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: _______ < 2500g: _______ Natimortos: _______
Data do último parto: ____/____/____ Tipo: ( ) VG ( ) CS
Data do último aborto: ____/____/____

 Gestação Atual:
D.U.M.: ____/____/____  D.P.P.: ____/____/____
IG: __________ semanas
Risco gestacional (intercorrências): _____________________________
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4) História - alterações corporais:

Estado Nutricional: _______________________________________

Atividade física:____________ Freqüência:________ Tempo: ________
Tabagismo: ( ) Sim ( ) Não
Etilismo: ( ) Sim ( ) Não
Pressão arterial: ___________________

5) História clínica

História familiar: ( ) DM ( ) Eclampsia ( ) HAS ( ) Pré-eclampsia

( ) Gemelar ( ) Outras: ______________________________________
História pregressa: __________________________________________
História atual: ______________________________________________
Medicações e/ou suplementos nutricionais: _______________________
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6) Alimentação pregressa:

Dietas realizadas: ___________________________________________

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7) Anamnese alimentar:

Aversões: _________________________________________________
Preferências: _______________________________________________
Responsável pela compra dos alimentos: _________________________
Responsável pela preparação dos alimentos: _____________________
Alergia Alimentar:____________________________________________
Função intestinal: ___________________________________________
Ingestão Hídrica:____________________________________________

8) Avaliação laboratorial:

Data
Hemácias
Hemoglobina
Hematócrito
Linfócitos
Leucócitos
Plaquetas
Albumina
Colesterol Total
HDL-colesterol
LDL-colesterol
VLDL - colesterol
Triglicerídeos
Glicose
Uréia
Creatinina
Ácido úrico
Sódio
Potássio
Cálcio
Magnésio
 Ficha de Acompanhamento de Gestantes
___ Consulta
Data: ___/___/___.

Nome: ______________________________________________________Idade: ____________

Peso Atual: _______Kg Altura: _______m IMC Gestacional: _______Kg/m²

(Classificação: _______________)

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

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Ganhar _____Kg por semana

Ganho ponderal nas semanas restantes:

1 Kg  6400 Kcal
____Kg  x = ________Kcal/semana ÷ 7 dias  _________Kcal/dia somado ao VET

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
Anamnese: Exames, Queixas, Intercorrências, Recordatório Alimentar, Conduta.
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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:

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

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

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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