PREFEITURA MUNICIPAL DE ALTO PARANÁ

Estado do Paraná
CNPJ Nº 76.279.967/0001-16
Rua José de Anchieta, 1641 – Fone/Fax: (44) 3447-1122 – Cx. Postal 61 – CEP: 87750-000 – Alto Paraná-PR
E-mail: pmaltopr@altoprnet.com.br – htttp://www.altoparana.pr.gov.br
SECRETARIA DA SAÚDE

TRIAGEM PSICOLÓGICA

IDENTIFICAÇÃO
Nome: ____________________________________________________________________________
Sexo: ___________________ Idade: ____________ Data de Nascimento: _______/_______/_______
Estado Civil: ________________________ Escolaridade: ___________________________________
Profissão: __________________________________________________________________________
Filiação: ___________________________________________________________________________
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Endereço: _________________________________________________________________________
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Contato telefônico: __________________________________________________________________
Encaminhado por: _________________________________ PSF: _____________________________

QUEIXA
Queixa principal: ____________________________________________________________________
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Evolução da queixa (histórico, mudanças relacionadas, sintomas): _____________________________
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Queixas secundárias: _________________________________________________________________
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 PREFEITURA MUNICIPAL DE ALTO PARANÁ
Estado do Paraná
CNPJ Nº 76.279.967/0001-16
Rua José de Anchieta, 1641 – Fone/Fax: (44) 3447-1122 – Cx. Postal 61 – CEP: 87750-000 – Alto Paraná-PR
E-mail: pmaltopr@altoprnet.com.br – htttp://www.altoparana.pr.gov.br
SECRETARIA DA SAÚDE

HISTÓRIA CLÍNICA (doença crônica, uso de medicamentos, casos de internação: ______________

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COMPOSIÇÃO FAMILIAR
Mora com: _________________________________________________________________________
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DISPONIBILIDADE PARA ATENDIMENTO:

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OUTRAS CONSIDERAÇÕES
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PSICÓLOGO / CRP

Alto Paraná,
Data: ____/____/____