Include P12 V2 - HSPAHR87

HSPAHR87.CH

 #DEFINE STR0001 FWI18NLang("HSPAHR87","STR0001",1)
#DEFINE STR0002 FWI18NLang("HSPAHR87","STR0002",2)
#DEFINE STR0003 FWI18NLang("HSPAHR87","STR0003",3)
#DEFINE STR0004 FWI18NLang("HSPAHR87","STR0004",4)
#DEFINE STR0005 FWI18NLang("HSPAHR87","STR0005",5)
#DEFINE STR0006 FWI18NLang("HSPAHR87","STR0006",6)
#DEFINE STR0007 FWI18NLang("HSPAHR87","STR0007",7)
#DEFINE STR0008 FWI18NLang("HSPAHR87","STR0008",8)
#DEFINE STR0009 FWI18NLang("HSPAHR87","STR0009",9)
#DEFINE STR0010 FWI18NLang("HSPAHR87","STR0010",10)
#DEFINE STR0011 FWI18NLang("HSPAHR87","STR0011",11)
#DEFINE STR0012 FWI18NLang("HSPAHR87","STR0012",12)
#DEFINE STR0013 FWI18NLang("HSPAHR87","STR0013",13)
#DEFINE STR0014 FWI18NLang("HSPAHR87","STR0014",14)
#DEFINE STR0015 FWI18NLang("HSPAHR87","STR0015",15)
#DEFINE STR0016 FWI18NLang("HSPAHR87","STR0016",16)
#DEFINE STR0017 FWI18NLang("HSPAHR87","STR0017",17)
#DEFINE STR0018 FWI18NLang("HSPAHR87","STR0018",18)
#DEFINE STR0019 FWI18NLang("HSPAHR87","STR0019",19)
#DEFINE STR0020 FWI18NLang("HSPAHR87","STR0020",20)
#DEFINE STR0021 FWI18NLang("HSPAHR87","STR0021",21)
#DEFINE STR0022 FWI18NLang("HSPAHR87","STR0022",22)
#DEFINE STR0023 FWI18NLang("HSPAHR87","STR0023",23)
#DEFINE STR0024 FWI18NLang("HSPAHR87","STR0024",24)
#DEFINE STR0025 FWI18NLang("HSPAHR87","STR0025",25)
#DEFINE STR0026 FWI18NLang("HSPAHR87","STR0026",26)
#DEFINE STR0027 FWI18NLang("HSPAHR87","STR0027",27)
#DEFINE STR0029 FWI18NLang("HSPAHR87","STR0029",28)
#DEFINE STR0030 FWI18NLang("HSPAHR87","STR0030",29)
#DEFINE STR0031 FWI18NLang("HSPAHR87","STR0031",30)
#DEFINE STR0032 FWI18NLang("HSPAHR87","STR0032",31)
#DEFINE STR0033 FWI18NLang("HSPAHR87","STR0033",32)
#DEFINE STR0034 FWI18NLang("HSPAHR87","STR0034",33)
#DEFINE STR0035 FWI18NLang("HSPAHR87","STR0035",34)
#DEFINE STR0036 FWI18NLang("HSPAHR87","STR0036",35)
#DEFINE STR0037 FWI18NLang("HSPAHR87","STR0037",36)
#DEFINE STR0038 FWI18NLang("HSPAHR87","STR0038",37)
#DEFINE STR0039 FWI18NLang("HSPAHR87","STR0039",38)
#DEFINE STR0040 FWI18NLang("HSPAHR87","STR0040",39)
#DEFINE STR0041 FWI18NLang("HSPAHR87","STR0041",40)
#DEFINE STR0042 FWI18NLang("HSPAHR87","STR0042",41)
#DEFINE STR0043 FWI18NLang("HSPAHR87","STR0043",42)
#DEFINE STR0044 FWI18NLang("HSPAHR87","STR0044",43)
#DEFINE STR0045 FWI18NLang("HSPAHR87","STR0045",44)
#DEFINE STR0046 FWI18NLang("HSPAHR87","STR0046",45)
#DEFINE STR0047 FWI18NLang("HSPAHR87","STR0047",46)
#DEFINE STR0048 FWI18NLang("HSPAHR87","STR0048",47)
#DEFINE STR0049 FWI18NLang("HSPAHR87","STR0049",48)
#DEFINE STR0050 FWI18NLang("HSPAHR87","STR0050",49)
#DEFINE STR0051 FWI18NLang("HSPAHR87","STR0051",50)
#DEFINE STR0052 FWI18NLang("HSPAHR87","STR0052",51)
#DEFINE STR0053 FWI18NLang("HSPAHR87","STR0053",52)
#DEFINE STR0054 FWI18NLang("HSPAHR87","STR0054",53)
#DEFINE STR0055 FWI18NLang("HSPAHR87","STR0055",54)
#DEFINE STR0056 FWI18NLang("HSPAHR87","STR0056",55)
#DEFINE STR0057 FWI18NLang("HSPAHR87","STR0057",56)
#DEFINE STR0058 FWI18NLang("HSPAHR87","STR0058",57)
#DEFINE STR0059 FWI18NLang("HSPAHR87","STR0059",58)
#DEFINE STR0060 FWI18NLang("HSPAHR87","STR0060",59)
#DEFINE STR0061 FWI18NLang("HSPAHR87","STR0061",60)
#DEFINE STR0062 FWI18NLang("HSPAHR87","STR0062",61)
#DEFINE STR0063 FWI18NLang("HSPAHR87","STR0063",62)
#DEFINE STR0064 FWI18NLang("HSPAHR87","STR0064",63)
#DEFINE STR0065 FWI18NLang("HSPAHR87","STR0065",64)
#DEFINE STR0066 FWI18NLang("HSPAHR87","STR0066",65)
#DEFINE STR0067 FWI18NLang("HSPAHR87","STR0067",66)
#DEFINE STR0068 FWI18NLang("HSPAHR87","STR0068",67)
#DEFINE STR0069 FWI18NLang("HSPAHR87","STR0069",68)
#DEFINE STR0070 FWI18NLang("HSPAHR87","STR0070",69)
#DEFINE STR0071 FWI18NLang("HSPAHR87","STR0071",70)
#DEFINE STR0072 FWI18NLang("HSPAHR87","STR0072",71)
#DEFINE STR0073 FWI18NLang("HSPAHR87","STR0073",72)
#DEFINE STR0074 FWI18NLang("HSPAHR87","STR0074",73)
#DEFINE STR0075 FWI18NLang("HSPAHR87","STR0075",74)
#DEFINE STR0076 FWI18NLang("HSPAHR87","STR0076",75)
#DEFINE STR0077 FWI18NLang("HSPAHR87","STR0077",76)
#DEFINE STR0078 FWI18NLang("HSPAHR87","STR0078",77)
#DEFINE STR0079 FWI18NLang("HSPAHR87","STR0079",78)
#DEFINE STR0080 FWI18NLang("HSPAHR87","STR0080",79)
#DEFINE STR0081 FWI18NLang("HSPAHR87","STR0081",80)
#DEFINE STR0082 FWI18NLang("HSPAHR87","STR0082",81)
#DEFINE STR0083 FWI18NLang("HSPAHR87","STR0083",82)
#DEFINE STR0084 FWI18NLang("HSPAHR87","STR0084",83)
