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1.

IDENTIFICATION
_________________________________________________ :_____________________________
______________ NAME :___________________________________________ SEX AGE :______
____ COLOR: white / brown / black MARITAL STATUS :______________________________
____ OCCUPATION :______________________________________ NATURAL Coming :________
____________________________ ____________________________________ 2. MAIN COMPLA
INT AND DURATION _________________________________________________ _____________
____________________________________ ___________________________________________
______ HISTORY OF PRESENT ILLNESS (HDA) (total duration, onset, course, characte
ristics, associated symptoms, treatment effects, progression, impact on the pati
ent's life, chronologically, associated symptoms) ______________________________
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3.
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___________________ 4. EXAMINATION SINTOMATOLOGIA
General symptoms: weight change (how long), fever, chills, malaise, night sweats
,€anorexia _________________________________________________ __________________
_______________________________ ________________________________________________
_ _________________________________________________ ____________________________
_____________________ _________________________________________________ ________
_________________________________________ phanero and Skin: itching, skin lesion
s (location), alopecia, pigmentation changes, abnormalities in hair and nail app
earance _________________________________________________ ______________________
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_________________ _________________________________________________ ____________
_____________________________________ Head and neck: headache, neck pain, limita
tion of movement of the neck, neck lump ________________________________________
_________ _________________________________________________ ____________________
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___________________ _________________________________________________ __________
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_________ Eyes: eye pain, visual acuity, diplopia, photophobia, lacrimation, con
junctival secretions, visual scotomata, blurred vision correction with glasses o
r contact lenses _________________________________________________ _____________
____________________________________ ___________________________________________
______ _________________________________________________ _______________________
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___________________ Ear, nose and paranasal sinuses: earache, facial pain, perio
rbital congestion, epistaxis, otorrhea, rhinorrhea, stuffy nose, frequent sneezi
ng, post-nasal drip, tinnitus, auditory acuity, dizziness ______________________
___________________________ _________________________________________________ __
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_________________ _________________________________________________ ____________
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_______ _________________________________________________ Cavity Oral: toothache
, gum ulceration of the mucosa, burning or stinging of the tongue, sore throat,
sialose, pain in ATM _________________________________________________ _________
________________________________________ _______________________________________
__________ _________________________________________________ ___________________
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____________________ Breasts: breast pain, nipple discharge, palpable masses. Gy
necomastia in men _________________________________________________ ____________
_____________________________________ __________________________________________
_______ _________________________________________________ Respiratory: cough, sp
utum (appearance and quantity), hoarseness, hemoptysis, chest pain, dyspnea, whe
ezing in the chest _________________________________________________ ___________
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____________________________ Cardiovascular: chest pain, palpitation, dyspnea ef
fort, and nocturnal recumbency, syncope, edema, cyanosis, intermittent claudicat
ion, varicose veins, leg ulcers ________________________________________________
_ _________________________________________________ ____________________________
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_ _________________________________________________ ____________________________
_____________________ _________________________________________________ Gastroin
testinal: dysphagia, heartburn, food intolerance,€eructation, fullness,, regurg
itation, epigastric pain, cramping, jaundice, nausea and vomiting, hematemesis,
habit
intestinal (n0 loose stools per day, an aspect of the droppings - color and cons
istency - presence of abnormal elements - blood, mucus and / or pus), defecation
tenesmus, rectal pain and itching, rectal bleeding, melena, meteors, cramps, fl
atulence, constipation _________________________________________________ _______
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____________ _________________________________________________ _________________
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______________________ Urinary pain (lumbar, flank, bladder), dysuria, urinary c
hanges, strangury, pollakiuria, discoloration and odor of urine, nocturia, enure
sis, oliguria, polyuria, urinary incontinence (female), drip terminal and streng
th of urinary stream (man), removal of stones during urination _________________
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__ _________________________________________________ ___________________________
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____________ _________________________________________________ _________________
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__ Genital man (urethral discharge, genital lesions, sexual dysfunctions) ; woma
n (leukorrhea, vulvovaginal pruritus, intermenstrual bleeding, pelvic pain, dysp
areunia) _________________________________________________ _____________________
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________________________________________________ Osteoarticular: arthralgia, mor
ning stiffness, joint swelling, limitation of motion, deformities, low back pain
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Hematopoietic: pallor, bleeding tendencies, lymphadenopathy, splenomegaly, hepa
tomegaly
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_________ Endocrine: intolerance to cold or heat, polyuria, polyphagia and polyd
ipsia, hirsutism _________________________________________________ _____________
____________________________________ ___________________________________________
______ _________________________________________________ _______________________
__________________________ _________________________________________________ Ner
vous paresis (mild paralysis), paralysis, paresthesia, muscle atrophy, tremors,
convulsions, absences, impaired memory (amnesia transient or permanent) ________
_________________________________________ ______________________________________
___________ _________________________________________________ __________________
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_ _________________________________________________ ____________________________
_____________________ Psyche: insomnia, nervousness, frequent crying, irritabili
ty, sadness, guilt, loss of interest and pleasure in work and leisure __________
_______________________________________ ________________________________________
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___________________ _________________________________________________ __________
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___________________ _________________________________________________ Climacteri
c: (age mennopausa, hot flashes, vaginal dryness) ______________________________
_ _________________________________________________ ____________________________
_____________________ _________________________________________________ ________
_________________________________________ ______________________________________
___________ _________________________________________________ senescence: (as th
e patient sits in the family, loneliness, widowhood, pension, retirement, daily
activities) _________________________________________________ __________________
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_ _________________________________________________ ____________________________
_____________________ _________________________________________________ 6. Patho
logical personal antecedents
5.
