Modelo de Anamnese
Identificao:
Nome:___________________________________________________________________
Idade: __________Sexo: _________________ Nacionalidade: ______________________
Estado Civil: ____________________ Data de nasc.:______________________________
Grau de instruo:__________________________________________________________
Profisso:________________________________________________________________
Residncia (cidade/estado): __________________________________________________
Telefones para contado: _____________________________________________________
Atendimento:
Frequencia:___________________________ Data/hora:___________________________
Queixa Principal:
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Secundria:
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Sintomas:
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