1.
IDEN IDENTI TIFI FICA CAÇÃ ÇÃO O
NOME:___________________________________________ _________________________________________________ SEXO:___________________________________________ IDADE:__________ COR: branca/parda/preta ESTADO CIVIL:__________________________________ PROFISSÃO:______________________________________ NATURAL NATURAL DE:____________________________________ DE:___________________________ _________ PROCEDENTE ____________________________________ 2. QUEIXA PRINCIPAL PRINCIPAL E DURAÇÃO _________________________________________________ _________________________________________________ _________________________________________________
3.
HISTÓRIA DA DOENÇA ATUAL (HDA) (duração total, início, curso, características, sintomas associados, efeitos de tratamentos, progressão, progressão, repercussões repercussões sobre a vida do paciente, paciente, ordem cronológica, sintomas associados) _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________
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INTERROGA INTERROGATÓRIO TÓRIO SINTOMA SINTOMATOLÓGI TOLÓGICO CO
Sintoma Sintomass gerais gerais:: altera alterações ções do peso peso (em quanto quanto tempo) tempo),, febre, calafrios, astenia, sudorese noturna , anorexia _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Pele e fâneros: prurido, lesões cutâneas (localização), alopecia, alterações da pigmentação, anormalidades nos pêlos e na aparência ungueal _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Cabeça e pescoço: cefaléia, cervicalgia, limitação da movimentação do pescoço, tumorações cervicais _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Olhos: dor ocular, acuidade visual, diplopia, fotofobia, lacrimejamento, secreção conjuntival, escotomas visuais, visão turva, correção com óculos ou lentes de contato _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________
_________________________________________________ _________________________________________________ Ouvidos, nariz e seios da face: otalgia, algias faciais, congestão periorbitária, epistaxe, otorréia, rinorréia, obstrução nasal, espirros freqüentes, gota pós-nasal, zumbidos, acuidade auditiva, vertigem _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Cavidade Oral: odontalgia, odontalgia, gengivorragi gengivorragias, as, ulcerações ulcerações da mucosa, queimação ou ardência da língua, odinofagia, sialose, dor em ATM ATM _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Mamas: mastalgia, descarga mamilar, nódulos palpáveis. Ginecomastia no homem _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Respiratório: tosse, expectoração (aspecto e quantidade), rouquidão, hemoptise, dor torácica, dispnéia, chiado no tórax _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Cardiovascular: precordialgia, palpitações, dispnéia de esforç esforço, o, noturn noturnaa e de decúbit decúbito, o, síncop síncope, e, edema, edema, cianos cianose, e, claudicação intermitente, veias varicosas, úlceras de perna _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Gastrintestinal: disfagia, pirose, intolerância alimentar, eructações, empachamento, regurgitação, epigastralgia, cólicas, cólicas, icterícia, icterícia, náuseas náuseas e vômitos, vômitos, hematêmese, hematêmese, hábito
intestinal (n0 de evacuações diárias, diárias, aspecto das fezes - cor e consistência consistência -, presença presença elementos elementos anormais - sangue, muco e/ou pus), tenesmo evacuatório, dor e prurido retal, enterorragia, melena, meteorismo, cólicas, flatulência, obstipação intestinal _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Urinário: dor (lombar, no flanco, vesical), disúria, alterações miccionais, estrangúria, polaciúria, alterações da cor e odor da urina, nictúria, enurese, oligúria, poliúria, incontinência urinária de esforço (mulher), gotejamento terminal e força do jato jato urinár urinário io (homem (homem), ), eliminaç eliminação ão de cálculo cálculoss durant durantee a micção _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Genital: homem (corrimento uretral, lesões genitais, disfunções disfunções sexuais); sexuais); mulher (leucorréia, (leucorréia, prurido vulvovaginal, sangramento intermenstrual, dor pélvica, dispareunia) _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Osteoarticular: artralgias, rigidez matinal, edema articular, limitação de movimentos, deformidades, lombalgia _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Hematopoiético Hematopoiético:: palidez, palidez, tendências tendências hemorrágicas, hemorrágicas, linfadenomegalias, esplenomegalia, hepatomegalia
_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Endócrino: intolerância ao frio ou ao calor, poliúria, polifagia e polidipsia, hirsutismo _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Nervoso: Nervoso: paresias paresias (paralisia (paralisia moderada), moderada), paralisias, paralisias, parestesias, atrofias musculares, tremores, convulsões, ausências, perturbações da memória (amnésia transitória ou permanente) _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Psiquismo: Psiquismo: insônia, insônia, nervosismo, nervosismo, choro freqüente, freqüente, irritabilidade, tristeza, sentimento de culpa, perda de interesse e prazer no trabalho e no lazer _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________
5.
