PREFEITURA DE JABOATÃO DOS GUARARAPES

SECRETARIA MUNICIPAL DE SAÚDE

UNIDADE DE SAÚDE DA FAMÍLIA PORTA LARGA

Nome:

Nome da Mãe:

Endereço:

Data de Nascimento: ____/____/_____ Naturalidade:

CNS: Telefone:
# PRIMEIRA CONSULTA #
Prontuário:
DATA:____/____/____ HORA:_____:_____

QPD:___________________________________________________________________

HDA:___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

IS:_____________________________________________________________________
________________________________________________________________________
________________________________________________________________________

HV:

Etilismo: ( ) Faz uso: Qual?_________________ Frequência:__________Período:__________

( ) Parou: Há quanto tempo?______________________________
( ) Nega
Tabagismo: ( ) Faz uso: Qual?______________ Frequência:_____________Período:__________
( ) Parou: Há quanto tempo?______________________________
( ) Nega
Atividade ( ) Sim: Qual?________________ Frequência:________________
física: ( ) Não

AP: DM ( ) HAS ( ) DLP ( ) AVE ( ) ACV ( )

Cirurgias prévias: _________________________________________________________

Internamentos:___________________________________________________________

Outros:__________________________________________________________________

Medicamentos em uso:
__________________________________________________________________________
__________________________________________________________________________
 PREFEITURA DE JABOATÃO DOS GUARARAPES
SECRETARIA MUNICIPAL DE SAÚDE
UNIDADE DE SAÚDE DA FAMÍLIA PORTA LARGA

Nome:___________________________________________________DN:___/___/_____

AF: DM:_____________ HAS:______________ DLP:______________

AVE:______________ ACV:_______________ Câncer:___________________________
Outros:________________________________________________________________

TRIAGEM: Peso:_______ Altura:_______ IMC:_______ PA:____________ HGT:______

EF_____________________________________________________________________

ACV:___________________________________________________________________

AR:_____________________________________________________________________

Abd:____________________________________________________________________
________________________________________________________________________

Ext:____________________________________________________________________
________________________________________________________________________

Pele:___________________________________________________________________

Outros__________________________________________________________________
________________________________________________________________________

HD:_____________________________________________________________________
________________________________________________________________________
________________________________________________________________________

CD:_____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 PREFEITURA DE JABOATÃO DOS GUARARAPES
SECRETARIA MUNICIPAL DE SAÚDE
UNIDADE DE SAÚDE DA FAMÍLIA PORTA LARGA

Prontuário:
# CONSULTA SUBSEQUENTE #

Nome:_________________________________________________DN:___/___/_____
DATA:____/____/____ HORA:_____:_____
Evolução:______________________________________________________________________
_______________________________________________________________________________

Novas queixas:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Medicamentos em uso:___________________________________________________________

TRIAGEM: Peso:______ Altura:______ IMC:______ PA:___________ HGT:______

EF_____________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
HD:____________________________________________________________________________
CD:____________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
# CONSULTA SUBSEQUENTE #

DATA:____/____/____ HORA:_____:_____

Evolução:______________________________________________________________________
_______________________________________________________________________________

Novas queixas:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Medicamentos em uso:___________________________________________________________

TRIAGEM: Peso:______ Altura:______ IMC:______ PA:___________ HGT:______

EF_____________________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________________
HD:____________________________________________________________________________
CD:____________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
 PREFEITURA DE JABOATÃO DOS GUARARAPES
SECRETARIA MUNICIPAL DE SAÚDE
UNIDADE DE SAÚDE DA FAMÍLIA PORTA LARGA

# RESULTADOS DE EXAMES LABORATORIAIS #

Nome:___________________________________________________DN:___/___/_____

DATA
Hb/Ht
Plqts
Leuco
Seg
Linf
GJ
GPP
HbA1c
CT
HDL
LDL
VLDL
Trig
TGO
TGP
Cr
Ureia
Ác.Úr
K+
Na+
TSH
T4livre
T4total
PSAt
PSAliv
VDRL
HIV

# RESULTADOS DE EXAMES DE IMAGEM E OUTROS #

 PREFEITURA DE JABOATÃO DOS GUARARAPES
SECRETARIA MUNICIPAL DE SAÚDE
UNIDADE DE SAÚDE DA FAMÍLIA PORTA LARGA

Nome:_____________________________________________DN:___/___/_____

Exame:_____________________ Data:_________
Resultado:_____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Exame:_____________________ Data:_________
Resultado:_____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Exame:_____________________ Data:_________
Resultado:_____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Exame:_____________________ Data:_________
Resultado:_____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Exame:_____________________ Data:_________
Resultado:_____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________