CAR001 - Consulta Cardiológica

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CONSULTA CARDIOLÓGICA
Nome Completo:____________________________________________________________
Data de Nascimento:_________________ 	Idade: _________ 
Sexo:____________________________
Encaminhado por:
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HISTÓRICO
Queixas (sintomas, duração, história pregressa de queixa):
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História de doença atual:
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Hospitalizações:
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Alergias / Intolerâncias:
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Cirurgias / Procedimentos:
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Medicamentos em uso:
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História familiar:
( ) AVC
( ) DAC
( ) DM
( ) Dislipedemia
( ) HAS
( ) Tiroidopatia
( )Asma 
( ) Bronquite
Outros:
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Atividade Física:
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Outros aspectos sociais:
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Outros antecedentes familiares:
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Tabagismo
( ) Sim ( ) Não ( ) Socialmente
Hipóteses diagnósticas:
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Exame Físico:
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Exames Complementares:
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Exames Complementares:
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