Histria Clnica

Identificao do Paciente

Nome___________________________________________________________________
Idade:________________________
Sexo: ( ) Feminino ( ) Masculino

Cor/Etnia: ( ) Branca ( ) Preta ( ) Parda ( ) Amarela ( ) Indgena

Estado Civil: ( ) Solteiro ( ) Casado ( ) Divorciado ( ) Vivo ( ) Unio Estvel

Profisso:________________________ Naturalidade:______________________________

Residncia:_________________________________________________________________

Procedncia_________________________________________________________________
Tempo de permanncia no DF:_________________________________________________
Data da Internao:___/___/201__ Data do Exame:___/___/2016

N de Registro no Hospital:____________________ Leito:___________________________

Plano de Sade:____________________________________________________________

Fonte: ( ) Paciente ( ) Acompanhante:__________________________________________

Fidedignidade: ( ) Boa ( ) Regular ( ) Ruim ( ) Se contradiz ( ) Duvidosa
Queixa Principal

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Histria da Doena Atual

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Antecedentes Fisiolgicos, Epidemiolgicos, Profissionais e Sociais (Histria Pessoal)
Condio de Nascimento: ( ) Parto Normal ( ) Cirurgia Cesariana ( ) Frcipe ( ) N/S

Desenvolvimento:
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Vacinas:
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Hbitos Alimentares:

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Quantidade de refeies:_______________________________________________________

Intervalo entre refeies:_______________________________________________________

Habitao: ( ) gua Encanada ( ) Rua Pavimentada ( ) Casa de Alvenaria

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Banhos de Rio: ( ) No ( ) Sim. Se sim, onde:____________________________________
Parasitoses: ( ) No ( ) Sim. Se sim, especificar:__________________________________
Residncias Anteriores:

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Escolaridade: ( ) Analfabeto ( ) Ensino Fundamental Incompleto ( ) Ensino Fundamental

Completo ( ) Ensino Mdio Incompleto ( ) Ensino Mdio Completo ( ) Ensino Superior
Incompleto ( ) Ensino Superior Completo
Profisso Anterior:___________________________________________________________

Profisso Atual:______________________________________________________________
Vida no Lar:

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Uso de Drogas Ilcitas: ( ) No ( ) Sim. Se sim, especificar tipo e tempo de uso:

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lcool: ( ) No ( ) Sim.
Se sim:

Quantidade:_________________________________________________________________
Tipo:______________________________________________________________________

Frequncia:_________________________________________________________________
Tempo:____________________________________________________________________
CAGE: ( ) Positivo ( ) Negativo
Fumo: ( ) No ( ) Sim.

Se sim:

Quantidade:_________________________________________________________________
Tipo:______________________________________________________________________

Frequncia:_________________________________________________________________

Tempo_____________________________________________________________________
N cigarros/dia:______/20 x N de anos:______ =______
N maos/dia:______ x N de anos:______=______

Data/Idade da Menarca: _____________________________________________( ) N/A

N de Gestaes:______ Abortos:______ Tipo de parto: Normal:______ Cesrea:_______

Data/Idade da Menopausa: ___________________________________________( ) N/A
Ciclo
Menstrual:______
Regular: ( ) Sim ( ) No

dias

Durao

do

sangramento:______dias

Fluxo: ( ) Leve ( ) Moderado ( ) Intenso

Exames preventivos:

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Antecedentes Patolgicos Pessoais Pregressos e Atuais
Doenas:

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Cirurgias:

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Traumas:

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Alergias:

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Hemotransfuses:

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DSTs:

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Outros:

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Histria Familiar

Me:
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Pai:

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Filhos:

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Cnjuge:

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Doenas Comuns: ( ) Hipertenso Arterial Sistmica. Quem:_______________________

( ) Doenas Cardiovasculares. Quais e quem:____________________________________
(
) Dislipidemias. Quem:___________________________________________________
( ) Diabetes. Quem:__________________________________________________________

( ) Hemopatias. Quem:_______________________________________________________
( ) Tuberculose. Quem:_______________________________________________________
( ) Psicopatias. Quais e quem:__________________________________________________
( ) Epilepsia. Quem:_________________________________________________________
( ) Alergia. Quais e quem:___________________________________________________
Reviso dos Sistemas

- Peso: ( ) Ganho ( ) Perda ( ) Estvel

Peso atual:______kg Provvel Causa:______________________________________( )N/A

- Linfonodos: ( ) Aumento ( ) Dor Localizao:___________________________________

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- Pele e Anexos:

Alterao de cor:_____________________________________________________________
Hiperemia: ( ) No ( ) Sim Onde:______________________________________________