#DEFINE STR0085 FWI18NLang("HSPAHR87","STR0085",84)
#DEFINE STR0086 FWI18NLang("HSPAHR87","STR0086",85)
#DEFINE STR0087 FWI18NLang("HSPAHR87","STR0087",86)
#DEFINE STR0088 FWI18NLang("HSPAHR87","STR0088",87)
#DEFINE STR0089 FWI18NLang("HSPAHR87","STR0089",88)
#DEFINE STR0090 FWI18NLang("HSPAHR87","STR0090",89)
#DEFINE STR0091 FWI18NLang("HSPAHR87","STR0091",90)
#DEFINE STR0092 FWI18NLang("HSPAHR87","STR0092",91)
#DEFINE STR0093 FWI18NLang("HSPAHR87","STR0093",92)
#DEFINE STR0094 FWI18NLang("HSPAHR87","STR0094",93)
#DEFINE STR0095 FWI18NLang("HSPAHR87","STR0095",94)
#DEFINE STR0096 FWI18NLang("HSPAHR87","STR0096",95)
#DEFINE STR0097 FWI18NLang("HSPAHR87","STR0097",96)
#DEFINE STR0098 FWI18NLang("HSPAHR87","STR0098",97)
#DEFINE STR0099 FWI18NLang("HSPAHR87","STR0099",98)
#DEFINE STR0100 FWI18NLang("HSPAHR87","STR0100",99)
#DEFINE STR0101 FWI18NLang("HSPAHR87","STR0101",100)
#DEFINE STR0102 FWI18NLang("HSPAHR87","STR0102",101)
#DEFINE STR0103 FWI18NLang("HSPAHR87","STR0103",102)
#DEFINE STR0104 FWI18NLang("HSPAHR87","STR0104",103)
#DEFINE STR0105 FWI18NLang("HSPAHR87","STR0105",104)
#DEFINE STR0106 FWI18NLang("HSPAHR87","STR0106",105)
#DEFINE STR0107 FWI18NLang("HSPAHR87","STR0107",106)
#DEFINE STR0108 FWI18NLang("HSPAHR87","STR0108",107)
#DEFINE STR0109 FWI18NLang("HSPAHR87","STR0109",108)
#DEFINE STR0110 FWI18NLang("HSPAHR87","STR0110",109)
#DEFINE STR0111 FWI18NLang("HSPAHR87","STR0111",110)
#DEFINE STR0112 FWI18NLang("HSPAHR87","STR0112",111)
#DEFINE STR0113 FWI18NLang("HSPAHR87","STR0113",112)
#DEFINE STR0114 FWI18NLang("HSPAHR87","STR0114",113)
#DEFINE STR0115 FWI18NLang("HSPAHR87","STR0115",114)
#DEFINE STR0116 FWI18NLang("HSPAHR87","STR0116",115)
#DEFINE STR0117 FWI18NLang("HSPAHR87","STR0117",116)
#DEFINE STR0118 FWI18NLang("HSPAHR87","STR0118",117)
#DEFINE STR0119 FWI18NLang("HSPAHR87","STR0119",118)
#DEFINE STR0120 FWI18NLang("HSPAHR87","STR0120",119)
#DEFINE STR0121 FWI18NLang("HSPAHR87","STR0121",120)
#DEFINE STR0122 FWI18NLang("HSPAHR87","STR0122",121)
#DEFINE STR0123 FWI18NLang("HSPAHR87","STR0123",122)
#DEFINE STR0124 FWI18NLang("HSPAHR87","STR0124",123)
#DEFINE STR0125 FWI18NLang("HSPAHR87","STR0125",124)
#DEFINE STR0126 FWI18NLang("HSPAHR87","STR0126",125)
#DEFINE STR0127 FWI18NLang("HSPAHR87","STR0127",126)
#DEFINE STR0128 FWI18NLang("HSPAHR87","STR0128",127)
#DEFINE STR0129 FWI18NLang("HSPAHR87","STR0129",128)
#DEFINE STR0130 FWI18NLang("HSPAHR87","STR0130",129)
#DEFINE STR0131 FWI18NLang("HSPAHR87","STR0131",130)
#DEFINE STR0132 FWI18NLang("HSPAHR87","STR0132",131)
#DEFINE STR0133 FWI18NLang("HSPAHR87","STR0133",132)
#DEFINE STR0134 FWI18NLang("HSPAHR87","STR0134",133)
#DEFINE STR0135 FWI18NLang("HSPAHR87","STR0135",134)
#DEFINE STR0136 FWI18NLang("HSPAHR87","STR0136",135)
#DEFINE STR0137 FWI18NLang("HSPAHR87","STR0137",136)
#DEFINE STR0138 FWI18NLang("HSPAHR87","STR0138",137)
#DEFINE STR0139 FWI18NLang("HSPAHR87","STR0139",138)
#DEFINE STR0140 FWI18NLang("HSPAHR87","STR0140",139)
#DEFINE STR0141 FWI18NLang("HSPAHR87","STR0141",140)
#DEFINE STR0142 FWI18NLang("HSPAHR87","STR0142",141)
#DEFINE STR0143 FWI18NLang("HSPAHR87","STR0143",142)
#DEFINE STR0144 FWI18NLang("HSPAHR87","STR0144",143)
#DEFINE STR0145 FWI18NLang("HSPAHR87","STR0145",144)
#DEFINE STR0146 FWI18NLang("HSPAHR87","STR0146",145)
#DEFINE STR0147 FWI18NLang("HSPAHR87","STR0147",146)
#DEFINE STR0148 FWI18NLang("HSPAHR87","STR0148",147)
#DEFINE STR0149 FWI18NLang("HSPAHR87","STR0149",148)
#DEFINE STR0150 FWI18NLang("HSPAHR87","STR0150",149)
#DEFINE STR0151 FWI18NLang("HSPAHR87","STR0151",150)
#DEFINE STR0152 FWI18NLang("HSPAHR87","STR0152",151)
#DEFINE STR0153 FWI18NLang("HSPAHR87","STR0153",152)
#DEFINE STR0154 FWI18NLang("HSPAHR87","STR0154",153)
#DEFINE STR0155 FWI18NLang("HSPAHR87","STR0155",154)
#DEFINE STR0156 FWI18NLang("HSPAHR87","STR0156",155)
#DEFINE STR0157 FWI18NLang("HSPAHR87","STR0157",156)
#DEFINE STR0158 FWI18NLang("HSPAHR87","STR0158",157)
#DEFINE STR0159 FWI18NLang("HSPAHR87","STR0159",158)
#DEFINE STR0160 FWI18NLang("HSPAHR87","STR0160",159)
#DEFINE STR0161 FWI18NLang("HSPAHR87","STR0161",160)
#DEFINE STR0162 FWI18NLang("HSPAHR87","STR0162",161)
#DEFINE STR0163 FWI18NLang("HSPAHR87","STR0163",162)
#DEFINE STR0164 FWI18NLang("HSPAHR87","STR0164",163)
#DEFINE STR0165 FWI18NLang("HSPAHR87","STR0165",164)
#DEFINE STR0166 FWI18NLang("HSPAHR87","STR0166",165)
#DEFINE STR0167 FWI18NLang("HSPAHR87","STR0167",166)
