Medicine">
Formulário Médico Padrão - Dpu
Formulário Médico Padrão - Dpu
Formulário Médico Padrão - Dpu
________________________________________________________________________________
RG: ____________________________________________________________________________
OBSERVAÇÃO: O preenchimento do formulário deve ser feito pelo médico do(a) requerente(a),
com letra legível, conforme art. 39 da Resolução n° 1.601/2000 do CRM.
1. Qual(is) a(s) doença(s) que acomete(m) o(a) paciente acima nominado(a)? (Indicar o(s) CID(s)
correspondentes).
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
1
2. Justifique o(s) motivo(s) pelo(s) qual(is) o paciente só pode fazer uso da(s) alternativa(s)
terapêutica(s) acima apontada (s):
________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
( ) Contínuo.
( ) Tempo determinado.
Qual a previsão?_____________________________________________________________
5. Qual(is) a(s) consequência(s) caso o(a) paciente não seja submetido(a) ao tratamento indicado?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2
6. Há risco de vida ou de agravamento do quadro clínico atual?
( ) Sim.
( ) Não.
Justifique:_______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
( ) Sim.
( ) Não.
Justifique:_______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___________________________________________________
Carimbo e assinatura