ANEXO
FICHA MÉDICA
I – IDENTIFICAÇÃO
a) NOME ___________________________________________________________________________________________________
b) INSCRIÇÃO / CARGO_____________________________________________________________________________________
c) IDADE_________ d) SEXO_______________ e) ESTADO CIVIL_______________________________________________
f) IDENTIDADE Nº _________________________ g) ÓRGÃO EXPEDIDOR _________________________________________
h) CIDADE_________________________________ i) UF_________
II – BIOMETRIA
a) EXAMES LABORATORIAIS
___HEMOGRAMA COMPLETO ___CREATININA ___ABO+RH ___URINAS (EAS)
___GLICOSE ___COLESTEROL ___ BETA-HCG ___PARASITOLÓGICO
___URÉIA ___MACHADO GUERREIRO ___BILIRRUBINAS ___TOXICOLÓGICO
___ÁCIDO ÚRICO ___VDRL ___TGP/TGO ___OUTROS
b) EXAMES COMPLEMENTARES
___ELETROENCEFALOGRAMA (EEG) ___OFTALMOLÓGICOS
___ELETROCARDIOGRAMA (ECG) ___OTORRINOLARINGOLÓGICOS
___ECOCARDIOGRAMA ___AUDIOMETRIA TONAL
___ RX TORAX ___OUTROS
III – RELAÇÃO DOS EXAMES LABORATORIAIS / COMPLEMENTARES ALTERADOS
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
IV – ECTOSCOPIA
a) PESO________________ b) ALTURA____________
c) BIOTIPO_________________________________________________________________________________________________
d) DEFEITOS FÍSICOS_______________________________________________________________________________________
e) DEFORMAÇÕES__________________________________________________________________________________________
f) ALTERAÇÕES DA FALA DA E DA MÍMICA________________________________________________________________
g) ALTERAÇÕES DA MARCHA______________________________________________________________________________
h) USO DE PRÓTESES_______________________________________________________________________________________
i) OBSERVAÇÕES _________________________________________________________________________________________
______________________________________________________________________________________________________________
V – ANAMNESE GERAL
a) SINTOMATOLOGIA________________________________________________________________________________________
______________________________________________________________________________________________________________
b) ANTECEDENTES PESSOAIS
1 - DOENÇAS E CIRURGIAS ANTERIORES_________________________________________________________________
______________________________________________________________________________________________________________
2 HÁBITOS ____________________________________________________________________________________________
3 ACIDENTES EM SERVIÇO/DOENÇAS PROFISSIONAIS__________________________________________________
______________________________________________________________________________________________________________
c) ANTECEDENTES FAMILIARES _____________________________________________________________________________
d) OBSERVAÇÕES ___________________________________________________________________________________________
______________________________________________________________________________________________________________
VI – EXAME DO APARELHO CARDIOVASCULAR
a) FREQUËNCIA CARDÍACA ________________________________________________________________________________
b) PRESSÃO ARTERIAL_____________________________________________________________________________________
c) AUSCULTA CARDÍACA___________________________________________________________________________________
d) VASCULOPATIAS________________________________________________________________________________________
e) OBSERVAÇÕES__________________________________________________________________________________________
_____________________________________________________________________________________________________________
VII – EXAME DO APARELHO RESPIRATÓRIO
a) FREQUËNCIA RESPIRATÓRIA____________________________________________________________________________
b) AUSCULTA PULMONAR__________________________________________________________________________________
c) OBSERVAÇÕES __________________________________________________________________________________________
_________________________________________________________________________________________________________
VIII – EXAME DO SISTEMA NEUROLÓGICO
a) LAUDO DO EXAME NEUROLÓGICO ______________________________________________________________________
b) OBSERVAÇÕES __________________________________________________________________________________________
IX – EXAME DO APARELHO DIGESTIVO E ABDÔMEM
a) DENTES_________________________________________________________________________________________________
b) OROFARINGE____________________________________________________________________________________________
c) PALPAÇÃO E PERCUSSÃO DO ABDÔMEM
1 – VISCEROMEGALIAS_____________________________________________________________
2 – HÉRNIAS________________________________________________________________________
3 – VARICOCELE ___________________________________________________________________
4 – HIDROCELE_____________________________________________________________________
5 – GRAVIDEZ ___________________________________________________________________
d) OBSERVAÇÕES__________________________________________________________________________________________
_______________________________________________________________
X – EXAME DO APARELHO OSTEOMUSCULAR
a) DESVIO DA COLUNA VERTEBRAL___________________________________________________
b) ARTROPATIAS_____________________________________________________________________
d) OSTEOPATIAS______________________________________________________________________
e) OBSERVAÕES______________________________________________________________________
XI – DIAGNÓSTICO DO EXAME CLÍNICO
________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________
MÉDICO__________________________________________CRM______________LOCAL____________
MÉDICO__________________________________________CRM______________DATA ____________
XII – PARECER FINAL DOS EXAMES CLÍNICOS / LABORATORIAIS / COMPLEMENTARES
a) O CANDIDATO ESTÁ ___APTO ___INAPTO
b) JUSTIFICATIVA DA INAPTDÃO_____________________________________________________
MÉDICO____________________________________________CRM______________LOCAL__________
MÉDICO____________________________________________CRM______________DATA___________
MÉDICO____________________________________________CRM______________
Republicada no DOU 137, de 19.07.2004-Seção I – pág. 53