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Alterao da temperatura: ( ) No ( ) Sim Onde:__________________________________

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Leses de Pele: ( ) No ( ) Sim Onde:___________________________________________

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Prurido: ( ) No ( ) Sim Onde:________________________________________________

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Sensibilidade: ( ) No ( ) Sim Onde:____________________________________________

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Alterao dos Anexos: ( ) No ( ) Sim Onde:_____________________________________

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- Cabea:

Cefalia: ( ) No ( ) Sim

Incio:
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Periodicidade:_______________________________________________________________
Localizao:________________________________________________________________

Intensidade: ( ) Leve ( ) Moderada ( ) Intensa Escala de 1 a 10:_____________________

Carter:____________________________________________________________________
Associao com distrbios visuais: ( ) No ( ) Sim
Nusea: ( ) Sim ( ) No

Vmitos: ( ) No ( ) Sim. Se sim, caractersticas:__________________________________

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Relao com ansiedade, menstruao, tosse, exerccio, posio e movimentos: ( ) No

( ) Sim. Se sim, com o qu:____________________________________________________
Sintomas Associados:________________________________________________________

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- Olhos:

Viso:_____________________________________________________________________

Escotoma: ( ) No ( ) Sim. Se sim, uni ou bilateral:________________________________

Dor: ( ) No ( ) Sim

Diplopia: ( ) No ( ) Sim

Alucinaes Visuais: ( ) No ( ) Sim

- Ouvidos:

Audio:___________________________________________________________________
Presena de zumbido: ( ) No ( ) Sim
Secreo: ( ) Ausente ( ) Presente
Dor: ( ) No ( ) Sim
- Nariz:

Secreo Nasal: ( ) Presente ( ) Ausente Ps Nasal: ( ) Presente ( ) Ausente

Epistaxe: ( ) No ( ) Sim. Se sim, descrever:_____________________________________

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Obstruo: ( ) Sim ( ) No

Prurido Nasal: ( ) Sim ( ) No

- Boca e Garganta

Leses dos lbios, lngua ou mucosa bucal: ( ) Ausentes ( ) Presentes. Especificar:

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Condio dos dentes e gengivas:_________________________________________________
Hemorragia gengival: ( ) Ausente ( ) Presente. Especificar:__________________________
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Rouquido: ( ) Sim ( ) No

Alteraes de hlito:__________________________________________________________
- Pescoo:

Dor: ( ) No ( ) Sim. Especificar:______________________________________________

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Tumorao: ( ) No ( ) Sim Localizao:________________________________________
Rigidez: ( ) Sim ( ) No
- Mamas:

Dor: ( ) No ( ) Sim. Especificar:______________________________________________

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Ndulos: ( ) Ausentes ( ) Presentes. Especificar:__________________________________

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Secreo: ( ) Ausentes ( ) Presentes. Especificar:__________________________________

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Alteraes do mamilo_________________________________________________________

Alteraes do volume:_________________________________________________________
- Sistema Respiratrio

Tosse: ( ) Ausente ( ) Presente. Especificar:______________________________________

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Expectorao: : ( ) Ausente ( ) Presente. Especificar:______________________________

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Hemoptise: : ( ) Ausente ( ) Presente. Especificar:_________________________________

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Dor torcica: : ( ) Ausente ( ) Presente. Especificar:_______________________________

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Dispneia: : ( ) Ausente ( ) Presente. Especificar:__________________________________

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Cianose: : ( ) Ausente ( ) Presente. Especificar:___________________________________

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Sibilos: : ( ) Ausente ( ) Presente. Especificar:____________________________________

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- Sistema Circulatrio:

Ortopneia: : ( ) Ausente ( ) Presente. Especificar:_________________________________

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Dispneia Paroxstica Noturna: : ( ) Ausente ( ) Presente. Especificar:__________________

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Dor Precordial: : ( ) Ausente ( ) Presente. Especificar:______________________________

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Palpitao: : ( ) Ausente ( ) Presente. Especificar:_________________________________

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Edema: : ( ) Ausente ( ) Presente. Especificar:____________________________________

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Cianose: : ( ) Ausente ( ) Presente. Especificar:___________________________________

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Claudicao Intermitente: : ( ) Ausente ( ) Presente. Especificar:_____________________

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Varizes nos Membros Inferiores: : ( ) Ausente ( ) Presente. Especificar:________________

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- Sistema Digestivo:

Apetite: ( ) Normal ( ) Reduzido ( ) Aumentado ( ) Ausente

Deglutio: ( ) Com dificuldade ( ) Dolorosa ( ) Normal

Sensao de peso ou empachamento:_____________________________________________

Erucato: __________________________________________________________________
Regurgitao: ( ) Ausente ( ) Presente. Especificar:________________________________

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Pirose: ( ) Ausente ( ) Presente. Especificar:_____________________________________

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Soluos: ( ) Ausente ( ) Presente.

