2.PERFIL CLÍNICO-EPIDEMIOLÓGICO
3. FATORES DE RISCO PARA TB 1 Febre recentemente:
( )Sim ( )Não
Temperatura no momento da entrevista:
________________________ 3.2 Gripe recentemente:
( )Sim ( )Não
3.3 Diagnóstico de Pneumonia recentemente:
( )Sim ( )Não
quanto tempo?
____________________________________________
3.4 Diagnóstico de Asma recentemente:
121 quanto tempo? ____________________________________________
3.5 Diagnóstico de Doença Pulmonar Obstrutiva Crônica
recentemente:
( )Sim ( )Não
quanto tempo? ________________________________________ 3.6 Diagnóstico de Doenças respiratórias ocupacionais (exposição a gases, vapores, fumos e poeiras no ambiente de trabalho) recentemente:
( )Sim ( )Não
3.7 Realização de tratamento para alguma doença respiratória?
( )Sim ( )Não
quanto tempo?________ qual doença?_______________________ 3.8 Tratamento prolongado com corticosteroides?
( )Sim ( )Não
quanto tempo?_______qual ?______________________________ 3.9 Tratamento com drogas imunossupressoras (período superior a um mês);
( )Sim ( )Não
122
3.10 Diagnóstico de alguma doença renal crônica?
( )Sim ( )Não
qual? ____________________________________________ 3.11 Realização de hemodiálise?
( )Sim ( )Não
quanto tempo?______________
3.12 Diagnóstico de alguma como: Artrite reumatoide, lúpus, Tireoidite de Hashimoto, Vitiligo, Diabetes Mellitus, doença de Crohn, esclerose múltipla, câncer, etc.
( )Sim ( )Não qual? ____________________________________________ 3.13 Diagnóstico de HIV? ( )Sim ( )Não quanto tempo?________________________________________ 3.14 Tabagismo: ( )Sim ( )Não quanto tempo?________________________________________ 3.15 Etilismo:
( ) Não ( ) 2 vezes na semana
( ) 1 vez na semana ( ) 3 vezes na semana
123
3.16. Pratica exercícios físicos regularmente?
( )Sim ( )Não
quanto tempo?________________________________________ 3.17 Diagnóstico de anemias?
( )Sim ( )Não
qual? ____________________________________________ 3.18 Realização de alguma dieta alimentar?
( )Sim ( )Não
tempo?________________________________________ 3.19 Uso de algum esteroide anabolizante?
( )Sim ( )Não
qual? ____________________________________________ 3.20 Uso de alguma suplementação alimentar?
( )Sim ( )Não
qual? ____________________________________________ 3.21 Perda de peso acentuada recentemente?
( )Sim ( )Não
quanto ?______________________________________________ 3.21 Perda de apetite acentuada recentemente ou uso de algum medicamento para reduzir o apetite?
124 ( )Sim ( )Não qual? ____________________________________________ 3.21 Presença de suores noturnos?
( )Sim ( )Não
quanto tempo?________________________________________
3.22 Presença de calafrios, fadiga ou dor torácica?
( )Sim ( )Não
qual? ____________________________________________ 3.23 Alguma dificuldade para respirar (dispneia)?
( )Sim ( )Não
quanto tempo?________________________________________ 3.24 Presença de rouquidão na voz?
( )Sim ( )Não
quanto tempo?________________________________________ 3.25 Diagnóstico de laringite recentemente?
( )Sim ( )Não
125
3.25 Uso de medicamentos como: prednisona, anti-TNF-Į,
ciclosporina, Azatiprina, a 6-Mercaptopurina (Purinethol), o
Metotrexate (Metotrexate), Betametasona, Dexametasona,
Triancinolona, etc.
( )Sim ( )Não
qual? ______________________quanto tempo?
________________
3.26. Apresentou desnutrição recentemente?
( )Sim ( )Não
quanto tempo?________________________________________ 3.27 Uso de drogas ilícitas (injetáveis, inaladas, fumadas, anfetaminas):
( )Sim ( )Não
qual? ______________________quanto tempo?
________________
3.28. Apresenta parceiro (a) sexual fixo?
( )Sim ( )Não
quanto tempo?________________________________________ 3.29. Apresenta múltiplos parceiros (as) sexual?
( )Sim ( )Não
126
3.30 Estilo de vida sedentário:
( )Sim ( )Não
3.30 Estilo de vida saudável:
( )Sim ( )Não
Qual atividade física?______________________________________ ___________________________________________________
Assinatura/CPF
___________________________________________________ Assinatura do pesquisador
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