Professional Documents
Culture Documents
IDENTIFICAÇÃO _________________________________________________
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NOME:___________________________________________ _________________________________________________
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SEXO:___________________________________________ _________________________________________________
IDADE:__________ COR: branca/parda/preta _________________________________________________
ESTADO CIVIL:__________________________________ _________________________________________________
PROFISSÃO:______________________________________ _________________________________________________
NATURAL DE:____________________________________ _________________________________________________
PROCEDENTE ____________________________________ _________________________________________________
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2. QUEIXA PRINCIPAL E DURAÇÃO _________________________________________________
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3. HISTÓRIA DA DOENÇA ATUAL (HDA) _________________________________________________
(duração total, início, curso, características, _________________________________________________
sintomas associados, efeitos de tratamentos, _________________________________________________
progressão, repercussões sobre a vida do paciente, _________________________________________________
ordem cronológica, sintomas associados) _________________________________________________
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_________________________________________________ 4. INTERROGATÓRIO SINTOMATOLÓGICO
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_________________________________________________ Sintomas gerais: alterações do peso (em quanto tempo),
_________________________________________________ febre, calafrios, astenia, sudorese noturna , anorexia
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_________________________________________________ Pele e fâneros: prurido, lesões cutâneas (localização),
_________________________________________________ alopecia, alterações da pigmentação, anormalidades nos pêlos
_________________________________________________ e na aparência ungueal
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_________________________________________________ Cabeça e pescoço: cefaléia, cervicalgia, limitação da
_________________________________________________ movimentação do pescoço, tumorações cervicais
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_________________________________________________ Olhos: dor ocular, acuidade visual, diplopia, fotofobia,
_________________________________________________ lacrimejamento, secreção conjuntival, escotomas visuais,
_________________________________________________ visão turva, correção com óculos ou lentes de contato
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_________________________________________________ intestinal (n0 de evacuações diárias, aspecto das fezes - cor e
_________________________________________________ consistência -, presença elementos anormais - sangue, muco
e/ou pus), tenesmo evacuatório, dor e prurido retal,
Ouvidos, nariz e seios da face: otalgia, algias faciais, enterorragia, melena, meteorismo, cólicas, flatulência,
congestão periorbitária, epistaxe, otorréia, rinorréia, obstipação intestinal
obstrução nasal, espirros freqüentes, gota pós-nasal, _________________________________________________
zumbidos, acuidade auditiva, vertigem _________________________________________________
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Cavidade Oral: odontalgia, gengivorragias, ulcerações da _________________________________________________
mucosa, queimação ou ardência da língua, odinofagia, _________________________________________________
sialose, dor em ATM _________________________________________________
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_________________________________________________ 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 urinário (homem), eliminação de cálculos durante a
micção
Mamas: mastalgia, descarga mamilar, nódulos palpáveis. _________________________________________________
Ginecomastia no homem _________________________________________________
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Respiratório: tosse, expectoração (aspecto e quantidade), _________________________________________________
rouquidão, hemoptise, dor torácica, dispnéia, chiado no tórax _________________________________________________
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_________________________________________________ Genital: homem (corrimento uretral, lesões genitais,
_________________________________________________ disfunções sexuais); mulher (leucorréia, prurido
_________________________________________________ vulvovaginal, sangramento intermenstrual, dor pélvica,
_________________________________________________ dispareunia)
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Cardiovascular: precordialgia, palpitações, dispnéia de _________________________________________________
esforço, noturna e de decúbito, síncope, edema, cianose, _________________________________________________
claudicação intermitente, veias varicosas, úlceras de perna _________________________________________________
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_________________________________________________ Osteoarticular: artralgias, rigidez matinal, edema articular,
_________________________________________________ limitação de movimentos, deformidades, lombalgia
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