PERSONAL BACKGROUND PHYSIOLOGICAL
Childhood diseases (measles, chickenpox, rubella, mumps ):______________________
___________________ _________________________________________________ __________
_______________________________________ ________________________________________
_________ Diseases presented in adulthood (TB, STDs, hepatitis, diabetes, hieprt
ensão pressure, heart disease, epilepsy, rheumatic fever, asthma, miscarriage o
r not, sexual dysfunction ): ___________________ _______________________________
__________________ _________________________________________________ ___________
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________ _________________________________________________ History of allergy: _
___________________________ _________________________________________________ __
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_____________________________________ Surgeries :_______________________________
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Hospitalizations :____________________________________
Terms of gestation and birth :__________________ _______________________________
__________________ _________________________________________________ ___________
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________ Developmental status: __________________ ______________________________
___________________ _________________________________________________ __________
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_________ Immunization (BCG, DPT, anti-polio, viral hepatitis, tetanus, flu) ___
_________________________________ ______________________________________________
___ _________________________________________________ __________________________
_______________________ _________________________________________________ ______
___________________________________________ Adolescence: (puberty, character app
earances secondary )_______________________________________ ____________________
_____________________________ _________________________________________________
_________________________________________________ ______________________________
__________________ Sexual activity and reproductive life (first contact, partner
s, frequency of relations, condoms, emnstruação (flow, cycle), pregnancy, chil
dbirth) _________________________________________________ ______________________
___________________________ _________________________________________________
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__________________ _________________________________________________ ___________
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________ _________________________________________________ _____________________
____________________________ _________________________________________________ _
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__________________ Injuries :_____________________________________ _____________
____________________________________ ___________________________________________
______ ________________________________________________ ________________________
_________________________ _________________________________________________ bloo
d transfusions :___________________________________ ____________________________
_____________________ ________________________________________________ Use of in
jectable drugs :____________________________ ___________________________________
______________ _________________________________________________ prolonged use o
f medications :______________________ __________________________________________
_______ _________________________________________________ ______________________
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_________________ _________________________________________________ 7. FAMILY BA
CKGROUND _________________________________________________ _____________________
____________________________ _________________________________________________ _
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________ 8. SOCIAL BACKGROUND
_________________________________________________ ______________________________
___________________ Education level: ________________________________ __________
_______________________________________ Occupational History: __________________
____________ _________________________________________________ _________________
________________________________ _______________________________________________
__ _________________________________________________ ___________________________
______________________ Religion: _________________________________________ Month
ly family income: ____________________________ Interpersonal relations: (if ther
e is problem in the family relationship - if the patient has friends - feels lon
eliness has resentment) _________________________________________________ ______
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_____________ _________________________________________________ ________________
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___ _________________________________________________ __________________________
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_____________ _________________________________________________ Psychosocial Pro
blems: (most concern the patient, what he stressed before admission - has suffer
ed some major loss in the past - feel accomplished - if there was unfulfilled ex
pectations )_____________________________ ______________________________________
___________ _________________________________________________ __________________
_______________________________ ________________________________________________
_ _________________________________________________ ____________________________
_____________________ _________________________________________________ ________
_________________________________________ habits and customs: smoking (duration,
cigarette type, number of cigarettes smoked per day), alcohol consumption (dura
tion, type of drink, amount consumed), bathing in rivers dams and lakes (locatio
n and time), contact with the triatomine, contact with pets, regular physical ex
ercise (type and frequency), sleep, leisure, travel,€use of illicit drugs _____
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Housing conditions and hygiene: ____________________ ___________________________
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__ _________________________________________________ Terms of supply: __________
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