A ri

Ad
ria
ian
ana
na Bra
rag
ra
aga
ga

Data: ______/______/______

Prtese - Implante - DTM

Pronturio N: __________________

PRONTURIO CLNICO E ANAMNESE

IDENTIFICAO
Nome: __________________________________________________________________________ RG: ________________________
rgo Expedidor: _________________ CPF: ________________________________ Data de Nascimento: ______/______/_______
Sexo:

Masculino

Feminino

Estado Civil: ____________________ Profisso: ________________________________

Endereo Residencial: _________________________________________________________________________________________

Telefone: ____________________________________________ Email: __________________________________________________
Indicado por _________________________________________________________________________________________________
ANAMNESE

Queixa principal - Motivo da consulta: ____________________________________________________________________________

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
QUESTIONRIO DE SADE
Qual(is)? _____________________________________________

Sofre de alguma doena:...............................

Sim

No

Est em tratamento mdico atualmente?........

Sim

No

Est fazendo uso de alguma medicao?.......

Sim

No

Nome e telefone do Mdico para contato:......

Sim

No

(anestesia, medicamentos, luva).....................

Sim

No

Fuma?...........................................................

Sim

No

Hepatite?.......................................................

Sim

No

Problemas com cicatrizao?.........................

Sim

No

Problemas com anestesia?............................

Sim

No

Problemas de hemorragia?.............................

Sim

No

Febre Reumtica?..........................................

Sim

No

Problemas Cardacos?...................................

Sim

No

Diabetes?......................................................

Sim

No

Problemas Renais?........................................

Sim

No

Presso Alta?................................................

Sim

No

Problemas de Estmago?..............................

Sim

No

Cncer?........................................................

Sim

No

Problemas Respiratrios?...............................

Sim

No

DST?............................................................

Sim

No

Problemas Articulares?...................................

Sim

No

Endocardite bacteriana?.................................

Sim

No

Problemas Sanguneos?................................

Sim

No

Osteoporose?...............................................

Sim

No

Qual(is)? _____________________________________________

Teve ou tem algum tipo de alergia?

Qual(is)? _____________________________________________

Apresenta ou j apresentou............................

Qual? _______________________________________________

Antecedentes Familiares:_______________________________________________________________________________________
Alguma informao importante com relao a sua sade que no foi perguntado? ________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Aceita o registro fotogrficodo tratamento?

Sim

No

Declaro que as informaes acima prestadas so totalmente verdadeiras, livres e espontneas.

_______/_______/_______

____________________________________________________

Data

Assinatura do paciente

ODONTOGRAMA

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

PLANOS DE TRATAMENTO
Opo 1: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Opo 2: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Opo 3: ____________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Opes escolhida e informaes adicionais: _______________________________________________________________________

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Declaro que, aps ter sido devidamente esclarecido(a) sobre os propsitos, riscos, custos e alternativas de tratamento,
conforme acima apresentados, aceito e autorizo a execuo do tratamento, comprometendo-me a cumprir as orientaes da
profissional assistente e arcar com os custos estipulados no oramento apresentado.

_______/_______/_______

________________________________________

_______________________________________

Data

Assinatura do paciente ou representante legal

Assinatura do cirurgio

PROCEDIMENTOS CLNICOS

Data

Procedimentos

Assinatura

A ri
Ad
ria
ian
ana
na Bra
rag
ra
aga
ga
Prtese - Implante - DTM

Data: ______/______/______
Pronturio N: __________________