Dr.

Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762

Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança
PRONTUÁRIO DE NEUROCIRURGIA

DATA:_____/____/__________

A- Identificação:

Nome:________________________________________________________________________

Endereço:_____________________________________________________________________

Fone:______________________ DN:___________________________ Idade: ______________

Plano:_______________________________ Nº carteira:_______________________________

B- Queixas:

1.____________________________________________________________________________
_____________________________________________________________________________

2.____________________________________________________________________________
_____________________________________________________________________________

3.____________________________________________________________________________
_____________________________________________________________________________

C- Hábitos, Fatores individuais e familiares:

Casa:_________________________________________________________________________

Trabalho: _____________________________________________________________________

Doenças:______________________________________________________________________

Exercício:_____________________________________________________________________

Alimentação:__________________________________________________________________

Álcool, fumo e drogas:___________________________________________________________

História de câncer ou aneurisma:__________________________________________________

Hábitos de sono:_______________________________________________________________

Ansiedade:____________________________________________________________________

Depressão:____________________________________________________________________

Cirurgias:_____________________________________________________________________

Medicações fixas:_______________________________________________________________

Med ataque:___________________________________________________________________

Psico/psi:_____________________________________________________________________

Piora:________________________________________________________________________

Veretigem/náusea:_____________________________________________________________
Dr. Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762
Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança
D- História da doença atual:

1.____________________________________________________________________________
_____________________________________________________________________________

2.____________________________________________________________________________
_____________________________________________________________________________

3.____________________________________________________________________________
_____________________________________________________________________________

E- Exame físico:

Geral:________________________________________________________________________
_____________________________________________________________________________

SN:

Funções superiores, hemisféricas e de pares cranianos:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Coordenação motora, marcha e equilíbrio:

_____________________________________________________________________________
_____________________________________________________________________________

Funções motora e sensitiva:

_____________________________________________________________________________
_____________________________________________________________________________

Reflexos profundos:_____________________________________________________________

SN (outros):

_____________________________________________________________________________
_____________________________________________________________________________

Palpação do escalpe/cervical(gráfico na próxima página):

_____________________________________________________________________________
_____________________________________________________________________________

Palpação do dorso, lombar/nádegas e pernas:

_____________________________________________________________________________
_____________________________________________________________________________

SCV:_________________________________________________________________________

Abdômen:_____________________________________________________________________
Dr. Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762
Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança
Dr. Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762
Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança
Dr. Ricardo Jorge Vasconcelos Barbosa CREMEPE: 15762
Neurocirurgia e Cefaleia
Contatos: 3445-9044 Núcleo Integrado de Consultórios NIC
3131-7879 Hospital Esperança

F- Exames complementares:

1._____________ (___/___/_____):
_____________________________________________________________________________
_____________________________________________________________________________

2. ._____________ (___/___/_____):
_____________________________________________________________________________
_____________________________________________________________________________

3._____________ (___/___/_____):
_____________________________________________________________________________
_____________________________________________________________________________

G- Hipótese diagnóstica:

1. ___________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________

5.____________________________________________________________________________

H- Condutas e orientações:

1.
_____________________________________________________________________________
_____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________

5.____________________________________________________________________________

6.____________________________________________________________________________