Fundação Educacional da Região de Joinville – FURJ

Universidade da Região de Joinville – UNIVILLE

Clínica Odontológica

PRONTUÁRIO ODONTOLÓGICO Nº

Paciente: ______________________________________________________ Idade: _____ Sexo: ☐M ☐F

Data de Nasc.: _______________________ Estado Civil: _______________________ Cor: ______________
Naturalidade: ___________________________________ Nacionalidade: ______________________________
Profissão: ____________________________________ Local de Trabalho: _____________________________
Endereço: ____________________________________________ Nº: ______ Bairro: _____________________
Cidade: __________________________ UF: _____ Fone Res.: _______________ Celular: ________________
Documento de Id.: _______________________________ Escolaridade: ________________________________
Data da Consulta: ___________________________________________________________________________
Nome de pessoa/parente para contato: ________________________________ Fone: ______________________
CNS Nº: __________________________________________________________________________________

1. Queixa Principal (motivo da consulta):

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2. História da Doença Atual:

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3. Historia Médica:

3.1. Você está atualmente sobe tratamento médico? ___________________________ ☐Sim ☐Não ☐Não Sei
Se está, qual motivo: ________________________________________________________________________
3.2. Qual o nome e endereço do seu médico? _____________________________________________________
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3.3. Teve alguma doença ou cirurgia séria? ___________________________________ ☐Sim ☐Não ☐Não Sei
Qual? ____________________________________________________________________________________
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3.4. Você foi hospitalizado nos últimos 5 anos? _______________________________ ☐Sim ☐Não ☐Não Sei
Qual motivo? ______________________________________________________________________________
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3.5. Você teve algum desses problemas:

Febre reumática ou doença cardíaca reumática ________________________________ ☐Sim ☐Não ☐Não Sei
Asma ________________________________________________________________ ☐Sim ☐Não ☐Não Sei
Desmaios ou epilepsia ___________________________________________________ ☐Sim ☐Não ☐Não Sei
Diabetes ______________________________________________________________ ☐Sim ☐Não ☐Não Sei
Hepatite, icterícia ou doença hepática _______________________________________ ☐Sim ☐Não ☐Não Sei
Artrite ou outros problemas articulares ______________________________________ ☐Sim ☐Não ☐Não Sei
Ulcera gástrica _________________________________________________________ ☐Sim ☐Não ☐Não Sei
Problemas renais _______________________________________________________ ☐Sim ☐Não ☐Não Sei
Tuberculose ___________________________________________________________ ☐Sim ☐Não ☐Não Sei
Doença cardiovascular (Infarto, angina ou Hipertensão) _________________________ ☐Sim ☐Não ☐Não Sei
DST _________________________________________________________________ ☐Sim ☐Não ☐Não Sei
Outros: ___________________________________________________________________________________
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3.6. Já teve algum sangramento anormal associado a cirurgia e/ou traumatismo? ______☐Sim ☐Não ☐Não Sei
3.7. Já doou sangue? _____________________________________________________ ☐Sim ☐Não ☐Não Sei
3.8. Já necessitou de transfusão? ___________________________________________ ☐Sim ☐Não ☐Não Sei
3.9. Já teve algum distúrbio sanguíneo? (anemia) ______________________________ ☐Sim ☐Não ☐Não Sei
3.10. Está usando algum medicamento? ____________________________________ ☐Sim ☐Não ☐Não Sei
Qual? ____________________________________________________________________________________
3.11. Já teve alergia ou alguma reação adversa a algum medicamento ou anestésico local? _ ☐Sim ☐Não ☐Não Sei
3.12. Você tem alguma doença ou problema não listado acima que julga importante ser informado?
Se sim, explique: ___________________________________________________________________________
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3.13. Sinais Vitais:

PA ____________________ Pulso ____________________ Respiração ____________________

Para Mulheres
3.14. Você suspeita ou está grávida? _______________________________________ ☐Sim ☐Não ☐Não Sei
4. Observação em Relação a História Médica:
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5. História Familiar:
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6. História Pessoal e Social:

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Declaro para os devidos fins que as informações acima são verdadeiras, e autorizo a execução de
procedimentos clínicos e/ou cirúrgicos que se fazem necessárias para o reestabelecimento da minha saúde
bucal. Autorizo a realização de fotografias, modelos de estudos, apresentação e/ou publicação do meu
caso.

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Assinatura do Paciente/Responsável Assinatura do Professor Orientador

Joinville, ____ de ________________ de 20____.

7. Exame Físico:
7.1 . Extra-oral:

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7.2. Intra-Oral:

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Direita Esquerda
8. Descrição da Lesão:
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9. Exames Complementares:
9.1. Imaginológicos:

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9.2. Laboratoriais:
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10. Hipótese Diagnóstica:

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11. Tratamento (Clínico/Cirúrgico)

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12. Indicação de Cirurgia:

12.1. Dentes Indicados para Exodontia

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12.2. Biópsia
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13. Pré-operatório
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14. Descrição da Cirurgia

1º Cirurgia

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2º Cirurgia

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3º Cirurgia

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4º Cirurgia

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15. Trans-Operatório
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16. Pós-Operatório
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17. Diagnóstico Definitivo

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18. Trabalhos Executados:

Data Dentes Trabalho Executado Aluno Professor