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Nome:

Idade:
Profisso:

Queixa Principal:
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Histria do distrbio:
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Sintomas:
Pigarro:

Dor:

Secura:

Fadiga:

Irritao:

Disfnia:

Hbitos:
Tosse:
Alcool:

Bebe gua:

Fumo:

Outros:

Caf:
Antecedentes cirrgicos:
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Investigao complementar:
Rinite:

Disturbios Bucais:

Disturbios audiolgicos:

Disturbios pulmonares:

Distrbios gstricos:

Outros:

Sinusite:
Realizou tratamentos anteriores? quais?
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O que o paciente acha da sua voz?
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O que os outros acham da sua voz?
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Avaliao:
Corpo durante a fala:
Tenso corporal:
OBS:_________________________________________________________________________________
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Qualidade vocal:
Tipo de voz:
Ressonncia:
Pitch:
Loudeness:

Tipo e modo respiratrio:


Articulao:
Pronncia:
Velocidade de fala:
Entonao:
Emisso vocal: /a/:

/i/:

/u/:

/s/:

/z/:

Relao s/z:
Estruturas orofuncionais articulatrias:
Lbios:
Lngua:
Bochecha:
Palato duro:
Dentes e ocluso:
Mandibula e ATM:

OBS finais:
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