Nome Completo:____________________________________________________________

Data de Nascimento:_________________ Idade: _________

Sexo:____________________________

Encaminhado por:

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Histórico
Queixas (sintomas, duração, história pregressa de queixa)

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História de doença atual

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Hospitalizações

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Alergias / Intolerâncias

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Cirurgias / Procedimentos

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Medicamentos em uso

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Alergias

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Medicamento em uso

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História Familiar

⃝ AVC ⃝ DAC ⃝ DM ⃝ Dislipidemia ⃝ HAS

⃝ Tiroidopatia ⃝ Asma ⃝ Bronquite ⃝ Outras

Atividade física
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Outros aspectos sociais

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Outros Antecedentes familiares

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Tabagismo
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Hipóteses Diagnósticas
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Exame Físico
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Exames Complementares
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Conduta
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