Dados do Preceptor:______________________________________________

Dados do aluno:_________________________________________________
RA:______________
Observador:_____________________________________________________
Carimbo: Assinatura:

Tipo do atendimento:_____________________________________________
Local:__________________________________________________________
Data: / /
Hora da consulta: início: : - término: :

Dados do paciente:
Nome:_______________________
Idade:_______________________
Data de nascimento:___________
Sexo:________________________
Etnia:________________________
Naturalidade:_________________
Procedência:_________________
Escolaridade:_________________

Dados do guardião:
Nome:_______________________
Idade:_______________________
Data de nascimento:___________
Sexo:________________________
Etnia:________________________
Estado Civil:__________________
Naturalidade:_________________
Procedência:_________________
Escolaridade:_________________
Religião:_____________________
Profissão:____________________
Telefone:_____________________
Queixa Principal:
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Histórico da doença atual:
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Investigação de diversos aparelhos:
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Histórico da gestação, parto e nascimento:
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Antecedentes pessoais:
Doenças crônicas e prévias:
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Cirurgias:
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Alergias:
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Vacinação:
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Medicamentos (em uso e usados):
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Vacina de Covid – 19:
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Histórico de desenvolvimento:
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Histórico Alimentar:
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História Social:
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Antecedentes familiares:
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Antecedentes psicossociais:
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Necessidades referidas:
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Necessidades percebidas:
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Plano de cuidado:
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Reflexão:
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