#DEFINE STR0168 FWI18NLang("HSPAHR87","STR0168",167)
#DEFINE STR0169 FWI18NLang("HSPAHR87","STR0169",168)
#DEFINE STR0170 FWI18NLang("HSPAHR87","STR0170",169)
#DEFINE STR0171 FWI18NLang("HSPAHR87","STR0171",170)
#DEFINE STR0172 FWI18NLang("HSPAHR87","STR0172",171)
#DEFINE STR0173 FWI18NLang("HSPAHR87","STR0173",172)
#DEFINE STR0174 FWI18NLang("HSPAHR87","STR0174",173)
#DEFINE STR0175 FWI18NLang("HSPAHR87","STR0175",174)
#DEFINE STR0176 FWI18NLang("HSPAHR87","STR0176",175)
#DEFINE STR0177 FWI18NLang("HSPAHR87","STR0177",176)
#DEFINE STR0178 FWI18NLang("HSPAHR87","STR0178",177)
#DEFINE STR0179 FWI18NLang("HSPAHR87","STR0179",178)
#DEFINE STR0180 FWI18NLang("HSPAHR87","STR0180",179)
#DEFINE STR0181 FWI18NLang("HSPAHR87","STR0181",180)
#DEFINE STR0182 FWI18NLang("HSPAHR87","STR0182",181)
#DEFINE STR0183 FWI18NLang("HSPAHR87","STR0183",182)
#DEFINE STR0184 FWI18NLang("HSPAHR87","STR0184",183)
#DEFINE STR0185 FWI18NLang("HSPAHR87","STR0185",184)
#DEFINE STR0186 FWI18NLang("HSPAHR87","STR0186",185)
#DEFINE STR0187 FWI18NLang("HSPAHR87","STR0187",186)
#DEFINE STR0188 FWI18NLang("HSPAHR87","STR0188",187)
#DEFINE STR0189 FWI18NLang("HSPAHR87","STR0189",188)
#DEFINE STR0190 FWI18NLang("HSPAHR87","STR0190",189)
#DEFINE STR0191 FWI18NLang("HSPAHR87","STR0191",190)
#DEFINE STR0192 FWI18NLang("HSPAHR87","STR0192",191)
#DEFINE STR0193 FWI18NLang("HSPAHR87","STR0193",192)
#DEFINE STR0194 FWI18NLang("HSPAHR87","STR0194",193)
#DEFINE STR0195 FWI18NLang("HSPAHR87","STR0195",194)
#DEFINE STR0196 FWI18NLang("HSPAHR87","STR0196",195)
#DEFINE STR0197 FWI18NLang("HSPAHR87","STR0197",196)
#DEFINE STR0198 FWI18NLang("HSPAHR87","STR0198",197)
#DEFINE STR0199 FWI18NLang("HSPAHR87","STR0199",198)
#DEFINE STR0200 FWI18NLang("HSPAHR87","STR0200",199)
#DEFINE STR0201 FWI18NLang("HSPAHR87","STR0201",200)
#DEFINE STR0202 FWI18NLang("HSPAHR87","STR0202",201)
#DEFINE STR0203 FWI18NLang("HSPAHR87","STR0203",202)
#DEFINE STR0204 FWI18NLang("HSPAHR87","STR0204",203)
#DEFINE STR0205 FWI18NLang("HSPAHR87","STR0205",204)
#DEFINE STR0206 FWI18NLang("HSPAHR87","STR0206",205)
#DEFINE STR0207 FWI18NLang("HSPAHR87","STR0207",206)
#DEFINE STR0208 FWI18NLang("HSPAHR87","STR0208",207)
#DEFINE STR0209 FWI18NLang("HSPAHR87","STR0209",208)
#DEFINE STR0210 FWI18NLang("HSPAHR87","STR0210",209)
#DEFINE STR0211 FWI18NLang("HSPAHR87","STR0211",210)
#DEFINE STR0212 FWI18NLang("HSPAHR87","STR0212",211)
#DEFINE STR0213 FWI18NLang("HSPAHR87","STR0213",212)
#DEFINE STR0214 FWI18NLang("HSPAHR87","STR0214",213)
#DEFINE STR0215 FWI18NLang("HSPAHR87","STR0215",214)
#DEFINE STR0216 FWI18NLang("HSPAHR87","STR0216",215)
#DEFINE STR0217 FWI18NLang("HSPAHR87","STR0217",216)
#DEFINE STR0218 FWI18NLang("HSPAHR87","STR0218",217)
#DEFINE STR0219 FWI18NLang("HSPAHR87","STR0219",218)
#DEFINE STR0220 FWI18NLang("HSPAHR87","STR0220",219)
#DEFINE STR0221 FWI18NLang("HSPAHR87","STR0221",220)
#DEFINE STR0222 FWI18NLang("HSPAHR87","STR0222",221)
#DEFINE STR0223 FWI18NLang("HSPAHR87","STR0223",222)
#DEFINE STR0224 FWI18NLang("HSPAHR87","STR0224",223)
#DEFINE STR0225 FWI18NLang("HSPAHR87","STR0225",224)
#DEFINE STR0226 FWI18NLang("HSPAHR87","STR0226",225)
#DEFINE STR0227 FWI18NLang("HSPAHR87","STR0227",226)
#DEFINE STR0228 FWI18NLang("HSPAHR87","STR0228",227)
#DEFINE STR0229 FWI18NLang("HSPAHR87","STR0229",228)
#DEFINE STR0230 FWI18NLang("HSPAHR87","STR0230",229)
#DEFINE STR0231 FWI18NLang("HSPAHR87","STR0231",230)
#DEFINE STR0232 FWI18NLang("HSPAHR87","STR0232",231)
#DEFINE STR0233 FWI18NLang("HSPAHR87","STR0233",232)
#DEFINE STR0234 FWI18NLang("HSPAHR87","STR0234",233)
#DEFINE STR0235 FWI18NLang("HSPAHR87","STR0235",234)
#DEFINE STR0236 FWI18NLang("HSPAHR87","STR0236",235)
#DEFINE STR0237 FWI18NLang("HSPAHR87","STR0237",236)
#DEFINE STR0238 FWI18NLang("HSPAHR87","STR0238",237)
#DEFINE STR0239 FWI18NLang("HSPAHR87","STR0239",238)
#DEFINE STR0240 FWI18NLang("HSPAHR87","STR0240",239)
#DEFINE STR0241 FWI18NLang("HSPAHR87","STR0241",240)
#DEFINE STR0242 FWI18NLang("HSPAHR87","STR0242",241)
#DEFINE STR0243 FWI18NLang("HSPAHR87","STR0243",242)
#DEFINE STR0244 FWI18NLang("HSPAHR87","STR0244",243)
#DEFINE STR0245 FWI18NLang("HSPAHR87","STR0245",244)
#DEFINE STR0246 FWI18NLang("HSPAHR87","STR0246",245)
#DEFINE STR0247 FWI18NLang("HSPAHR87","STR0247",246)
#DEFINE STR0248 FWI18NLang("HSPAHR87","STR0248",247)
#DEFINE STR0249 FWI18NLang("HSPAHR87","STR0249",248)
