Escolar Documentos
Profissional Documentos
Cultura Documentos
Data:___/____/_____
Nome:_____________________________________________________ Idade:________________
Endereço___________________________________CEP:________________Bairro:____________
Profissão:________________________________________________ Sexo: Fem ( ) Masc ( )
Est. Civil: __________________________ Escolaridade:__________________________________
Como chegou até nós: _____________________________________________________________
Queixa Principal:__________________________________________________________________
_________________________________________________________________________________
Problema Emocional Qual?__________________________________________________________
( ) Dor Crônica ( ) Dor por trauma Quando teve início o problema? ____________________
Mulheres: Está grávida? ( )Sim ( )Não Se sim, de quanto tempo _____________ Quantas
gestações: _________ Está na menopausa ( )Sim ( )Não há quanto tempo?______________
DOR
1-Local da dor: ( )Cabeça ( )Occiptal ( )Temporal ( )Frontal ( )ATM ( )Sinusite
Hematológica ( ) Hepatológica ( )
________________________ _________________________
1
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Data ___/___/____ Como paciente retornou:
2
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
_
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Data ___/___/____ Como paciente retornou:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
_
Data ___/___/____ Como paciente retornou:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
_
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Data ___/___/____ Como paciente retornou:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________