Anamnese de Gestantes pdf(1)

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Avaliação Nutricional de Gestantes 
___ Consulta 
 
Data: ___/___/___. 
1) Dados Pessoais: 
 
Nome: ____________________________________________________ 
Idade: ___________ Data de nascimento: ___/___/___ 
Profissão/ocupação: _________________________________________ 
Bairro: _________________________ Telefone: ___________________ 
 
 
2) Objetivo: __________________________________________________ 
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3) História Gestacional: 
 
➢ Antecedentes obstétricos: 
Gesta: _________ Para:_________ Aborto:_________ 
Partos vaginais: _______ Cesáreas: _______ Fórceps: _______ 
Filhos: A termo: _______ Prematuros: _______ 
Nativivos: > 2500g: ____________________________________________________________________________________
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9) Ingestão Habitual: 
 
Desjejum : Horário : ___________ Local: ____________________ 
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Colação : Horário : ___________ Local: ____________________ 
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Almoço : Horário : ___________ Local: ____________________ 
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Lanche : Horário : ___________ Local: ____________________ 
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Jantar : Horário : ___________ Local: ____________________ 
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Ceia : Horário : ___________ Local: ____________________ 
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10) Dados Antropométricos: 
 
Peso Pré Gestacional: _______Kg Altura: _______m IMC Pré Gestacional: ______Kg/m² 
 (Classificação: _______________) 
 
Peso Atual: _____Kg IMC Gestacional: _______Kg/m² (Classificação: _______________) 
 
 
11) Cálculo para estimativa de ganho de peso durante a gestação: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12) Prescrição: 
Peso utilizado: 
( ) Peso Pré Gestacional (PPG): _____Kg 
( ) Peso Desejável (PD): ______Kg (IMC médio 20,8Kg/m²) 
TMB: ______________Kcal/dia 
VET: ______________ Kcal/dia F.A. utilizado: ____________ 
Ganho: ________Kg em 1 semana +________ Kcal/dia VET final: ___________Kcal/dia 
 
 % Kcal g g/Kg/dia 
Proteínas 
Glicídios 
Lipídios 
 
 
 
 
 
 
Peso Pré Gestacional (PPG): _____Kg IG:_____semanas 
IMC Pré Gestacional: _____Kg/m² (Classificação:______________) 
Ganho de peso previsto para o 1º trimestre (até a 13ª semana): _____Kg 
Ganho de peso semanal previsto para 2º e 3º trimestres: _____Kg por semana 
Ganho total de peso previsto até o final da gestação: _____Kg (entre_____e_____) 
Ganho total de peso previsto até o momento: _____Kg 
Peso Desejável até o momento: _____Kg 
Peso Atual (PA): _____Kg Já ganhou (PA – PPG): _____Kg 
 
Ganho total de peso previsto até o final da gestação (____Kg) - Quanto já ganhou (____Kg) 
_____ semanas que faltam para o final da gestação 
↓ 
 
Ganhar _____Kg por semana 
 
 
 
 
 
 
 
Ganho ponderal nas semanas restantes: 
1 Kg → 6400 Kcal 
____Kg → x = ________Kcal/semana ÷ 7 dias → _________Kcal/dia somado ao VET 
 
 
 
 
 
 
 
 
 
13) Conduta : 
 
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14) Observações: 
 
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PLANEJAMENTO DIETÉTICO PARA GESTANTE 
 
 
Paciente: ______________________________________ Data da consulta: ___/___/___ 
Peso:_______ Altura: _______ Idade: _______ Motivo da consulta: _______________Ganho de _____ kg por semana IMC: ________ kg/m² 
 
Desjejum : Horário : ___________ 
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Colação : Horário : ___________ 
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Almoço : Horário : ___________ 
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Lanche : Horário : ___________ 
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Jantar : Horário : ___________ 
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Ceia : Horário : ___________ 
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