Hora: ___:___hs
Quarto: _____
Leito: ____
CID: ________
Sexo: ( )F ( )M
Etnia: ( )Branco
( )Negro
( )Pardo
( )Amarelo
( )ndio
Profisso: _____________________________________________________________________
Proveniente: ( )Casa
( )Trabalho
( )Hospital
( )UBS
( )Rua
( )Outros ___________
( )Lento
( )Balbuciada
( )Afasia
Altura: _______
( )Sim
( )Grau II
Onde? _____________________________
( )Grau III
( )Grau IV
( ) Sim
( )Sim Qual?__________________________________
Qual? ______________________________________
( )Sim
Onde? ________________________________________
( )Sim
Quanto: ____________
Tempo: ________________
( )Sim
( )Sim
( )Sim
( )Sim
Onde? _______________________________________
Detalhes: _____________________________________
Onde? __________________________________________
( )Sim
( )Globoso
( )Distendido
( )Doloroso a Palpao
( )8
( )9
( )10
________________________________________________
Assinatura/Carimbo/COREN