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Rua: Antônio Vieira 472- Nova Iguaçu – RJ / CEP:26255-530 Contato: 21 2797-3655 / 21 9329-2895 Data 28 de outubro de 2023 Anamnese Masculina Paciente: _____________________________________________________________________________________ Data de nascimento: _____/______/_____ Data consulta: ______/______/______ Retorno: ______/_____/_____ Motivo da Consulta: _____________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Dados Antropométricos: Peso: _______ Altura: ________ IMC:______ Circunferências C. Panturrilha: ________ C. Quadril: _______C. Cintura:________ C. Abdome:_______ C. Coxa: ________ C. Braço:_______. Dobras Cutâneas DTR (Tríceps): ________ DSB (subescapular): ________ DBI (bíceps): _______ DSI (supra ilíaca): _________ DCX (coxa): ________ DPM (panturrilha média): __________. Patologias: __________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Medicamentos: ______________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Histórico familiar de patologias: _________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Escala de Bristol: _____________ Urina: ____________. Desconforto abdominal: ____________ Hidratação: __________ Constipação: _____________ Náuseas: _______________ Obs: ______________________________________________ Alimentos que não consome de forma alguma: _____________________________________________________________ ___________________________________________________________________________________________________ Alimentos com consumo frequente: ______________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________________________________ Alterações nos exames: _______________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Rua: Antônio Vieira 472- Nova Iguaçu – RJ / CEP:26255-530 Contato: 21 2797-3655 / 21 9329-2895 Data 28 de outubro de 2023 Conduta 1: ___________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ Conduta 2: ___________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ Suplementos indicados: ________________________________________________________________________________ ____________________________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ Orientações adicionais: _________________________________________________________________________________ ____________________________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________
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