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FICHA DE ANAMNESE 1- DADOS DO PACIENTE Nome:_________________________________________________________________ Nascimento: ___/___/___ idade: ____sexo: __________nacionalidade:___________ Estado civil:______________ filhos: ( ) ________ idade:_______________________ Religião: _________________ profissão:_____________________________________ Bairro:_________________________________________________________________ Cidade: ______________________ estado: _________ UF: ____CEP:______________ Telefone: ____________ celular: ( ) __________ e-mail:_______________________ CPF: ___________________RG:________________ órgão emissor: _______________ Em caso de emergência Nome: __________________________ contato: _______________________________ Médico:_________________________ contato: _______________________________ Convenio: _______________________ cartão: ________________________________ hospital:_______________________________________________________________ Queixa principal: ________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 2- AVALIAÇÃO DO PACIENTE Sinais vitais PA: FC: T: Peso: Altura: Diabetes ( ) Tabagismo ( ) Próteses dentárias ( ) Epilepsia ( ) Varizes ( ) Lesões ( ) Hipertensão arterial ( ) Hipotensão arterial ( ) Colesterol ( ) Faz ou já fez algum tratamento médico? S ( ) N ( ) quais: _____________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Tem antecedente oncológico? S ( ) N ( ) Antecedente familiar: ____________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Já fez tratamento estético? S ( ) N ( ) quais:________________________________ _______________________________________________________________________ _______________________________________________________________________ Toma algum remédio? S ( ) N ( ) quais: ___________________________________ _______________________________________________________________________ _______________________________________________________________________ Pratica exercícios físicos? S ( ) N ( ) frequência: _____________________________ Ingere água com frequência? S ( ) N ( ) Tem a alimentação balanceada? S ( ) N ( ) Ingere álcool? S ( ) N ( ) frequência: ______________________________________ Usa drogas ilícitas? S ( ) N ( ) Tem alguma alergia? S ( ) N ( ) quais:_____________________________________ _______________________________________________________________________ Tem alguma doença transmissível? S ( ) N ( ) É gestante ou amamenta? S ( ) N ( ) Usa anticoncepcional? S ( ) N ( ) Ciclo menstrual regular? S ( ) N ( ) Presença de metais: S ( ) N ( ) Tem algum problema ortopédico? S ( ) N ( ) É portador de marca passo? S ( ) N ( ) Tem sensibilidade a dor? S ( ) N ( ) Adicionais:______________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________