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1.0 IDENTIFICAÇÃO:
Nome: ______________________________________________________________________________
Data de Nascimento: ____/___/____ Telefone: ____________________Sexo:___________________
Cidade: ____________________Bairro: __________________________ Profissão: _______________
Endereço Residencial: _________________________________________________________________
Crença/Fé: ___________________________________________________________________________
Naturalidade: ___________________________________ Estado Civil: ________________________
Diagnóstico Clínico: __________________________________________________________________
Diagnóstico Terapêutico:
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2.0 AVALIAÇÃO:
2.1 História Clínica:____________________________________________________________________
2.2 Queixa Principal do Paciente: _________________________________________________________
2.3 Hábitos de Vida:____________________________________________________________________
2.4 HDA:____________________________________________________________________________
2.5 HDP:____________________________________________________________________________
2.6 Antecedentes Pessoais: _____________________________________________________________
2.7 Antecedentes Familiares:_____________________________________________________________
2.8 Tratamentos Realizados:_____________________________________________________________
3.5 INSPEÇÃO/PALPAÇÃO:
( ) Normal ( ) Edema ( ) Cicatrização incompleta ( ) Eritemas-vermelidão ( ) Outros
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