Anamnese Nutricional

Nome Completo:

Data de Nascimento:

Peso Atual (Preenchido na consulta):

Peso Habitual:

Peso Desejado:

Altura:

Objetivo com a Dieta?

( ) Manutenção do peso

( ) Perda de peso . Quanto_______________________________________________________

( ) Ganho de peso. Quanto_______________________________________________________

( ) Ganho de massa muscular

Outros objetivos________________________________________________________________

_____________________________________________________________________________

Atividade física?

( ) Não ( ) Sim. Qual_____________________________________________________

Freqüência atividade física

( ) 1 vez na semana Qual dia _____________________________ Horário______________

( ) 2 vezes na semana.Quais dias_____________________________ Horário______________

( ) 3 vezes na semana Quais dias_____________________________ Horário______________

( ) 4 vezes na semana Quais dias_____________________________ Horário______________

( ) 5 vezes na semana Quais dias_____________________________ Horário______________

( ) 6 dias na semana Quais dias_____________________________ Horário______________

( ) 7 dias na semana Quais dias_____________________________ Horário______________

Horários da atividade física

Modalidade_____________________________ início_____________ término________

Modalidade_____________________________ início_____________ término________

Modalidade_____________________________ início_____________ término________

Anamnese Nutricional

Já utilizou suplementos alimentares ?

Não ( ) Sim ( ) Quais_______________________________________________

Utiliza atualmente algum suplemento alimentar ?

Não ( )

Sim ( ) Quais________________ Marca comercial _____________Horários_________

Patologias:

Não ( ) Sim ( ) Quais_______________________________________________

Medicamentos:

Não ( ) Sim ( ) Quais_______________________________________________

Habito Intestinal:

( ) Normal ( ) Constipado ( ) Diarréia

Dificuldade para mastigar?

Não ( ) Sim ( ) Por quê______________________________________________

Dificuldade para deglutir?

Não ( ) Sim ( ) Por quê______________________________________________

Alergia Alimentar?

Não ( ) Sim ( ) Quais alimentos_______________________________________

Alimentos que NÃO GOSTA

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Refeições que realiza em casa

Desjejum ( ) Almoço ( ) Jantar ( ) Todas ( )

Alimentos no Jantar

( ) Lanche ( Pão, leite, frios, etc) ( ) Comida de sal ( Como no almoço)

( ) Outros:________________________________________________________________

_________________________________________________________________________

Anamnese Nutricional

Questionário sobre hábito alimentar

Alimento Não Gosta Gosta Gosta muito Come diariamente Raramente
Água pura sem gás
Água pura com gás
Sucos Industrializados

Normais

Sucos Industrializados

Lights ou Diets

Refrigerante Normal
Refrigerante Light ou Diet
Chás com açúcar
Chás sem açúcar
Café Preto com açucar
Café Preto sem açucar
Leite Desnatado
Leite semi-desnatado
Leite Integral
Leite Integral
Leite Light
Leite Normal
Leite Fermentado

( Ex: Yakult)

Achocolatedo em pó p/ misturar no leite
Açucar
Adoçante
Pão Francês
Pão de Sanduíche
Pão Light
Pão Integral
Margarina Normal
Margarina Light
Geléia industrializada

normal

Geléia industrializada

Light

Geléia industrializada

Diet

Maionese industrializada

normal

Maionese industrializada

light

Mél ou melado
Nata
Creme de leite
Leite condensado
Salame ou Copa
Presunto Gordo
Presunto Magro
Chester, peito de peru, etc.
Queijos Brancos
Queijos Amarelos
Requeijão normal
Requeijão light
Frutas
Saladas
Alimentos Integrais
Alimentos Integrais

(arroz, massa)

Aveia
Farelo de Trigo
Granola
Sucrilios
Linhaça
Feijão
Lentilha
Carne de Gado
Carne de Vaca
Carne de frango
Carne de Peixe
Carne de Porco
Carne de Carneiro
Carne de Ovelha
Salsicha
Linguiça
Empanados
Frituras
Barras de Cereal
Bolacha Recheada
Bolacha doçe sem recheio
Bolacha Salgada
Bolos
Tortas
Doçes de Padaria
Salgados de Padaria

Outros alimentos: ________________________________________________________________

_______________________________________________________________________________

Outras observações importantes sobre sua alimentação:

________________________________________________________________________________

Anamnese Nutricional

<table border=”1″ cellpadding=”1″ cellspacing=”1″ style=”width: 500px; height: 1595px;”>
<tbody>
<tr>
<td>
<strong>Alimento</strong></td>
<td>
<strong>N&atilde;o Gosta</strong></td>
<td>
<strong>Gosta</strong></td>
<td>
<strong>Gosta muito</strong></td>
<td>
<strong>Come diariamente</strong></td>
<td>
<strong>Raramente</strong></td>
</tr>
<tr>
<td>
&Aacute;gua pura sem g&aacute;s</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
&Aacute;gua pura com g&aacute;s</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Sucos Industrializados<br />
Normais</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Sucos Industrializados<br />
Lights ou Diets</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Refrigerante Normal</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Refrigerante Light ou Diet</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Ch&aacute;s com a&ccedil;&uacute;car</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Ch&aacute;s sem a&ccedil;&uacute;car</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Caf&eacute; Preto com a&ccedil;ucar</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Caf&eacute; Preto sem a&ccedil;ucar</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Leite Desnatado</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Leite semi-desnatado</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Leite Integral</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Leite Integral</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Leite Light</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Leite Normal</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Leite Fermentado<br />
( Ex: Yakult)</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Achocolatedo em p&oacute; p/ misturar no leite</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
A&ccedil;ucar</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Ado&ccedil;ante</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
P&atilde;o Franc&ecirc;s</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
P&atilde;o de Sandu&iacute;che</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
P&atilde;o Light</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
P&atilde;o Integral</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Margarina Normal</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Margarina Light</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Gel&eacute;ia industrializada<br />
normal</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Gel&eacute;ia industrializada<br />
Light</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Gel&eacute;ia industrializada<br />
Diet</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Maionese industrializada<br />
normal</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Maionese industrializada<br />
light</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
M&eacute;l ou melado</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Nata</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Creme de leite</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Leite condensado</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Salame ou Copa</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Presunto Gordo</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Presunto Magro</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Chester, peito de peru, etc.</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Queijos Brancos</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Queijos Amarelos</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Requeij&atilde;o normal</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Requeij&atilde;o light</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Frutas</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Saladas</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Alimentos Integrais</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Alimentos Integrais<br />
(arroz, massa)</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Aveia</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Farelo de Trigo</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Granola</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Sucrilios</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Linha&ccedil;a</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Feij&atilde;o</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Lentilha</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Carne de Gado</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Carne de Vaca</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Carne de frango</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Carne de Peixe</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Carne de Porco</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Carne de Carneiro</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Carne de Ovelha</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Salsicha</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Lingui&ccedil;a</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Empanados</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Frituras</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Barras de Cereal</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Bolacha Recheada</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Bolacha do&ccedil;e sem recheio</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Bolacha Salgada</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
<tr>
<td>
Bolos</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
<td>
&nbsp;</td>
</tr>
</tbody>
</table>
<p>
&nbsp;</p>