ANTECEDENTES PESSOAIS FISIOLÓGICOS
Condições de gestação e nascimento:__________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Desenvolvimento neuropsicomotor: __________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Imunizações (BCG, DTP, anti-polio, hepatite viral, antitetanica, gripe ) ____________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Adolescência: (puberdade, surgimentos dos caracteres secundários)_______________________________________ _________________________________________________ _________________________________________________ _________________________________________________ ________________________________________________ Atividade sexual e vida reprodutiva (primeiro contato, parcei parceiros ros,, freqüên freqüência cia de relaçõ relações, es, camisin camisinha, ha, emnstru emnstruação ação(fl (fluxo, uxo, ciclo) ciclo),, gestaç gestações ões,, partos partos)) _________________________________________________ _________________________________________________ _________________________________________________
_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Climatério: (idade da mennopausa, ondas de calor, ressecamento vaginal) _______________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Senectude: ( como o paciente se sente no ambiente familiar, solidão, solidão, viuvez, pensão, aposentadori aposentadoria, a, atividades atividades diárias) diárias) _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ 6.
ANTECEDENTES ANTECEDENTES PESSOAIS PESSOAIS PATOLÓGICOS TOLÓGICOS
Doenças da infância (sarampo, catapora, rubéola, caxumba):_________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Doenças apresentadas apresentadas na vida adulta ( tuberculose, tuberculose, DST, DST, hepatite, diabetes, hieprtensão arterial, cardiopatias, epilepsias, febre reumática, asma, aborto espontâneo ou não, disf disfun unção ção sexu sexual) al) : ____ ______ _____ _____ ____ ____ _____ ____ _ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Antecedentes Antecedentes de alergia: alergia: _____________ ____________________ ______________ ________ _ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Cirurgias:_________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ ________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Hospitalizações:____________________________________ _________________________________________________
_________________________________________________ ________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Traumatismos:_____________________________________ _________________________________________________ _________________________________________________ ________________________________________________ _________________________________________________ _________________________________________________ Hemotransfusões:___________________________________ _________________________________________________ ________________________________________________ Uso de drogas injetáveis:____________________________ _________________________________________________ _________________________________________________ Medicações Medicações de uso prolongado:__ prolongado:_________ ______________ _____________ ______ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ 7. ANTECEDENTES ANTECEDENTES FAMILIARES AMILIARES _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ 8.
ANTECEDE ANTECEDENTE NTES S SOCIAIS SOCIAIS
Condições de habitação e higiene: ____________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Condições de alimentação: __________________________ _________________________________________________ _________________________________________________ _________________________________________________
_________________________________________________ _________________________________________________ Nível de instrução: ________________________________ _________________________________________________ História História Ocupacional: Ocupacional: ______________ _____________________ _____________ _________ ___ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Religião: _________________________________________ Renda familiar mensal: ____________________________ Relações interpessoai interpessoais: s: ( se existe problema problema de relacionamento na família – se o paciente tem amigos – sente solidão tem ressentime imento nto ) _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Problemas psicossociais: ( maior preocupação do paciente -o que lhe estressava antes da internação - sofreu alguma perda importante importante no passado passado - sente-se realizado realizado – se houve expectativas frustradas)_____________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Hábitos e costumes: tabagismo (duração, tipo de cigarro, nº de cigarros consumidos por dia), consumo de álcool (duração, (duração, tipo de bebida, quantidade quantidade consumida), consumida), banhos de rios açudes e lagoas (localidade e época), contato com o triatomíneo, contato com animais domésticos, prática regular de exercícios físicos (tipo e freqüência), sono, lazer, viagens, uso de drogas ilícitas _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________
