Roteiro de Anamnese Pediátrica

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Nome: ________________________________________________ N° cartão:______________ 
Sexo: __________________Cor:________________________ Idade:____________________ 
Data de nascimento: ___/___/___ Local de 
nascimento:________________________________ 
Residência: __________________________________________________________________ 
Nome da mãe: _______________________________________________________Idade:____ 
Nome do pai: ________________________________________________________Idade:____ 
Informante: _________________________________ Credibilidade:______________________ 
Queixa principal: ______________________________________________________________ 
História da moléstia atual: 
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Revisão de sistemas 
Geral: _______________________________________________________________________ 
SN: 
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Pele e anexos: ________________________________________________________________ 
Linfonodos: __________________________________________________________________ 
Cabeça: _____________________________________________________________________ 
Olhos: ______________________________________________________________________ 
Nariz: _______________________________________________________________________ 
Ouvidos: ____________________________________________________________________ 
Boca:_______________________________________________________________________ 
Pescoço: ____________________________________________________________________ 
Tórax e Ap. respiratório: ________________________________________________________ 
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Ap. cv: ______________________________________________________________________ 
Abdome e Aparelho digestivo: 
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ANAMNESE DE PEDIATRIA 
 
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Ap. genito-urinário: ____________________________________________________________ 
Ap. músculo-esquelético: 
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Antecedentes pessoais 
Pré-natais: 
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Natais:______________________________________________________________________
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Pós-natais (aleitamento materno, testes de tragem, crescimento e desenvolvimento): 
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Vacinais:_____________________________________________________________________
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Patológicos (infecções, internações, uso de medicações, cirurgias, convulsões, 
alergias):_____________________________________________________________________
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Antecedentes familiares (constituição familiar, condições de moradia, animais domésticos, 
doenças heredo familiares e infectocontagiantes, tabagismo): 
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Hábitos de vida (alimentação atual, funcionamento intestinal, controle esficteriano e condições 
neuropsíquicas):_______________________________________________________________
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Dados vitais e antropométricos 
Peso: _______ Estatura:__________ PC:____________PT:____________PA:_____________ 
Temperatura:___________ FC:_____________ FR:_______________ PA:________________ 
Ectoscopia 
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Exame segmentar 
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EXAME FÍSICO 
 
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Observações 
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Diagnósticos 
Alimentar:____________________________________________________________________ 
Nutricional: __________________________________________________________________ 
Crescimento:_________________________________________________________________ 
DNPM:______________________________________________________________________ 
Vacinal:______________________________________________________________________ 
Clínico:______________________________________________________________________ 
Exames solicitados 
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Orientações 
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Prescrição 
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Araguari, ______de ______________________ de 20______ 
Acadêmicos responsáveis 
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Médico responsável: __________________________________________________________ 
Nome, CRM, assinatura e carimbo