Avaliao Nutricional - Data: _____/_____/_____

IDENTIFICAO
Nome: __________________________________________________________ Idade: ____ Data Nasc.: ____/____/____
Sexo: Feminino

Masculino

Estado civil:____________________

Escolaridade: _______________________

Profisso: ______________________________ Trabalha atualmente ? Sim No

Estuda atualmente ? Sim No
Endereo: __________________________________________________________________________________________
Bairro: ______________________ Cidade / UF :______________CEP : __________-______Tel:____ _______________
Indicao:__________________________________________________________________________________________
Objetivo Principal:____________________________________________________________________________________
HBITOS SOCIAIS E DE SADE

Tipo Sangneo:_______

Peso:_______

Altura:_______

IMC:_______

Fumante: Sim

No

Sim Quais ? _______________________________________________

Quantas vezes por semana ? ____________________________Quantos minutos por vez ?____________________________

Atividade Fsica No

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Bruxismo (e/ou tensionamento): Sim
No __________________________________________
Sono: Normal

Irregular

Disposio Fsica:
Manh: Boa

Regular

Ruim

Tarde: Boa

Regular

Ruim

Noite: Boa

Regular

Ruim

Regular

Ruim

Noite: Boa

Regular

Ruim

Concentrao para as atividades intelectuais:

Manh: Boa

Regular

Ruim

Tarde: Boa

Memria:
Para fatos recentes: Boa

Regular

Ruim

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Para fatos antigos:

Regular

Ruim

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Boa

Antecedentes Mdicos: Doenas mais freqentes (que teve e/ou tem): ______________________________

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Cirurgias: ____________________________________________________________________________________________

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Antecedentes Mdicos Familiares: _____________________________________________________________________

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Medicao/Suplementao:
J utilizou: _________________________________________________________________________________________
Utiliza atualmente: ____________________________________________________________

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Histrico de desequilbrios (peso) corpreos:_______________________________________________________________
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Avaliao Nutricional - Data: _____/_____/_____

HBITOS ALIMENTARES
Apetite: Bom Regular Ruim
Digesto: Boa

Regular

Ruim

Horrio de maior apetite: M A T

Azia: Sim

Dores Abdominais e/ou estufamento: Sim

Produo / Eliminao de Gases: Normal
Evacuao: Normal

Obstipado

Diurese freqente: Sim

Diarrico

No

No

MD

Mastigao: Lenta Rpida

Horrio:_________________________________________

Horrio:________________________________________________

Aumentada

Dirio

Horrio:_________

Irregular

Sensao esvaz. completo: Sim

No

No _________________________________________________________________________

Qt. lquidos durante o dia: _________________________Lquido nas refeies: Sim No ______________

Alergias (Alimentares/Medicamentos/Picada insetos): ______________________________________________
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Averses / Intolerncias Alimentares: ___________________________________________________________
_______________________________________________________________________________________________
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Preferncias Alimentares: _____________________________________________________________________
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Salgado
Azedo
Preferncia: Doce
Observaes:________________________________________________________________________________
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No
J fez algum tipo de dieta? Sim
Quando?_______________________________________________________________________________________________
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Usou alguma medicao? Sim

No Qual? ___________________________________________________________
___________________________________________________________________________________________
Faz dieta atualmente? Sim No _________________________________________________
_______________________________________________________________________________________________
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Frequncia em Restaurantes / Bares / Lanchonetes / Delivery: ____________________________________________
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Observaes:____________________________________________________________________________________
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Avaliao Nutricional - Data: _____/_____/_____

Paciente: ______________________________________________________________________ Data :_____/_____/_____

Avaliao de Hbito Alimentar

Horrio habitual de acordar? ___________
Voc ingere algum alimento ao acordar?

Horrio habitual de dormir? ___________

SIM

NO

Alimento: _________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Voc est habituado a consumir outro alimento antes do almoo?

SIM

NO Horrio: __________________

Alimento: _________________________________________________________________________________________
__________________________________________________________________________________________________
Voc est habituado a almoar?

