Professional Documents
Culture Documents
Nome: _____________________________
Trato: __________
Morada: _______________________________________________
_____________________________________________________
Telefone: ______________
Mdico Assistente:_________________________________________
Habilitaes Literrias: _____________________________________
Profisso: ______________________________________________
Ocupao (reformado?): ________________________
Histria Militar: __________________________________________
_____________________________________________________
Estado Civil: ____________________________________________
Agregado Familiar: ________________________________________
_____________________________________________________
Pessoas Significativas: _____________________________________
_____________________________________________________
Linguagem Predominante: ___________________________________
Histria Scio-Cultural: _____________________________________
_____________________________________________________
_____________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_____________________________________________
Valores e Crenas Espirituais: _________________________________
_____________________________________________________
_____________________________________________________
Actividade Cognitiva:
- Auto-conceito: ____________________________________
Auto-imagem (efeitos da doena): __________________
_________________________________________
Auto-estima:________________________________
_________________________________________
Desempenho de papis: _________________________
_________________________________________
Histria de Sade:
Razo de procura do Servio/ Motivo de Internamento: _______________
_____________________________________________________
Data: ___________________________________________
Transferncia:_____________________________________
Sintomas Predominantes:
_______________________________________________________
_______________________________________________________
_________________________________________________
Histria de Doena Actual: ___________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Exames Auxiliares de Diagnstico:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Diagnstico Clnico:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Medicao Habitual vs. Actual:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Preocupaes Presentes:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Antecedentes Pessoais (doenas anteriores? traumatismos? cirurgias?):
_____________________________________________________
_____________________________________________________
Antecedentes Familiares:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Percepo do Indivduo:
Compreenso da doena:______________________________
_______________________________________________
_______________________________________________
Adeso aos tratamentos (nvel de interveno e cooperao):______
_______________________________________________
_______________________________________________
Avaliao Fsica
Altura: __________ cm
Peso: __________ Kg
Nvel de Conscincia:
_______________________________________________________
___________________________________________________
Comportamento:
_______________________________________________________
___________________________________________________
Pele e Mucosas:
Textura: _________________________________________
Integridade: ______________________________________
Descamao: ______________________________________
Hidratada? _______________________________________
Colorao: _______________________________________
Textura: _________________________________________
Solues de Continuidade: _____________________________
Turgor: __________________________________________
Rubor:___________________________________________
Abdmen:
Cicatrizes:________________________________________
Simetria: _________________________________________
Forma do umbigo: __________________________________
Permetro Abdominal:________________________________
Edema: __________________________________________
Cabea, Face e Pescoo:
Crnio (forma, tamanho, posio): _______________________
_______________________________________________
Couro Cabeludo (cor, textura, leses):_____________________
_______________________________________________
Nariz e Boca:
Permeabilidade das Vias: ______________________________
Alinhamento, insero e simetria do nariz: __________________
_______________________________________________
Alinhamento do septo: _______________________________
Boca, mucosas e Lngua: ______________________________
Prteses: _____________________________
Dentes: ______________________________
Olhos e Ouvidos:
Cor dos olhos: _______________________________
Acuidade Visual: _____________________________
Campo Visual: _______________________________
Plpebras: _________________________________
Sobrancelhas: _______________________________
Conjuntiva: ________________________________
Ouvido Externo: _____________________________
Implantao: __________________________
Tamanho: ____________________________
Simetria: _____________________________
Cor: ________________________________
Exsudado: ____________________________
Leses/dor: ___________________________
Acuidade Auditiva: ___________________________
rgos Genitais e Recto:
_______________________________________________________
_______________________________________________________
_________________________________________________
Funo Msculo-Esqueltica:
Forma de marcha:___________________________________
_______________________________________________
Alinhamento Postural:________________________________
_______________________________________________
Amplitude de Movimento e Simetria das Articulaes: __________
_______________________________________________
Fora Muscular:____________________________________
_______________________________________________
Respirar
Comer e Beber
Eliminar
Dormir e Repousar
Vestir-se e Despir-se
Recrear-se
Aprender