#DEFINE STR0250 FWI18NLang("HSPAHR87","STR0250",249)
#DEFINE STR0251 FWI18NLang("HSPAHR87","STR0251",250)
#DEFINE STR0252 FWI18NLang("HSPAHR87","STR0252",251)
#DEFINE STR0253 FWI18NLang("HSPAHR87","STR0253",252)
#DEFINE STR0254 FWI18NLang("HSPAHR87","STR0254",253)
#DEFINE STR0255 FWI18NLang("HSPAHR87","STR0255",254)
#DEFINE STR0256 FWI18NLang("HSPAHR87","STR0256",255)
#DEFINE STR0257 FWI18NLang("HSPAHR87","STR0257",256)
#DEFINE STR0258 FWI18NLang("HSPAHR87","STR0258",257)
#DEFINE STR0259 FWI18NLang("HSPAHR87","STR0259",258)
#DEFINE STR0260 FWI18NLang("HSPAHR87","STR0260",259)
#DEFINE STR0261 FWI18NLang("HSPAHR87","STR0261",260)
#DEFINE STR0262 FWI18NLang("HSPAHR87","STR0262",261)
#DEFINE STR0263 FWI18NLang("HSPAHR87","STR0263",262)
#DEFINE STR0264 FWI18NLang("HSPAHR87","STR0264",263)
#DEFINE STR0265 FWI18NLang("HSPAHR87","STR0265",264)
#DEFINE STR0266 FWI18NLang("HSPAHR87","STR0266",265)
#DEFINE STR0267 FWI18NLang("HSPAHR87","STR0267",266)
#DEFINE STR0268 FWI18NLang("HSPAHR87","STR0268",267)
#DEFINE STR0269 FWI18NLang("HSPAHR87","STR0269",268)
#DEFINE STR0270 FWI18NLang("HSPAHR87","STR0270",269)
#DEFINE STR0271 FWI18NLang("HSPAHR87","STR0271",270)
#DEFINE STR0272 FWI18NLang("HSPAHR87","STR0272",271)
#DEFINE STR0273 FWI18NLang("HSPAHR87","STR0273",272)
#DEFINE STR0274 FWI18NLang("HSPAHR87","STR0274",273)
#DEFINE STR0275 FWI18NLang("HSPAHR87","STR0275",274)
#DEFINE STR0276 FWI18NLang("HSPAHR87","STR0276",275)
#DEFINE STR0277 FWI18NLang("HSPAHR87","STR0277",276)
#DEFINE STR0278 FWI18NLang("HSPAHR87","STR0278",277)
#DEFINE STR0279 FWI18NLang("HSPAHR87","STR0279",278)
#DEFINE STR0280 FWI18NLang("HSPAHR87","STR0280",279)
#DEFINE STR0281 FWI18NLang("HSPAHR87","STR0281",280)
#DEFINE STR0282 FWI18NLang("HSPAHR87","STR0282",281)
#DEFINE STR0283 FWI18NLang("HSPAHR87","STR0283",282)
#DEFINE STR0284 FWI18NLang("HSPAHR87","STR0284",283)
#DEFINE STR0285 FWI18NLang("HSPAHR87","STR0285",284)
#DEFINE STR0286 FWI18NLang("HSPAHR87","STR0286",285)
#DEFINE STR0287 FWI18NLang("HSPAHR87","STR0287",286)
#DEFINE STR0288 FWI18NLang("HSPAHR87","STR0288",287)
#DEFINE STR0289 FWI18NLang("HSPAHR87","STR0289",288)
#DEFINE STR0290 FWI18NLang("HSPAHR87","STR0290",289)
#DEFINE STR0291 FWI18NLang("HSPAHR87","STR0291",290)
#DEFINE STR0292 FWI18NLang("HSPAHR87","STR0292",291)
#DEFINE STR0293 FWI18NLang("HSPAHR87","STR0293",292)
#DEFINE STR0294 FWI18NLang("HSPAHR87","STR0294",293)
#DEFINE STR0295 FWI18NLang("HSPAHR87","STR0295",294)
#DEFINE STR0296 FWI18NLang("HSPAHR87","STR0296",295)
#DEFINE STR0297 FWI18NLang("HSPAHR87","STR0297",296)
#DEFINE STR0298 FWI18NLang("HSPAHR87","STR0298",297)
#DEFINE STR0299 FWI18NLang("HSPAHR87","STR0299",298)
#DEFINE STR0300 FWI18NLang("HSPAHR87","STR0300",299)
#DEFINE STR0301 FWI18NLang("HSPAHR87","STR0301",300)
#DEFINE STR0302 FWI18NLang("HSPAHR87","STR0302",301)
#DEFINE STR0303 FWI18NLang("HSPAHR87","STR0303",302)
#DEFINE STR0304 FWI18NLang("HSPAHR87","STR0304",303)
#DEFINE STR0305 FWI18NLang("HSPAHR87","STR0305",304)
#DEFINE STR0306 FWI18NLang("HSPAHR87","STR0306",305)
#DEFINE STR0307 FWI18NLang("HSPAHR87","STR0307",306)
#DEFINE STR0308 FWI18NLang("HSPAHR87","STR0308",307)
#DEFINE STR0309 FWI18NLang("HSPAHR87","STR0309",308)
#DEFINE STR0310 FWI18NLang("HSPAHR87","STR0310",309)
#DEFINE STR0311 FWI18NLang("HSPAHR87","STR0311",310)
#DEFINE STR0312 FWI18NLang("HSPAHR87","STR0312",311)
#DEFINE STR0313 FWI18NLang("HSPAHR87","STR0313",312)
#DEFINE STR0314 FWI18NLang("HSPAHR87","STR0314",313)
#DEFINE STR0315 FWI18NLang("HSPAHR87","STR0315",314)
#DEFINE STR0316 FWI18NLang("HSPAHR87","STR0316",315)
#DEFINE STR0317 FWI18NLang("HSPAHR87","STR0317",316)
#DEFINE STR0318 FWI18NLang("HSPAHR87","STR0318",317)
#DEFINE STR0319 FWI18NLang("HSPAHR87","STR0319",318)
#DEFINE STR0320 FWI18NLang("HSPAHR87","STR0320",319)
#DEFINE STR0321 FWI18NLang("HSPAHR87","STR0321",320)
#DEFINE STR0322 FWI18NLang("HSPAHR87","STR0322",321)
#DEFINE STR0323 FWI18NLang("HSPAHR87","STR0323",322)
#DEFINE STR0324 FWI18NLang("HSPAHR87","STR0324",323)
#DEFINE STR0325 FWI18NLang("HSPAHR87","STR0325",324)
#DEFINE STR0326 FWI18NLang("HSPAHR87","STR0326",325)
#DEFINE STR0327 FWI18NLang("HSPAHR87","STR0327",326)
#DEFINE STR0328 FWI18NLang("HSPAHR87","STR0328",327)
#DEFINE STR0329 FWI18NLang("HSPAHR87","STR0329",328)
#DEFINE STR0330 FWI18NLang("HSPAHR87","STR0330",329)
#DEFINE STR0331 FWI18NLang("HSPAHR87","STR0331",330)
