FICHA DA GESTANTE

NOME COMPLETO:
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DATA DE NASCIMENTO: ______ / ______ / _________ IDADE: ___________
ESTADO CIVIL: _____________________________
TEL CELULAR: ______________________ TEL
RESIDENCIAL:___________________
INSTAGRAM: ____________________________ FACEBOOK:
__________________
EMAIL:
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ENDEREÇO COMPLETO: _______________________________________________
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RELIGIÃO:___________________PROFISSÃO/OCUPAÇÃO ___________________

DADOS DO CONJUGE/ACOMPANHANTE

NOME COMPLETO:
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TEL CELULAR: _________________ IDADE: ________ ESTADO CIVIL:
__________
EMAIL:
________________________________________________________________
RELIGIÃO:___________________PROFISSÃO/
OCUPAÇÃO:___________________

SOBRE A GESTAÇÃO

DUM: ____ / ____ / ____ DPP: ____ / ____ / ____

PLANO DE SAÚDE: ______________ OBST PRÉ NATAL:
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PARTO: ( ) DISPONIBILIDADE ( ) PLANTÃO: __________________________
HOSPITAL DE
PREFERÊNCIA:____________________________________________

SEXO DO BEBÊ: ( )M( )F ( ) SURPRESA

NOME: _______________________________________________________________
OUTROS FILHOS: ________ GESTAÇÕES: __________ABORTOS:_________
DATA ÚLTIMO: ___ / ___ / ____

OBSERVAÇOES SOBRE A GESTAÇÃO (alterações e intercorrências):

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TIPO DE CONTRATO:___________________________________________
DESC: __________ VALOR: ___________________
DESEJA CHÁ DE BENÇÃOS: ______________
PRINT DE PLACENTA: ___________________

FORMAS DE PAGAMENTO:
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ACOMPANHAMENTO

HISTORICO DO ACOMPANHAMENTO - OBSERVAÇÕES RELEVANTES:

ENCONTRO 1:
____ / ____ -
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ENCONTRO 2:
____ / ____ -
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ENCONTRO 3:
____ / ____ -
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GERAIS:
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PARTO: ____________________________________ DATA: ____ / ____ / ____

HORA: ____:____

PESO: __________________ TAMANHO: _________________ APGAR:

_____________________
CONSIDERAÇÕES: -
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