Dor e relao com a alimentao: ( ) Ausente ( ) Presente. Especificar:________________

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Nuseas: ( ) Ausente ( ) Presente. Especificar:____________________________________

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Sialorreia: ( ) Ausente ( ) Presente. Especificar:___________________________________

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Hematmese: ( ) Ausente ( ) Presente. Especificar:________________________________

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Melena: ( ) Ausente ( ) Presente. Especificar:____________________________________

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Frequncia e carter das fezes:__________________________________________________

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Eliminao de Parasitos: ( ) Ausente ( ) Presente. Especificar:_______________________

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Enterorragia: ( ) Ausente ( ) Presente. Especificar:________________________________

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Hematoquezia: ( ) Ausente ( ) Presente. Especificar:_______________________________

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Acolia: ( ) Ausente ( ) Presente. Especificar:_____________________________________

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Colria: ( ) Ausente ( ) Presente. Especificar:____________________________________

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- Sistema Urinrio

Poliria: ( ) Sim ( ) No

Polaciria: ( ) Sim ( ) No
Nictria: ( ) Sim ( ) No
Disria: ( ) Sim ( ) No

Calibre do jato:______________________________________________________________
Incontinncia: ( ) Sim ( ) No
Reteno: ( ) Sim ( ) No

Estrangria: ( ) Sim ( ) No
Hematria: ( ) Sim ( ) No

Edema Facial: ( ) Sim ( ) No

- Sistema Genital:
* Homens:

Puberdade:__________________________________________________________________
Funo Ertil: ( ) Potente ( ) Impotente

Dor: ( ) Ausente ( ) Presente. Especificar:_______________________________________

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Alteraes Testiculares: ( ) Ausente ( ) Presente. Especificar:________________________

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* Mulheres:

Metrorragia: ( ) Ausente ( ) Presente. Especificar:_________________________________

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Corrimento Vaginal: ( ) Ausente ( ) Presente. Especificar:__________________________

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Prurido Vulvar: ( ) Ausente ( ) Presente. Especificar:______________________________

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- Neuropsiquitricos:

Insnia: ( ) Ausente ( ) Presente. Especificar:____________________________________

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Roncos: ( ) Ausente ( ) Presente. Especificar:____________________________________

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Sonolncia Diurna: ( ) Ausente ( ) Presente. Especificar:___________________________

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Humor:____________________________________________________________________

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Delrio: ( ) Ausente ( ) Presente. Especificar:_____________________________________

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Tontura: ( ) Ausente ( ) Presente. Especificar:____________________________________

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Vertigem: ( ) Ausente ( ) Presente. Especificar:__________________________________

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Desmaios: ( ) Ausente ( ) Presente. Especificar:__________________________________

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Perda de conscincia: ( ) Ausente ( ) Presente. Especificar:__________________________
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Convulso: ( ) Ausente ( ) Presente. Especificar:_________________________________

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Tremores: ( ) Ausente ( ) Presente. Especificar:___________________________________

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Dficit Motor: ( ) Ausente ( ) Presente. Especificar:_______________________________

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Alterao da Fala: ( ) Ausente ( ) Presente. Especificar:____________________________

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Dficit de memria: ( ) Ausente ( ) Presente. Especificar:___________________________

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- Sistema Locomotor:

Deformidades: ( ) Ausente ( ) Presente. Especificar:______________________________

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Dor ou incapacidade funcional das articulaes: ( ) Ausente ( ) Presente. Especificar:

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Rigidez Matinal: ( ) Ausente ( ) Presente

Sinais Flogsticos: ( ) Ausentes ( ) Presentes. Especificar:__________________________

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Dores Musculares: ( ) Ausentes ( ) Presentes. Especificar:__________________________

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Fraqueza Muscular: ( ) Ausente ( ) Presente. Especificar:__________________________

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- Sistema Hematopoitico:

Sangramentos Espontneos: ( ) Ausente ( ) Presente. Especificar:____________________

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Alteraes da Coagulao: ( ) Ausente ( ) Presente. Especificar:______________________

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- Sistema Endcrino:

Polifagia: ( ) Sim ( ) No

Polidipsia: ( ) Sim ( ) No

Intolerncia ao frio ou calor: ( ) Ausente ( ) Presente. Especificar:___________________

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Alteraes na quantidade e distribuio dos plos: ( ) Ausente ( ) Presente. Especificar:

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