quant.

tratamento nº valor nome: nº

Ext
ração nasc.
: / / cpf: data t.
c.: / /
Res
taur
ação responda asperguntasabai
xo eentregue-
asao denti
sta:
Sel
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Tr
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Cl
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o marqueseteveoutem algum problema desaúde:
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abete(),Hepati
t e(),Tuber
culose(),Anemia(),Câncer(),DST()
:________________
DoençaRenal(),Distúrbi
odeTi reói
de(),FebreReumática(),Br
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te(),Convuls
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cooli
sta(),Fumante() .

OutrasInfor
maçõesquej ulgarnecessári
o:______________
Or
çament
oPar
cial Val
or: ___________________________________________________
___________________________________________________
Decl
aroqueorespondidoaci
maéver
dadei
roeconcordocom o
planodetrat
amentoeor
çamentopr
oposto.

Dat
a: / / ___________________________________________________________

quant. tratamento nº valor nome: nº

Ext
ração nasc.
: / / cpf: data t.
c.: / /
Res
taur
ação responda asperguntasabai
xo eentregue-
asao denti
sta:
Sel
ant
e

Tr
atament
odeCanal Nomoment
oes
táem t
rat
ament
omédi
co?-
---
---
---
---
---
---
---
---
---
---
---
---
---
---
-[s
im][
não] Qual
?_____________________________________________________
Li
mpeza[] RemoçãodeTár
tar
o[]
Es
tát
omandoal
gum t
ipodemedi
cament
o?-
---
---
---
---
---
---
---
---
---
---
---
---
---
--[
sim][
não] Qual
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Fl
úor[] Pol
iment
o[] Tem al
ergi
aaal
gum t
ipodemedi
cament
o?-
---
---
---
---
---
---
---
---
---
---
---
---
---
---[
sim][
não] Qual
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Bl
oco[] Cor
oa[] Fazus
odeal
gum medi
cament
oquecont
ém bi
sfos
fonat
os?-
---
---
---
---
---
---
--[
sim][
não] Qual
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Cons
ert
o
Suapr
ess
ãoar
ter
ialénor
mal
?--
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
--[
sim][
não] P.
A:_____________________________________________________
Núcl
eo
Sof
redepr
obl
emascar
díacos
,tont
urasoudes
mai
os?-
---
---
---
---
---
---
---
---
---
--[
sim][
não] _________________________________________________________
Pr
ovi
sór
io Ját
omouanes
tes
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---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
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--[
sim][
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Pont
eMóvel[] Pr
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sór
io[] Suagengi
vas
angr
acom f
aci
li
dade?-
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
--[
sim][
não] Háquant
otempo?
_________________________________________
RoachSuper
ior[] I
nfer
ior[] Sangr
amui
toquandos
efer
eouext
raident
e?-
---
---
---
---
---
---
---
---
---
---
---
---
---[
sim][
não] _________________________________________________________
Dent
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aSup.
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io[]
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dasdemor
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rizar
?--
---
---
---
---
---
---
---
---
---
---
---
-[s
im][
não] _________________________________________________________
Pr
ótes
eFl
exí
velSup.[] I
nf[] Vocêes
tágr
ávi
da?-
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
---
-[s
im][
não] Quant
osMes
es:
?__________________________________________
Radi
ogr
afia

Cl
areament
o marqueseteveoutem algum problema desaúde:
Di
abete(),Hepati
t e(),Tuber
culose(),Anemia(),Câncer(),DST()
:________________
DoençaRenal(),Distúrbi
odeTi reói
de(),FebreReumática(),Br
onquite(),
Asma(),Renite(),Si
nus i
te(),Convuls
ão/Epil
epsi
a(),Gastr
ite()
,Úl
cera() ,
Al
cooli
sta(),Fumante() .

OutrasInfor
maçõesquej ulgarnecessári
o:______________
Or
çament
oPar
cial Val
or: ___________________________________________________
___________________________________________________
Decl
aroqueorespondidoaci
maéver
dadei
roeconcordocom o
planodetrat
amentoeor
çamentopr
oposto.

Dat
a: / / ___________________________________________________________
 His
tór
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