Sei sulla pagina 1di 2
Tomes Neslioonee sary Empresa: CPF: Fanci Data do Baa [i al) Pe )_Demnl_)_ luv de Punto )_Retrnone Tete? sie aigam problema desoide no momenta? Smt) NioC)_Qual? os TvecedeneesFailive Dabs CC) Denardo Corgi “Rereile Grew | otras da or Benet poeueaNeligen =) tigen ema - PROBLEMAS DE SAUDE ANTERIORES: ‘SIM NAO SIM NAO aa cocoate, possi aa? cris toate ee? 60 Bet heer cu Probes do audio? aor ne Pres mcs eplsi?, onalliee oe ee es Sy comets? Soon enoe? Geigas"sosrne Sop? at eee sees seein menor? Beles pier no anguel? sega guarrte? Opals ooo. ou geste? Sasa ne fea se cura? core vemon cs nunte? So or nanos? eae oe 5 Vat omnis? evans Tem sium doveto ou doenga sea? dofeite ou doenga fisica? ay eee Soca ume cl? a apa no racine or ee Bea HisToRiCO SOCIAL Sint NO sim wo nat “assay lguaexlsto pero cas ootast? Co} pals destcos dara? teansuceds pu out TW? 5 eetgecrse ana do pate? se atta poo NSS? Ceres anveesat wen ‘Costuma ouvir musica em alto volume? Data da time menstrvagao: oooda0g0 aan | Esta gravids? ‘Teabalha ou trabathou exposio a ruides? eS | Fez atwaaces tas equarment Produtos quimicos? S 6 seu trabalho causa algum dano a sue Saude? Pootas? ‘Qual? T ceppeangehcacistatiaiiale Digitag8e continua? | Usa algurn medicamento regularmante? TOO Declare que so verdadeiras as informacies fornecidas oust? Coe" Tauvasdes bavuhertas fora daenpresa? CD CO ee | ERAME CLINICS. FARA USO DO MEDICO | Vials: PA x mana Z. Peso ¥ ahi uso Gurl 1 orasng 1 Jencorndon [Dorman (Tiss TT cianoica | SSS ama Sao ITT =| ino Respiraiorie: _Ovoferingel_JWC A _lnspecéo: CCRC IA Epona WJ ea vascular: |) Nommal_[—Jarritimias. 7 TSapr0s. Tamme “1a a sata (a [Eguealdadess (Normal Jedeme pags Palsas Bocas ie (eiSmal (Joo Rol Ext cAbaaae (10 (Je (Joera ao. bx dadvate (Jol 2 Purhos:l_INomail ‘Grepiiardo | _[Cisios 14 - Colovelos: reeraBo ‘Dor Eplcondio sere ae Escolose (]efose ( ]Limitacdo de Flexo Norns 50 APIO. TUsArTO. 7 sa | Aquarcands Exames _L_|Deverd ler Acompanhomento ol Anuatdando Parecer ervecdo: bi Orientagées Médicas: Walco - Garimbs 6 Assinalura coe Date OF BIDAR nnn - Passport Number: ae Function: so Date ssasl, L. ‘Admission( ) Periode( ) Resignation( ) Changefunction{ } —Return( ) Do you have a health problem? yes) No C) EEEEEEEE Eee eee : vii Diabetes f) Fiearl Disease (~) Tuberculosis[) Cancer Blood Disease [_] High Blood Pressure] Neurologic Disease{__] Psychiatie \ problems in the past ‘YES NO “ digesse, high blood pressure? Have you ever been hospitalized? oO * pal papitation? Why? Audition problems? Hiontal diseose nervous or convulsions? Headache, dizziness or setzures? Allergy, skin diseases? Allergy, to a medicine and or food? Frequent back pain? Spine problems? Rheumatism or vout? Varicosa veins of varicocele? Hemorrhoids or frequently diarrehea? ity? ease (Gastic or ulcer)? Sinusitis? OOOO Suffer fron non specific disease? hich? is YES NO Have you evar suffer any explosion close to the ears? (—] Dp you have dificulty to hear tv? ‘tay faleohotic drinks) srsalf over weight? ‘ourself out strosed? 1 hear loud rusle? Dete oftast period | 0 000000002) Ooooooooooon: DB 0 C0000 i Do you work or have you worked exposed to loud noise? o oO Chemical products? } f= nedicines on a regular basis? Dust? | wee “ He Continuas typing? oa | Dh you malice noly elves i you own tre? o Tadeclared thatthe information given is tre: i be :s "LINICO: / CLINICAL EXAM: FOR MEDICAL USEONLY _/ PARA USO DO MEDICO Vitsie: PA * mmhg 2- Peso © Altura, x ToWormal (_ictériea _)Ciandlica STineosas: _[JCoradas)Descoradas[—)Dermialoses iPescogo: TwesideT™NITJA GangiosCINTIA ‘Resplratéiio: _Orofaringe[NCIA inspect: CINTA Ex NAD we NAS vascular: (JNonmal CyAiimias CJSopros: ipagdo FNassas Dor ap: bios TExtremidades: (oj Normal (Edema (o]Varzes Pulsos Perfericos PE) ALT ‘9 Punhios:f—] Normal (J Edemaf—)Crepitacao[_cistos 11 - Cotovelos:{—Nomall_Parestesias( Jedemal_Jchoque| ‘qpacidade de Preensio "Der Episéndio Lateral (0 [JE Dor Eplcdndiio Medial —1D E| hamenios: __ C7) Ortopedista C)Cardiologisia (1 Otorine CINSS Cl abetwadecatT | (Jaro [7 INAPTO. ot (Devera ter Acompanhamente ci Cnscus., A bi Ovientagtes Médicas: Madica - Carimbo e assinatura

Potrebbero piacerti anche