#DEFINE STR0332 FWI18NLang("HSPAHR87","STR0332",331)
#DEFINE STR0333 FWI18NLang("HSPAHR87","STR0333",332)
#DEFINE STR0334 FWI18NLang("HSPAHR87","STR0334",333)
#DEFINE STR0335 FWI18NLang("HSPAHR87","STR0335",334)
#DEFINE STR0336 FWI18NLang("HSPAHR87","STR0336",335)
#DEFINE STR0337 FWI18NLang("HSPAHR87","STR0337",336)
#DEFINE STR0338 FWI18NLang("HSPAHR87","STR0338",337)
#DEFINE STR0339 FWI18NLang("HSPAHR87","STR0339",338)
#DEFINE STR0340 FWI18NLang("HSPAHR87","STR0340",339)
#DEFINE STR0341 FWI18NLang("HSPAHR87","STR0341",340)
#DEFINE STR0342 FWI18NLang("HSPAHR87","STR0342",341)
#DEFINE STR0343 FWI18NLang("HSPAHR87","STR0343",342)
#DEFINE STR0344 FWI18NLang("HSPAHR87","STR0344",343)
#DEFINE STR0345 FWI18NLang("HSPAHR87","STR0345",344)
#DEFINE STR0346 FWI18NLang("HSPAHR87","STR0346",345)
#DEFINE STR0347 FWI18NLang("HSPAHR87","STR0347",346)
#DEFINE STR0348 FWI18NLang("HSPAHR87","STR0348",347)
#DEFINE STR0349 FWI18NLang("HSPAHR87","STR0349",348)
#DEFINE STR0350 FWI18NLang("HSPAHR87","STR0350",349)
#DEFINE STR0351 FWI18NLang("HSPAHR87","STR0351",350)
#DEFINE STR0352 FWI18NLang("HSPAHR87","STR0352",351)
#DEFINE STR0353 FWI18NLang("HSPAHR87","STR0353",352)
#DEFINE STR0354 FWI18NLang("HSPAHR87","STR0354",353)
#DEFINE STR0355 FWI18NLang("HSPAHR87","STR0355",354)
 

HSPAHR87_EN.TRES

 0001#STR0001#ALL#Attendance Forms
0002#STR0002#ALL#Phone:
0003#STR0003#ALL# - Fax: 
0004#STR0004#ALL#ZipCd:
0005#STR0005#ALL#Male
0006#STR0006#ALL#Female
0007#STR0007#ALL# -Phone: 
0008#STR0008#ALL#-ZipC: 
0009#STR0009#ALL#Name: 
0010#STR0010#ALL#DATE
0011#STR0011#ALL#TIME
0012#STR0012#ALL# - CNPJ: 
0013#STR0013#ALL#Philantropy Purposes Certificate - Process 44006.002144    97-02 - UPUB.-FED.DEC. 64.412-280469
0014#STR0014#ALL# from 
0015#STR0015#ALL#              Bed: 
0016#STR0016#ALL#CONTROL SHEET AND HYDRAULIC BALANCE
0017#STR0017#ALL#Admission Date: ______/____/____                                 Registro: 
0018#STR0018#ALL#BLOOD-PLASMA EXPANSORS  
0019#STR0019#ALL#WATER
0020#STR0020#ALL#VITAL SIGNS
0021#STR0021#ALL#Admi-
0022#STR0022#ALL#Dele-
0023#STR0023#ALL#Balance
0024#STR0024#ALL#nistrated
0025#STR0025#ALL#ted
0026#STR0026#ALL#Managed     
0027#STR0027#ALL#Deleted
0028#STR0029#ALL#Oral
0029#STR0030#ALL#Parenteral
0030#STR0031#ALL#Urinary
0031#STR0032#ALL#Digest.
0032#STR0033#ALL#Others
0033#STR0034#ALL#Temper
0034#STR0035#ALL#-ature
0035#STR0036#ALL#Pulse
0036#STR0037#ALL#Respi-
0037#STR0038#ALL#ration
0038#STR0039#ALL#Pressure
0039#STR0040#ALL#V.C.
0040#STR0041#ALL#Wght
0041#STR0042#ALL#Height
0042#STR0043#ALL#C.A.
0043#STR0044#ALL#P.C.
0044#STR0045#ALL#P.T.
0045#STR0046#ALL#Hemogli
0046#STR0047#ALL#cotest
0047#STR0048#ALL#SPECIAL PROCEDURES
0048#STR0049#ALL#Procedures
0049#STR0050#ALL#Equipm PVC
0050#STR0051#ALL#Brth. Access
0051#STR0052#ALL#Nebul. Access
0052#STR0053#ALL#Nasal Cath
0053#STR0054#ALL#Bld    Sne
0054#STR0055#ALL#Vesical Cath.
0055#STR0056#ALL#Tracheostomy
0056#STR0057#ALL#Intra Cath D
0057#STR0058#ALL#Intra Cath E
0058#STR0059#ALL#Flebotomy
0059#STR0060#ALL#Thoraxdrain
0060#STR0061#ALL#Tracheo Tube
0061#STR0062#ALL#AUTHORIZATION
0062#STR0063#ALL#I,  
0063#STR0064#ALL#Authorize  
0064#STR0065#ALL#, to send
0065#STR0066#ALL# a copy of my dossier documents, to the Health Care Auditing
0066#STR0067#ALL#, of which I am part  relating to the period I was confined in
0067#STR0068#ALL#this hospital, to carry out financial-medicine analysis.
0068#STR0069#ALL#Name:_____________________________________
0069#STR0070#ALL#I.D.:______________________
0070#STR0071#ALL#Medical Report for SUS
0071#STR0072#ALL#Dossier:   
0072#STR0073#ALL#Hospital:
0073#STR0074#ALL#MEDICAL REPORT FOR AIH ISSUEING 
0074#STR0075#ALL#1-Authorization Code:   
0075#STR0076#ALL#2-Source Unit:      
0076#STR0077#ALL#3-CNPJ No.:
0077#STR0078#ALL#4-Target Unit:       
0078#STR0079#ALL#5-CNPJ No.:
0079#STR0080#ALL#6-Patient Name:    
0080#STR0081#ALL#7-Age:  
0081#STR0082#ALL#8-Birthdate:      
0082#STR0083#ALL#9-Gend:
0083#STR0084#ALL#10-Address: 
0084#STR0085#ALL#11-Zone:  
0085#STR0086#ALL#12-ZCd:
0086#STR0087#ALL#13-District: 
0087#STR0088#ALL#14-St:
0088#STR0089#ALL#15-Doc. Type:
0089#STR0090#ALL#16-Document Number:    
0090#STR0091#ALL#17-Responsible Name:    
0091#STR0092#ALL#18-Req. Doctor CPF:       
0092#STR0093#ALL#19-Clinical Dir. CPF:  
0093#STR0094#ALL#20-Bed Number:     
0094#STR0095#ALL#21-Infirmary Numb.
