Vous êtes sur la page 1sur 3

c 


    

 ebre [______] Calafrios [______] Variao de peso [________________] Indisposio Geral [_________]
Fraqueza [______]
Cansao[______] Sudorese [______] Sangramentos [___________] Ndulos [______] Intolerncia ao frio ou ao calor [_______]
________________________

____________________________________________________________________________________________________
_____________
   Alteraes de cor (ictercia, cianose, pal idez, rubor,
manchas)[____________________________________________________________]
Prurido [_____]Alteres em cabelos (espessura, alopcia, hirsutismo) [______________________] Leses ungueais [______] Est rias
[_____] Furnculos
[______] lceras [______]Outras leses [______] Alteraes na textura, umidade, oleosidade [_______]
___________________________________________
__________________________________________________________________________________________________________________
_______________

! Cefalia [______]Tonturas [______] Vertigens [______] Dor facial


[_______]_______________________________________________________
"# Alterao da viso [______] Prurido[_____] Inflamaes [_______] Secreo [_____] Lacrimejamento [ ______] Sensao de corpo
estranho [_____]
Fotofobia [_______]Diplopia [_______] Dor/ardncia [______] Escotomas [_____] Exoftalmo [_______] Edema palpebral
[______]_______________________
__________________________________________________________________________________________________________________
______________

$" Deficincia auditiva [______] Dor [_______] Secreo [______] Zumbidos [_______]
______________________________________________
%&  "%! Congesto/obstruo [______] Secreo [______]

Epistaxe [______]

Espirros [______] Olfao [_______]

_____________
__________________________________________________________________________________________________________________
______________

'(!%'(! !)*****+ , "-! )******+ Ateraes em lbios, gengivas, dentes, palato, bochechas e
lngua [________]
Dor na garganta [_____]Inflamao na garganta [_____] Alterao na voz
[_______]___________________________________________________________

#  !Protuberncias [______] Dor ao movimento [______] Alteraes em vasos [_____]


_______________________________________________

 .#  ./!"$ ! Tosse [_____]Expectorao [______] Hemoptise [______] Chiado [______] Dor
torcica [______]
Palpitaes [_______]Dispnia [_______] Ortopnia [______] DPN [______] Presso arterial prvia [________________________] Sopro
[______]
Claudicaointermitente [_____]Edema de extremidades [_____ _] Varizes [_____] Alteraes trficas em membros [______] Alteraes na
temperatura em
membros[______]____________________________________________________________________________________________________
______________

0 .#"' $ Apetite [______________________] Sialorria [______]Halitose [______] Disfagia [______] Odinofagia [______]
Intolerncia a
alimentos [__________________________________________] Polifagia [______] Polidipsia [______] Regurgitao [_____] Nuseas
[______] Vmitos[_____]
Hematmese [______]Azia [_____] Pirose [_____] Eructaes [_____]
[______] Dor

Plenitude/distenso abdominal [______] Saciedade pr ecoce

abdominal [_______] Flatulncia [_______] Diarria [_____] Constipao [________] Dor anal [______] Prurido anal [______] Tenesmo
[______] Uso
crnico de laxantes[______] Hbito intestinal e alteraes [___________________________________________________] Melena [____ __]
Enterorragia [_ ____]
Hematoquezia[______] Acolia
[______]________________________________________________________________________________________________

__________________________________________________________________________________________________________________
______________

 .#1 Alteraes na cor/cheiro da urina [______] Oligria [______]Anria [_______] Poliria [______] Disria [______]

Polaciria [______]

Nictria [______]Urgncia [______] Incontinncia [______] Ardncia miccional [______] Reteno [______] Hem atria [_______] Colria
[______]
Clicas/Eliminao de clculos [______]Dor lombar ou no flanco [______] Alterao do jato [______] Enurese [_______]
__________________________________________________________________________________________________________________
_____________
__________________________________________________________________________________________________________________
_____________

 .#."Relaes sexuais [_______________________________] Proteo contra DST [________] Libido [___ ________________]
Alteraes nos genitais[______] Distrbios sexuais [______] Infertilidade [______]
___________________________________________________________

2--Dor testicular [______] Aumento de bolsa escrotal [_______] Disfuno ertil [_______]
______________________________________________

# Mamas (dor, ndulos, secreo)[____________________________ _______] Ciclo menstrual [_________________________]


Dispareunia [_______]
Prurido vulvar [_______]Dismenorria [_______]
Menorragia [_______]

Tenso pr -menstrual [_______] Fluxo genital [________] Anticoncepo [_______]

Metrorragia [_______]Amenorria [______] Relao dos sintomas com o ciclo menstrual [_________________]
_____________________________________
__________________________________________________________________________________________________________________
____________

-3 --4 ! 56!Artralgia [______] Mialgia [______] Dor mobilizao [______] Limitao do movimento [______]
Deformidades
[_______]Traumatismos [_______] Caimbras [_______]
_____________________________________________________________ ___________________

3 -$ . 5 - Nervosismo [_______]Alteraes de conduta [_______] Irritabildade [______] Alucinaes
[_______] Confuso
mental [_____] Iinsnia [_____] Tremores [______] Convulses [______] Sncope [______] Perdas de conscincia [______] Paralisias [___ __]Paresias[_____]
Parestesias [______]Tetania [______] Alteraes da memria [______] Alteraes sensoriais [______] Sono [______]

7 23
  
  33 (Anotar poca ou idade, anotar hospital)
Doenas da infncia [_________________________________________________________]DST
[________________________________________________]
Doenas transmissveis (TBC, f. tifide, hepatite, d. Chagas, malria, etc.) [______________________________________________]Doenas
alrgicas e
alergias[_________________________________] Outras doenas (HAS, IAM,/DAC, FR, DM, AVE, d. Tireide, anemia,
etc.)[____________________________]
Cirurgias e
hospitalizaes[______________________________________________________________________________________________________
___]
Acidentes[______________________________________________________________________] Exames
[_______________________________________]
__________________________________________________________________________________________________________________
______________



8 23
   (DM, HAS, DAC, gota, cncer,d. contagiosas, nefropatias, d.alrgicas, distrrbioshereditr iso,
sangramentos, d.mental, epilepsia,etc)
Pai [___________________________]Me [______________________________] Irmos
[________________________________________________] Filhos
[____________________________________________________]Avs [ _____________ _______________________] Tios [_________
_________________]

Cnjuge/companheiro(a) [________________________________]
_________________________________________________________________________

m  m 
m           
      ! " !#
$  % & m '  !  ( )  *   
!"+  , ,       ) -
"   . #
/  /m$ 0m  1        -#
&2  !.  !   .    
!
3 !#
m
4  ) 3 #
$/m  .   5      *  " "#
m
mm   !#
678  "#
8  % /0  .   !     !#
 m%m
&2
%
m9
 /m
87m/6&m
 5  
3  " !  1         ! 
 ! !
:  m%m
&2 8 7     ;  !    
1     5  <!  .  )     
.       "5        1  
  ! " !-!     !     !#
  m%m
&2 6
=
 ! .    "    , ,
, , , " !, ,   !  5  !
-   ,     > - -   
  #
2  m%m
&2
%
86

 "! !    !     ,  3
-      1 >          
 #
 !"   .   3    .    
 ! 1 " !   1?!  3  #
  @/6&  m
/6&m0A     ! 
;!#
B   m 
7 m&
m0  %C6=
/m  !
 .        !  .  < 
 !  .     - *       
  ! !   .   #