SUGESTO DE MODELO DE PRONTURIO ODONTOLGICO

CONSELHO REGIONAL DE ODONTOLOGIA DE SO PAULO

FICHA CLNICA
(Identificao do Profissional)
NOME DO PROFISSIONAL
CIRURGIO-DENTISTA - CLNICO GERAL
CROSP N _______
Endereo completo
INFORMAES DO PACIENTE
Pronturio n ________________.
Nome: _____________________________________________________________________
RG. n. ___________________ rgo Expedidor ____________
CPF n.____________________/____
Data de Nascimento _______/_____________/________
Sexo _________________________
Naturalidade ________________________ Nacionalidade ____________________________
Estado Civil ____________________
Profisso ______________________________________
Endereo Residencial ________________________________________________________
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Endereo Profissional ________________________________________________________
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Indicado por ______________________________________________________________
Convnio _______________________ N de Inscrio ____________________________
CD. anterior _______________________________ Atendido em _____/__________/______
RESPONSVEL PELO TRATAMENTO
Nome _____________________________________________________________________
RG. n. __________________ rgo Expedidor ____________
CPF n.____________________/____
Estado Civil: _____________________
Cnjuge _____________________________________
RG. n. __________________ rgo Expedidor ____________
CPF n._____________/____

SUGESTO DE MODELO DE PRONTURIO ODONTOLGICO

CONSELHO REGIONAL DE ODONTOLOGIA DE SO PAULO
FICHA DE ANAMNESE
Queixa Principal e Evoluo da Doena Atual ______________________________________
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QUESTIONRIO DE SADE
Sofre de alguma doena: ( ) Sim ( ) No - Qual(is)_________________________________
Est em tratamento mdico atualmente? ( ) Sim ( ) No. Gravidez: Sim ( ) No ( )
Est fazendo uso de alguma Medicao? ( ) Sim ( ) No - Qual(is) _____________________
__________________________________________________________________________
Nome do Mdico Assistente/telefone: ____________________________________________
Teve alergia? ( ) Sim ( ) No -Qual(is) __________________________________________
J foi operado? ( ) Sim ( ) No -Qual(is) ________________________________________
Teve problemas com a cicatrizao? Sim ( ) No ( )
Teve problemas com a anestesia? Sim ( ) No ( )
Teve problemas de Hemorragia? Sim ( ) No ( )
Sofre de alguma das seguintes doenas?
Febre Reumtica: Sim ( ) No ( );
Problemas Cardacos: Sim ( ) No ( )
Problemas Renais: Sim ( ) No ( );
Problemas Gstricos: Sim ( ) No ( )
Problemas Respiratrios: Sim ( ) No ( );
Problemas Alrgicos: Sim ( ) No ( )
Problemas Articulares ou Reumatismo: Sim ( ) No ( ); Diabetes: Sim ( ) No ( )
Hipertenso Arterial: Sim ( ) No ( );
Antecedentes Familiares: _____________________________________________________
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Outras observaes importantes: ______________________________________________
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Declaro que as informaes acima prestadas so totalmente verdadeiras.
Local, Data Assinatura do Paciente ou seu Responsvel Legal

SUGESTO DE MODELO DE PRONTURIO ODONTOLGICO

CONSELHO REGIONAL DE ODONTOLOGIA DE SO PAULO
EXAME FSICO
GERAL:
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EXTRA-ORAL:
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INTRA-ORAL:
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EXAME DENTAL DESCRIO DENTE A - DENTE

18 ________________________________________________________________________________________
17 ________________________________________________________________________________________
16 ________________________________________________________________________________________
15 (55)____________________________________________________________________________________
14 (54)____________________________________________________________________________________
13 (53)____________________________________________________________________________________
12 (52)____________________________________________________________________________________
11 (51)____________________________________________________________________________________
21 (61)____________________________________________________________________________________
22 (62)____________________________________________________________________________________
23 (63)____________________________________________________________________________________
24 (64)________________________________________________________________________ ____________
25 (65)________________________________________________________________________ ____________
26 ___________________________________________________________________________ ____________
27 ___________________________________________________________________________ ____________
28 ___________________________________________________________________________ ____________
38 ___________________________________________________________________________ ____________
37 ___________________________________________________________________________ ____________
36 ___________________________________________________________________________ ____________
35 (75)________________________________________________________________________ ____________
34 (74)________________________________________________________________________ ____________
33 (73)________________________________________________________________________ ____________
32 (72)________________________________________________________________________ ____________
31 (71)________________________________________________________________________ ____________
41 (81)________________________________________________________________________ ____________
42 (82)________________________________________________________________________ ____________
43 (83)________________________________________________________________________ ____________
44 (84)________________________________________________________________________ ____________
45 (85)________________________________________________________________________ ____________
46 ___________________________________________________________________________ ____________
47 ___________________________________________________________________________ ____________
48 ________________________________________________________________________________________

SUGESTO DE MODELO DE PRONTURIO ODONTOLGICO

CONSELHO REGIONAL DE ODONTOLOGIA DE SO PAULO
ODONTOGRAMA
Registro de Anormalidades e Patologias

Situao Periodontal Exames Complementares

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SUGESTO DE MODELO DE PRONTURIO ODONTOLGICO

CONSELHO REGIONAL DE ODONTOLOGIA DE SO PAULO
PLANOS DE TRATAMENTOS
CONSENTIMENTO ESCLARECIDO
Opo 1:
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Opo 2:
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Opo 3:
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Opo escolhida, tempo de execuo e informaes adicionais:
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Declaro, que aps ter sido devidamente esclarecido sobre os propsitos, riscos, custos e
alternativas de tratamento, conforme acima apresentados, aceito e autorizo a execuo do
tratamento, comprometendo-me a cumprir as orientaes do profissional e arcar com os
custos estipulados no planejamento de custos apresentado.

Local e data.

Assinatura do Paciente
ou seu Representante Legal

Assinatura do Cirurgio-Dentista

SUGESTO DE MODELO DE PRONTURIO ODONTOLGICO

CONSELHO REGIONAL DE ODONTOLOGIA DE SO PAULO
Data

Evoluo e Intercorrncias
do tratamento

Assinatura do Paciente
ou Responsvel

Cirurgio-Dentista
(Carimbo e Assinatura)

SUGESTO DE MODELO DE PRONTURIO ODONTOLGICO

CONSELHO REGIONAL DE ODONTOLOGIA DE SO PAULO
INQURITO ODONTOLGICO
Data do ltimo atendimento: ____/____ /______
o Completo
o Incompleto
Experincia negativa no tratamento odontolgico ? Qual ?
___________________________________________________________________________
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HBITOS
roer unhas

respirar pela boca

morder caneta / lpis

tomar chimarro

ranger os dentes dia / noite

chupar bico/dedo
outros

HIGIENE BUCAL (utiliza)

fio / fita dental

interdental

escova macia / mdia / dura

unitufo / bitufo

palito

creme dental:

FLOR:

gel

creme dental

DIETA
Ingere alimentos / bebidas entre as refeies ?

bochecho

gua fluoretada

no

sim

ASSUMO INTEIRA RESPONSABILIDADE PELAS INFORMAES AQUI

PRESTADAS BEM COMO AUTORIZO O(S) PROFISSIONAl(IS) A REALIZAR(EM)
TODOS OS PROCEDIMENTOS NECESSRIOS PARA O MEU TRATAMENTO.
(Cidade),

, de ____________, de 2014.

Responsvel pelo Inqurito CD: ..........

Nome do Paciente: ...............................
________________________
Assinatura do Paciente/Responsvel