Paciente N°: Sexo: H( ) M( ). PA:________ T:________.

Faz uso diário de medicamento? Sim ( ) Não ( ). Alergia a medicação? Sim ( ) Não ( ) Qual?
Hipertensão ( ), Diabetes ( ), TA ( ) ou TAG ( ).
Sintomas Relatados:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Diagnóstico sugerido:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Tratamento:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Paciente N°: Sexo: H( ) M( ). PA:________ T:________.
Faz uso diário de medicamento? Sim ( ) Não ( ). Alergia a medicação? Sim ( ) Não ( ) Qual?
Hipertensão ( ), Diabetes ( ), TA ( ) ou TAG ( ).
Sintomas Relatados:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Diagnóstico sugerido:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Tratamento:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________