0095#STR0096#ALL#22-Confinement Character:
0096#STR0097#ALL#23-Confinement Date:  
0097#STR0098#ALL#In case of a Car    
0098#STR0099#ALL#Accident, fill out  
0099#STR0100#ALL#Working Accident    
0100#STR0101#ALL#24-External Cause:
0101#STR0102#ALL#25-Insurance CNPJ:    
0102#STR0103#ALL#26-Title Number:  
0103#STR0104#ALL#27-Series:
0104#STR0105#ALL#28-Working Accident Note:         
0105#STR0106#ALL#29-Employer CNPJ:     
0106#STR0107#ALL#SUS - SINGLE HEALTH SYSTEM
0107#STR0108#ALL#Ministry of Health 
0108#STR0109#ALL#STATE GOVERNMENT  
0109#STR0110#ALL#Special Department for Social Protect.
0110#STR0111#ALL#Executive Health Department
0111#STR0112#ALL#CONFINEMENT JUSTIFICATION AND MEDICAL REPORT
0112#STR0113#ALL#30-Clinical Main Signs and Indications  
0113#STR0114#ALL#31-Conditions which justify Confinement 
0114#STR0115#ALL#32-Diagnostical Exams Main Results             
0115#STR0116#ALL#33-Initial Diagnoses:  
0116#STR0117#ALL#34-ICD 10:
0117#STR0118#ALL#35-Clinic: 
0118#STR0119#ALL#1-Surgical   (  )
0119#STR0120#ALL#2-Obstetrics  (  )
0120#STR0121#ALL#3-Medical (  )
0121#STR0122#ALL#4-F.P.T.  (  )
0122#STR0123#ALL#5-Psychiatrical (  )
0123#STR0124#ALL#6-Phtisiological    (  )
0124#STR0125#ALL#7-Pediatrics  (  )
0125#STR0126#ALL#8-Rehabilitation (  )
0126#STR0127#ALL#9-Others   (  )
0127#STR0128#ALL#36-Requested Procedure:    
0128#STR0129#ALL#37-Procedure Code:        
0129#STR0130#ALL#38-Requit. Doctor:    
0130#STR0131#ALL#39-Clinical Dir.:  
0131#STR0132#ALL#40-Supervisor Doctor CPF:   
0132#STR0133#ALL#41-Supervisor Doctor:
0133#STR0134#ALL#42-Authorization Date: 
0134#STR0135#ALL#Signature/Stamp:  
0135#STR0136#ALL#CONFINEMENT:
0136#STR0137#ALL#DSCH
0137#STR0138#ALL#NEW PROCED. 
0138#STR0139#ALL#AUT. ICU DAYS
0139#STR0140#ALL#AC
0140#STR0141#ALL#DELIVERY
0141#STR0142#ALL#MO
0142#STR0143#ALL#Material/Medicine   
0143#STR0144#ALL#ICD
0144#STR0145#ALL#ICD II
0145#STR0146#ALL#WNG
0146#STR0147#ALL#TYPE
0147#STR0148#ALL#Days/Procedure   
0148#STR0149#ALL#SMB
0149#STR0150#ALL#TYPES SUM 
0150#STR0151#ALL#ORTHESE AND PROTHESE
0151#STR0152#ALL#EXAMS 
0152#STR0153#ALL#SADT
0153#STR0154#ALL#PROCEDURE   
0154#STR0155#ALL#QTY 
0155#STR0156#ALL#Invoice    
0156#STR0157#ALL#CODE
0157#STR0158#ALL#SADT SUM 
0158#STR0159#ALL#QUANTITY SUM   
0159#STR0160#ALL#CODE SUM   
0160#STR0161#ALL#QTY SUM 
0161#STR0162#ALL#SADT SUM 
0162#STR0163#ALL#Inst. Date
0163#STR0164#ALL#No. Days
0164#STR0165#ALL#Change Date
0165#STR0166#ALL#Signature 
0166#STR0167#ALL#MEDICAL REPORT TO ISSUE AIH     
0167#STR0168#ALL#01-Report number:  
0168#STR0169#ALL#02-Authorization number - PPI 
0169#STR0170#ALL#03-No. of Request for Vcncy
0170#STR0171#ALL#04-Origin unit:      
0171#STR0172#ALL#05-Code  
0172#STR0173#ALL#06-CNPJ No.:
0173#STR0174#ALL#07-Destination unit:  
0174#STR0175#ALL#08-Code  
0175#STR0176#ALL#09-CNPJ No.:
0176#STR0177#ALL#10-Patient name:    
0177#STR0178#ALL#Attendance number 
0178#STR0179#ALL#Age:  
0179#STR0180#ALL#11-Date of birth:     
0180#STR0181#ALL#12-Sex: 
0181#STR0182#ALL#13-Address: 
0182#STR0183#ALL#14-ZIP:
0183#STR0184#ALL#15-City:     
0184#STR0185#ALL#Distr.:
0185#STR0186#ALL#16-St:
0186#STR0187#ALL#Doc. Type:
0187#STR0188#ALL#17-Document number:    
0188#STR0189#ALL#18-Responsible's name:  
0189#STR0190#ALL#19-Requesting Doctor's CPF
0190#STR0191#ALL#20-Bed number:     
0191#STR0192#ALL#21-Policlinic No.:
0192#STR0193#ALL#22-HospitalizationPurpose
0193#STR0194#ALL#23-Hospitalizat. Date:
0194#STR0195#ALL#24-ClinicalDirectorCPF:
0195#STR0196#ALL#25-Hospital's Contact Employee       
0196#STR0197#ALL#26-Purpose of Request    
0197#STR0198#ALL#(  ) Self-Risk     (   ) Isolation    (   ) I.C.U.   (   ) AIDS   (   ) Other  ___________________
0198#STR0199#ALL#Fill out in case of 
0199#STR0200#ALL#Transit Accident    
0200#STR0201#ALL#27-ExternalCause:
0201#STR0202#ALL#28-Insurer's CNPJ no.:
0202#STR0203#ALL#29-Ticket Number: 
0203#STR0204#ALL#30-Series
0204#STR0205#ALL#SUS - UNIQUE HEALTH SYSTEM
0205#STR0206#ALL#Ministry of Health 
0206#STR0207#ALL#STATE GOVERNMENT  
0207#STR0208#ALL#Special Social Protection Secretary   
0208#STR0209#ALL#Executive Health Secretary   
0209#STR0210#ALL#TECHNICAL REPORT JUSTIFYING HOSPITALIZATION
0210#STR0211#ALL#31-Main Signals and Clinical Symptoms   
0211#STR0212#ALL#32-Conditions justifying Hospitalization
0212#STR0213#ALL#33-Main Results of Diagnostic Examinations     
0213#STR0214#ALL#34-Initial Diagnosis:  
0214#STR0215#ALL#35-Initial Diagnosys CID     
0215#STR0216#ALL#36-Clinic: 
0216#STR0217#ALL#1-Surgical   (  )
0217#STR0218#ALL#2-Obstetrical (  )
0218#STR0219#ALL#3-Doctor  (  )
0219#STR0220#ALL#4-F.P.T.  (  )
0220#STR0221#ALL#5-Psychiatric   (  )
0221#STR0222#ALL#6-Tsiopneumonologic (  )
0222#STR0223#ALL#7-Pediatric   (  )
0223#STR0224#ALL#8-Rehabilitation (  )
0224#STR0225#ALL#9-Other    (  )
0225#STR0226#ALL#37-Procedure Code:      
0226#STR0227#ALL#Descript.:
0227#STR0228#ALL#38-Report Status    
0228#STR0229#ALL#(   ) Cancelled      (   ) Authorized     (   ) Change of Procedure    
