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Ficha de controle para atendimento clinico

Propaganda
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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