Ficha de Anamnese (TRATAMENTO CORPORAL)
Ficha de Anamnese (TRATAMENTO CORPORAL)
Ficha de Anamnese (TRATAMENTO CORPORAL)
Data: ___/____/_______
IDENTIFICAÇÃO
ANAMNESE
QP: ______________________________________________________________________________
Medicamentos: __________________________________________________________________________________
HF: _______________________________________________________________________________
HPP: ______________________________________________________________________________
antecedente oncológico: _______________________________diabete:_________________________
Hipertensão ou Hipotensão: ___________ Problema circulatório:_________________________________
Alergias: __________________________________________________________________________
Tratamentos anteriores:
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Nome: __________________________________________________________________________
Telefone: _______________________________ Parentesco:_____________________________
Médico: _________________________________ Telefone: ______________________________
Convênio Médico: _______________________ Hospital: _______________________________
INSPEÇÃO
Observações:
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Procedimento proposto:
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Local e Data Assinatura do cliente
Eu, _____________________________, DECLARO que expliquei detalhadamente para o cliente e/ou responsável, o
propósito, os benefícios, os riscos e as alternativas para a procedimento acima descrito, bem como que existiu tempo hábil
para o paciente esclarecer suas dúvidas ou procurar outra opinião profissional.
___________________________________________ _______________________________________________
Local e Data Assinatura do profissional
FREQUÊNCIA DE TRATAMENTO
DATA ASSINATURA