FICHA DE ANAMNESE CLÍNICA
Nome: ____________________________________________________________________________
Idade: __________________ Sexo: ( M ) ( F ) Ocupação: ____________________________
CPF: _____._____._____-_____ RG: __________________ Contato: ( ) ___________________
Objetivo: ______________________________________________________________________
Onde faz as refeições: ( ) em casa ( ) na rua ( ) no trabalho
Vegetariano (a): ( ) sim ( ) não
Vegano (a): ( ) sim ( ) não
Fumante: ( ) sim ( ) não
Ingere bebidas alcoólicas? ( ) sim ( ) não Frequência: _________________
Prepara sua comida? ( ) sim ( ) não Frequência: _________________
Dorme bem? ( ) sim ( ) não Quantas horas: _____________
Faz atividade física? ( ) sim ( ) não Quais: ______________________
Mora com quantas pessoas? __________________ Outros: ___________________________
Possui alguma patologia?
Faz uso de medicamento ou
( ) Diabetes ( ) Dislipidemia
suplemento?
( ) Osteoporose ( ) Colite ___________________________
( ) Endócrino ( ) Câncer
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( ) Hipertensão ( ) Hipoglicemia
( ) Cardíaco ( ) Herpes ___________________________
( ) Refluxo ( ) Problema Renal ___________________________
( ) Gastroesofágico ( ) Hipotireoidismo ___________________________
( ) Gastrite ( ) Hipertireoidismo
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( ) Circulatório ( ) Fadiga Crônica
( ) Rinite/Sinusite ( ) Alergia ___________________________
( ) Dor de cabeça ___________________________
Outro:
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Mastigação: ( ) lenta ( ) normal ( ) rápida
Frequência de evacuação: ________________________________________________________
Hábito Urinário:
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Ingestão Hídrica:__________________________________________________________________
Histórico familiar - Predisposições
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O quanto sua saúde é importante pra você?
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Quais alimentos você não gosta?
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Quais alimentos gosta de comer no seu dia?
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Você pratica exercício físico? Qual horário?
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Detalha sua rotina, desde da hora que acorda/dorme:
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Qual seu peso e altura?
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DATA ASSINATURA
