Nome Completo:____________________________________________________________

Data de Nascimento:_________________ Idade: _________

Sexo:___________________________

Motivo da consulta: _______________________________________

Queixa principal

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História da doença atual

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Inspeção/Períneo

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Toque

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Colonoscopia / Exame prévios

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Anuscopia

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Retoscopia

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Medicações

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Frequência Evacuatória

Vez Dia Esforço

Histórico Gestacional

Gesta Para Normal Normal

Hábitos

⃝ Tabagismo ⃝ Etilismo ⃝ Etilismo Social

Histórico familiar

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Plano / tratamento proposto

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Cirurgia/ colonoscopia

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Conduta

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Avaliação Final

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