PUCPR - O.R.T.O.D.O.N.T.I.

A GRADUAO E PS-GRADUAO
RELATRIO DE CASO CLNICO
Paciente:.................................................................................Pronturio:......................
Aluno/a:...........................................................................................No:..........................
DATA:.........../.........../............

1. Nome do paciente:_____________________________Idade:_____Gnero :___

2. Queixa principal:__________________________________________________
3.Histricos
familiar,
mdico
e
odontolgico
(aspectos
principais)___________________________________________________________
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4. Sumrio do diagnstico (aspectos principais dos exames clnicos extra e intrabucal, exame funcional, exames radiogrficos, classificao da malocluso nos planos
horizontal, vertical e transversal, anlise de modelo e cefalomtrica, hbitos,
etc):_________________________________________________________________
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5.
Plano
de
tratamento
proposto:_____________________________
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6. Prognstico:_____________________________________________________
7.Comentrios:_______________________________________________________
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