SIM

NO

Horrio: __________________

Alimento: _________________________________________________________________________________________
__________________________________________________________________________________________________
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Voc est habituado a consumir outro alimento no perodo da tarde?

SIM

NO Horrio: ______________

Alimento: _________________________________________________________________________________________
__________________________________________________________________________________________________
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Voc est habituado a jantar?

SIM

NO

Horrio: ______________

Alimento: _________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Voc est habituado a fazer alguma refeio antes de deitar?
SIM
NO
Horrio: _______________
Alimento: _________________________________________________________________________________________
__________________________________________________________________________________________________
Alimentao no fim de semana:________________________________________________________________________
Com que freqncia os tens abaixo so consumidos?
ALIMENTOS
Dirio Semanal Mensal Nunca
Caf
Refrig. / gua c/ gs
Ch Mate ou Preto
Doces / Chocolate
Temperos prontos
Frituras
lcool
Embutidos
Cereais integrais
Hortalias cruas
Frutas
Leguminosas
Peixe
Leite e derivados

Qual ?

Avaliao Nutricional - Data: _____/_____/_____

Paciente: ______________________________________________________________________ Data :_____/_____/_____

A PRESENA DOS SINAIS E SINTOMAS ABAIXO PODE RELACIONAR-SE COM NVEIS

DEFICITRIOS DE NUTRIENTES E DE TOXICIDADE DE METAIS PESADOS.
SE VOC IDENTIFICA A PRESENA DE UM OU MAIS SINTOMAS, ASSINALE-OS NA COLUNA
CORRESPONDENTE:
INTESTINO PRESO
DIARRIA
FLATULENCIA (GASES EXCESSIVOS)
ERUCTAAO (ARROTAR)
DIGESTO LENTA
AZIA (QUEIMAO)
NAUSEAS E VOMITOS
HEMORROIDAS
AFTAS
SANGRAMENTO DAS GENGIVAS
ALTERAES NA LNGUA
MAU HLITO / BOCA AMARGA / BOCA SECA
RACHADURAS NOS LBIOS/ CANTOS DA BOCA
ALTERAES DE APETITE
PERDA DO PALADAR
ALTERAES DE PESO
FLACIDEZ MUSCULAR
INFECES FREQUENTES
DORES DE CABEA
DIABETES OU PR-DIABETES
HIPOGLICEMIA
TAXA DE TRIGLICRIDES ALTERADA
TAXA DE COLESTEROL ALTERADA
TONTURAS/ FALTA DE EQUILBRIO
FRAQUEZA / DESMAIO
ESPINHAS/ SEBORREIA
MICOSE/ ECZEMA/ PSORASE/ CASPA
ANEMIA
QUEDA DE CABELOS
UNHAS FRGEIS / QUEBRADIAS/ ESCAMAO
PELE RESSECADA
ALTERAES NAS UNHAS (ESTRIAS/ MANCHAS)

STEOPOROSE / OSTEOPENIA
DORES MUSCULARES / ARTICULARES
AMORTECIMENTO BRAOS E PERNAS
DIFICULDADE DE CICATRIZAO
CIMBRAS
ALT. NO RITMO CARDIO-RESPIRATRIO
MANCHAS ARROXEADAS NA PELE
PRESSO ALTA
PRESSO BAIXA
INCHAO
TRANSPIRAO EXCESSIVA
TENSO PR-MENSTRUAL
ALTERAES DE FLUXO MENSTRUAL
COMPULSIVIDADE
ANSIEDADE / APREENSO
IRRITABILIDADE
NERVOSISMO
HIPERATIVIDADE FSICA/ MENTAL
MENOR CAPACIDADE DE CONCENTRAO
DIMINUIO DE MEMRIA
FADIGA
SONOLNCIA
INSNIA
ALTERAES NA AUDIO / OUVIDO
ALTERAES NA VISO / OLHOS
ALTERAO DE HUMOR
DEPRESSO
SNDROME DO PNICO
MICROVASOS
CELULITE
ARDNCIA / PRURIDO (VAGINAL E/ OU ANAL)
BRUXISMO / TENSIONAMENTO

OUTROS SINTOMAS E OBSERVAES:

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