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Anamnese Can PDF
Anamnese Can PDF
1.) Identificao
Data da 1 Consulta: ______/______/______
Nome:____________________________________________________________________
Endereo: _________________________________________________________________
Bairro:_________________ Passos/MG E-mail: _____________________________
Telefone residencial: ___________________ Celular: _____________________________
Data de nascimento: ____/____/____ Idade:________ Sexo: ( )Masculino ( )Feminino
Motivo da Consulta: ________________________________________________________
Observaes: ______________________________________________________________
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4.) Dados Clnicos
Intolerncia Alimentar:_______________________________________________________
Preferncia Alimentar:________________________________________________________
Alteraes do Apetite: ( ) Sim ( ) No Desde quando: __________________________
Fase que iniciou obesidade /perda peso:__________________________________________
Segue alguma dieta especial:__________________________________________________
Quantas refeies faz por dia:__________________________________________________
Consumo de gua:__________________________________________________________
Consumo de sal / ms: ________________ Consumo de leo / ms:___________________
Faz uso de suplementos? Qual?_________________________________________________
Quem indicou?______________________________________________________________
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Jantar - ________ hrs Local:______________________ Humor:______________
Alimento Quantidade
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_______________________________________________________________________________ .
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