _______ Prematuros: _______ Nativivos: > 2500g: _______ < 2500g: _______ Natimortos: _______ Data do último parto: ____/____/____ Tipo: ( ) VG ( ) CS Data do último aborto: ____/____/____ Gestação Atual: D.U.M.: ____/____/____ D.P.P.: ____/____/____ IG: __________ semanas Risco gestacional (intercorrências): _____________________________ __________________________________________________________ 4) História - alterações corporais: Estado Nutricional: _______________________________________ Atividade física:____________ Freqüência:________ Tempo: ________ Tabagismo: ( ) Sim ( ) Não Etilismo: ( ) Sim ( ) Não Pressão arterial: ___________________ 5) História clínica História familiar: ( ) DM ( ) Eclampsia ( ) HAS ( ) Pré-eclampsia ( ) Gemelar ( ) Outras: ______________________________________ História pregressa: __________________________________________ História atual: ______________________________________________ Medicações e/ou suplementos nutricionais: _______________________ _______________________________________________________________ _____________________________________________________ 6) Alimentação pregressa: Dietas realizadas: ___________________________________________ __________________________________________________________ 7) Anamnese alimentar: Aversões: _________________________________________________ Preferências: _______________________________________________ Responsável pela compra dos alimentos: _________________________ Responsável pela preparação dos alimentos: _____________________ Alergia Alimentar:____________________________________________ Função intestinal: ___________________________________________ Ingestão Hídrica:____________________________________________ 8) Avaliação laboratorial: Data Hemácias Hemoglobina Hematócrito Linfócitos Leucócitos Plaquetas Albumina Colesterol Total HDL-colesterol LDL-colesterol VLDL - colesterol Triglicerídeos Glicose Uréia Creatinina Ácido úrico Sódio Potássio Cálcio Magnésio Ficha de Acompanhamento de Gestantes ___ Consulta Data: ___/___/___. Nome: ______________________________________________________Idade: ____________ Peso Atual: _______Kg Altura: _______m IMC Gestacional: _______Kg/m² (Classificação: _______________) Peso utilizado: ( ) Peso Pré Gestacional (PPG): _____Kg ( ) Peso Desejável (PD): ______Kg (IMC médio 20,8Kg/m²) TMB: ______________Kcal/dia VET: ______________ Kcal/dia F.A. utilizado: ____________ Ganho: ________Kg em 1 semana +________ Kcal/dia VET final: ___________Kcal/dia % Kcal G g/Kg/dia Proteínas Glicídios Lipídios Anamnese: Exames, Queixas, Intercorrências, Recordatório Alimentar, Conduta. ________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____ 9) Ingestão Habitual: Desjejum : Horário : ___________ Local: ____________________ ____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____ Colação : Horário : ___________ Local: ____________________ ____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____ Almoço : Horário : ___________ Local: ____________________ ____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____ Lanche : Horário : ___________ Local: ____________________ ____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____ Jantar : Horário : ___________ Local: ____________________ ____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____ Ceia : Horário : ___________ Local: ____________________ ____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____ 10) Dados Antropométricos: Peso Pré Gestacional: _______Kg Altura: _______m IMC Pré Gestacional: ______Kg/m² (Classificação: _______________) Peso Atual: _____Kg IMC Gestacional: _______Kg/m² (Classificação: _______________) 11) Cálculo para estimativa de ganho de peso durante a gestação: 12) Prescrição: Peso utilizado: ( ) Peso Pré Gestacional (PPG): _____Kg ( ) Peso Desejável (PD): ______Kg (IMC médio 20,8Kg/m²) TMB: ______________Kcal/dia VET: ______________ Kcal/dia F.A. utilizado: ____________ Ganho: ________Kg em 1 semana +________ Kcal/dia VET final: ___________Kcal/dia % Kcal g g/Kg/dia Proteínas Glicídios Lipídios 13) Conduta : ____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______ 14) Observações: ____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______ PLANEJAMENTO DIETÉTICO PARA GESTANTE Paciente: ______________________________________ Data da consulta: ___/___/___ Peso:_______ Altura: _______ Idade: _______ Motivo da consulta: _______________ Ganho de _____ kg por semana IMC: ________ kg/m² Desjejum : Horário : ___________ ____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______ Colação : Horário : ___________ ____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______ Almoço : Horário : ___________ ____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______ Lanche : Horário : ___________ ____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______ Jantar : Horário : ___________ ____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______ Ceia : Horário : ___________ ____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______
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