FICHA DE ANAMNESE GERIÁTRICA

Nome: ________________________________________________________Idade: _______________

Sexo: _____________________________________religião:__________________________________
Profissão / aposentado:___________________________estado civil:____________________________
Naturalidade: ________________________________residência:_______________________________

Data de
avaliação:_________ Diagnóstico clínico _____________________________________________________________
______________________________ ________________________________________________________________
___________________________________________ ___________________________________________________
________________________________________________________

Queixa principal _________________________________________________________________________________

Medicamentos em uso ____________________________________________________________________________
____________

Ausculta Pulmonar:_______________________________________________________________________________
Alimentação : ( ) Independente ( ) Com auxílioVeste-se: ( ) De forma independente ( ) Com
auxílioUso de auxílio para marcha: () sim ( ) não Cadeira de rodas ( ) Andador ( ) Bengala ( ) Muletas ( )Avaliação do P
adrão de marcha_________________________________________________________________________________
_ _____________________________________________________________________________________________
______________ ________________________________________________________________________________
___________________________

Trofismo Muscular ( ) Rígido ( ) Flácido Hipertrofia ( ) Hipotrofia ( ) Atrofia ( ) Pseudo-hipertrofia ( )Tônus muscular: (
) Hipotônico ( ) Hipertônico ( ) Normotônico
( )Inspeção______________________________________________________________________________________
______________ ________________________________________________________________________________
___________________________ ___________________________________________________________________

Palpação:

MMSS__________________________________________________________________________________________
___ ____________________________________________________________________________________

MMII___________________________________________________________________________________________
___ ____________________________________________________________________________________________
ADM:MMSS_____________________________________________________________________________________
________ _______________________________________________________________________________________
MMII___________________________________________________________________________________________
___ ____________________________________________________________________________________________
Força
Muscular:MMSS__________________________________________________________________________________
___________ ____________________________________________________________________________________
MMII___________________________________________________________________________________________
___ ____________________________________________________________________________________________

Observações adicionais____________________________________________________________________________
____________ __________________________________________________________________________________
_________________________ _____________________________________________________________________
______________________________________ _______________________________________________________