0229#STR0230#ALL#39-Problem     (   ) Yes     (   ) No                 40-Type
0230#STR0231#ALL#41-Date of Issue:  
0231#STR0232#ALL#42-Requesting Doctor: 
0232#STR0233#ALL#43-Clinical Doctor:
0233#STR0234#ALL#44-Supervising Doctor
0234#STR0235#ALL#Signature/Stamp:   
0235#STR0236#ALL#MEDICAL REPORT TO ISSUE AIH     
0236#STR0237#ALL#01-Report Number:  
0237#STR0238#ALL#02-Authorization Number - PPI 
0238#STR0239#ALL#03-Request Number for Vcncy
0239#STR0240#ALL#04-Origin Unit:      
0240#STR0241#ALL#05-Code  
0241#STR0242#ALL#06-CNPJ No.:
0242#STR0243#ALL#07-Destination Unit:  
0243#STR0244#ALL#08-Code  
0244#STR0245#ALL#09-CNPJ No.:
0245#STR0246#ALL#10-Patient Name:    
0246#STR0247#ALL#Attendance number 
0247#STR0248#ALL#Age:  
0248#STR0249#ALL#11-Date of Birth:     
0249#STR0250#ALL#12-Sex: 
0250#STR0251#ALL#13-Address: 
0251#STR0252#ALL#14-ZIP:
0252#STR0253#ALL#15-City:     
0253#STR0254#ALL#Distric
0254#STR0255#ALL#16-St:
0255#STR0256#ALL#Doc. Type:
0256#STR0257#ALL#17-Document Number:    
0257#STR0258#ALL#18-Responsible's Name:  
0258#STR0259#ALL#19-RequestingDoctor's CPF:
0259#STR0260#ALL#20-Bed Number:     
0260#STR0261#ALL#21-Policlinic No.:
0261#STR0262#ALL#22-HospitalizationPurpose
0262#STR0263#ALL#23-Date of Hospitaliz:
0263#STR0264#ALL#24-ClinicalDirectorCPF:
0264#STR0265#ALL#25-Hospital's Contact Employee       
0265#STR0266#ALL#26-Purpose of Request    
0266#STR0267#ALL#(  ) Self-Risk     (   ) Isolation    (   ) I.C.U.   (   ) AIDS   (   ) Other  ___________________
0267#STR0268#ALL#Fill out in case of 
0268#STR0269#ALL#Transit Accident    
0269#STR0270#ALL#27-External Cause
0270#STR0271#ALL#28-Insurer's CNPJ:    
0271#STR0272#ALL#29-Ticket Number: 
0272#STR0273#ALL#30-Series
0273#STR0274#ALL#SUS - SINGLE HEALTH SYSTEM  
0274#STR0275#ALL#Ministery of Health
0275#STR0276#ALL#GOVERNMENT OF STATE
0276#STR0277#ALL#Special Social Protection Secretary   
0277#STR0278#ALL#Executive Health Secretary   
0278#STR0279#ALL#Policlinic Medical Attendance  
0279#STR0280#ALL#Unit:   
0280#STR0281#ALL#Address: 
0281#STR0282#ALL#Patient: 
0282#STR0283#ALL#Age:  
0283#STR0284#ALL#Date of Birth:  
0284#STR0285#ALL#Sex: 
0285#STR0286#ALL#Address: 
0286#STR0287#ALL#Distric
0287#STR0288#ALL#District: 
0288#STR0289#ALL#Document: 
0289#STR0290#ALL#Address: 
0290#STR0291#ALL#Doctor:
0291#STR0292#ALL#ACCOUNT: 
0292#STR0293#ALL#                Date of Attend.:  
0293#STR0294#ALL#PROCEDURE:   
0294#STR0295#ALL#REASON FOR ATTENDANCE:
0295#STR0296#ALL#SUMMARY DESCRIPT. OF CLINICAL EXAM:
0296#STR0297#ALL#Diagnosis:  
0297#STR0298#ALL#ICD:
0298#STR0299#ALL#Nature of Attendance:   
0299#STR0300#ALL#___Clin    ___Surg   ____Obst  ____Pedi   ___Psic   ____Tisi   ____Odon
0300#STR0301#ALL#___Other   ___General accident            ___OccupationalAccident
0301#STR0302#ALL#Medication
0302#STR0303#ALL#___Prescribed     ___Applied 
0303#STR0304#ALL#Transfer:      
0304#STR0305#ALL#___To Resid   ___P/ Pub.Policl.    ___Hospit    ___Death    ___Other 
0305#STR0306#ALL# THUMB  
0306#STR0307#ALL#   Profissional's stamp and sign.                 Patient's/Responsible's sign.  
0307#STR0308#ALL#URGENCY POLICLINICAL MEDICAL ATTENDANCE BILL        
0308#STR0309#ALL#PROFESSIONAL SERVICES:         1-Consultation   2-Imobilization   3-Curative
0309#STR0310#ALL#                               4-Small Surgery  5-Other           6-Odontol.Attend.
0310#STR0311#ALL#Description of Procedure                                                          
0311#STR0312#ALL#SUPPLEMENTARY RESOURCES:       1-Lab Exam       2-X-ray           3-Oxigentherapy 
0312#STR0313#ALL#                               4-Hemotherapy    5-Rehydration     6-Other          
0313#STR0314#ALL#Description of Procedure                  Code     |  Description of Procedure                    Code   
0314#STR0315#ALL#MATERIAL AND MEDICINES:        1-Material       2-Medicines       3-Removal        
0315#STR0316#ALL#                               4-Other                                             
0316#STR0317#ALL#Description of Procedure                    Qty    |  Description of Procedure                      Qty  
0317#STR0318#ALL#     Director responsible for information                              Responsible's signature           
0318#STR0319#ALL#   Fill out clearly every field under penalty of attendance not being considered. Check with an X       
0319#STR0320#ALL#   the grids presided by numbers ticking the alternative. Responsible for said information: doctor or    
0320#STR0321#ALL#   odontologist assistant and directors of the healthcare or contracted entity. False statement and/or   
0321#STR0322#ALL#   fraud makes infractors liable to sanctions of sections 171 and/or 298 of the Criminal Code 
0322#STR0323#ALL#MEDICAL PRESCRIPTION FORM      
0323#STR0324#ALL#Patient..: 
0324#STR0325#ALL#          Record...: 
0325#STR0326#ALL#Healthcare 
0326#STR0327#ALL#           Date..: 
0327#STR0328#ALL#           Time.....: 
0328#STR0329#ALL#          Bed....: 
0329#STR0330#ALL#Doctor...: 
0330#STR0331#ALL#ITEM
0331#STR0332#ALL#PRESCRIPT.
