Post on 10-Nov-2015
description
ANAMNESE TOMOGRAFIA
NOME:______________________________________________IDADE:_______
EXAME:___________________________________________________________
TCNICO:_________________________________________________________
MOTIVO DO EXAME:________________________________________________
_________________________________________________________________
MOTIVO DA INTERNAO: ___________________________________________
_________________________________________________________________
FUMA? (__) SIM / (__) NO
QUANTOS MAOS POR DIA? _______ A QUANTO TEMPO FUMA? ___________
J FEZ ALGUMA CIRURGIA? (__) SIM / (__) NO
QUAL? ___________________________________________________________
_________________________________________________________________
J RETIROU A VESCULA BILIAR? (__) SIM / (__) NO
J RETIROU O APNDICE? (__) SIM / (__) NO
J RETIROU O TERO? (__) SIM / (__) NO
J TEVE ALGUM CANCER? (__) SIM / (__) NO
QUAL?
_________________________________________________________________
OBSERVAO SOBRE O EXAME: _______________________________________
_________________________________________________________________
_________________________________________________________________
AUTORIZA O USO DE CONTRASTE IODADO ENDOVENOSO? (__) SIM / (__) NO
ASSINATURA__________________________________________________
(PACIENTE OU RESPONSVEL)