FICHA DE CONTROLE PARA ATENDIMENTO CLÍNICO Identificação Nome__________________________________________________________________ Sexo ( )M ( )F Nasc.___/___/___ Idade _______ Est.Civil ____________ Natural de ____________________________ Endereço ____________________________________________________________________________ Escolaridade______________________________ Profissão/Ocupação ___________________________ Local de trabalho ______________________________________________________________________ Telefones resid ._____________ Cel.___________________Trab._______________________________ Responsável (se menor) _________________________________________________________________ Indicação / Encam. ____________________________________________ Entrevista inicial ___/___/___ Motivo da demanda _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Avaliação da demanda e definição de objetivos _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Observações _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Custos e forma de pagamento _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Data ___/___/___ Assin. do cliente ou responsável ________________________________________ REGISTRO DA EVOLUÇÃO DO ATENDIMENTO Cliente ___________________________________ Procedimento: _____________________________ Data – Nº. da Sessão – Resumo da Sessão – Percepções - Observações
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