0332#STR0333#ALL#TIME   
0333#STR0334#ALL#ICU
0334#STR0335#ALL#DEV
0335#STR0336#ALL#REQUEST FOR PROCEDURES      
0336#STR0337#ALL#THAT NEED PRIOR AUTHORIZATION    
0337#STR0338#ALL#Patient..: 
0338#STR0339#ALL#Record...: 
0339#STR0340#ALL#       Healthcare: 
0340#STR0341#ALL#Date.....: 
0341#STR0342#ALL#      Time.....: 
0342#STR0343#ALL#          Bed....: 
0343#STR0344#ALL#Doctor...: 
0344#STR0345#ALL#1-HIGH COST MATERIAL - Specify:               
0345#STR0346#ALL#2-CHANGE OF PROCEDURE:    
0346#STR0347#ALL#3-APPOINTMENT SPECIALIST - Specify:   
0347#STR0348#ALL#4-APPOINTMENT SPECIALIST - Specify:   
0348#STR0349#ALL#Justification:
0349#STR0350#ALL#Date:               Requesting Doctor:                      Auditor:
0350#STR0351#ALL#For Healthcares below, use own forms                   
0351#STR0352#ALL#AMIL (Special Exams)   
0352#STR0353#ALL#HapVida (All exams and procedures)       
0353#STR0354#ALL#Sa�de Bradesco (Change of Procedure)    
0354#STR0355#ALL#PETROBRAS (Procedures)   
 

HSPAHR87_ES.TRES

 0001#STR0001#ALL#Fichas de Atencion
0002#STR0002#ALL#Tel.: 
0003#STR0003#ALL# - Fax: 
0004#STR0004#ALL#CP:  
0005#STR0005#ALL#Masculino
0006#STR0006#ALL#Femenino
0007#STR0007#ALL# - Tel.: 
0008#STR0008#ALL#- CP:  
0009#STR0009#ALL#Nomb: 
0010#STR0010#ALL#FCHA
0011#STR0011#ALL#HORA
0012#STR0012#ALL# - CNPJ: 
0013#STR0013#ALL#Certificado Fines Filantropicos- Proceso 44006.002144/97-02 - U PUB.-FED.DEC. 64.412-280469
0014#STR0014#ALL# de 
0015#STR0015#ALL#            Cama:  
0016#STR0016#ALL#HOJA DE CONTROL Y BALANCE HIDRICO  
0017#STR0017#ALL#Fecha admision:   ____/____/____                                 Registro: 
0018#STR0018#ALL#SANGRE-PLASMA EXPANSORES
0019#STR0019#ALL#AGUA
0020#STR0020#ALL#SIGNOS VITALES
0021#STR0021#ALL#Admi-
0022#STR0022#ALL#Elimi-
0023#STR0023#ALL#Balance
0024#STR0024#ALL#nistrado
0025#STR0025#ALL#nado
0026#STR0026#ALL#Administrada
0027#STR0027#ALL#Eliminada
0028#STR0029#ALL#Oral
0029#STR0030#ALL#Parenteral
0030#STR0031#ALL#UrinAria
0031#STR0032#ALL#Digest.
0032#STR0033#ALL#Otras 
0033#STR0034#ALL#Tempe-
0034#STR0035#ALL#ratura
0035#STR0036#ALL#Pulso
0036#STR0037#ALL#Respi-
0037#STR0038#ALL#racio
0038#STR0039#ALL#Presion
0039#STR0040#ALL#V.C.
0040#STR0041#ALL#Peso
0041#STR0042#ALL#Altura
0042#STR0043#ALL#C.A.
0043#STR0044#ALL#P.C.
0044#STR0045#ALL#P.T.
0045#STR0046#ALL#Hemogli
0046#STR0047#ALL#cotest
0047#STR0048#ALL#PROCEDIMIENTOS ESPECIAL
0048#STR0049#ALL#Procedimientos
0049#STR0050#ALL#Equipo PVC
0050#STR0051#ALL#Aces. Resp. 
0051#STR0052#ALL#Aces. Nebul. 
0052#STR0053#ALL#Cat. Nasal
0053#STR0054#ALL#Sang   Sne
0054#STR0055#ALL#Sonda Vesical
0055#STR0056#ALL#Traqueotomia 
0056#STR0057#ALL#Intra Cath D
0057#STR0058#ALL#Intra Cath E
0058#STR0059#ALL#Flebotomia
0059#STR0060#ALL#Drenotoracico
0060#STR0061#ALL#Intub. Traqueal
0061#STR0062#ALL#AUTORIZACION
0062#STR0063#ALL#Yo, 
0063#STR0064#ALL#Autorizo a 
0064#STR0065#ALL#, a enviar
0065#STR0066#ALL#copias de documentos de mi ficha medica a la auditoria del convenio del que 
0066#STR0067#ALL#soy parte relativas al periodo que estuve internado en este hospital para e-
0067#STR0068#ALL#fectos de analisis medico-financiero
0068#STR0069#ALL#Nombre:___________________________________
0069#STR0070#ALL#Doc. Id.:__________________
0070#STR0071#ALL#Informe medico p/ SUS
0071#STR0072#ALL#Ficha med.:
0072#STR0073#ALL#Hospital:
0073#STR0074#ALL#INFORME MEDICO PARA EMITIR AIH
0074#STR0075#ALL#1-Codigo de Autorizacion
0075#STR0076#ALL#2-Unidad de Origen: 
0076#STR0077#ALL#3-CNPJ Nr.:
0077#STR0078#ALL#4-Unidad de Destino: 
0078#STR0079#ALL#5-CNPJ Nr.:
0079#STR0080#ALL#6-Nombre Paciente: 
0080#STR0081#ALL#7-Edad: 
0081#STR0082#ALL#8-Fecha nacimiento
0082#STR0083#ALL#9-Sexo:
0083#STR0084#ALL#10-Direccion
0084#STR0085#ALL#11-Barrio:
0085#STR0086#ALL#12-CP: 
0086#STR0087#ALL#13-Municipio:
0087#STR0088#ALL#14-UF:
0088#STR0089#ALL#15-Tipo Doc.:
0089#STR0090#ALL#16-Numero de Documento:
0090#STR0091#ALL#17-Nombre de responsable
0091#STR0092#ALL#18-CPF Medico Solicitante:
0092#STR0093#ALL#19-CPF DirectorClinico:
0093#STR0094#ALL#20-Numero de Cama: 
0094#STR0095#ALL#21-Enfermeria Nr.:
0095#STR0096#ALL#22-Caracter internacion: 
0096#STR0097#ALL#23-Fecha internacion: 
0097#STR0098#ALL#Completar en caso de
0098#STR0099#ALL#Accidente Transito  
0099#STR0100#ALL#Accidente Trabajo   
0100#STR0101#ALL#24-Causa Externa:
0101#STR0102#ALL#25-CNPJ Aseguradora:  
0102#STR0103#ALL#26-Nr. de Billete:
0103#STR0104#ALL#27-Serie:
0104#STR0105#ALL#28-Comunicado Accidente Trabajo:  
0105#STR0106#ALL#29-CNPJ del Empleador:
0106#STR0107#ALL#SUS - SISTEMA UNICO DE SALUD
0107#STR0108#ALL#Ministerio de Salud
0108#STR0109#ALL#GOVIERNO DEL ESTAD
0109#STR0110#ALL#Secretaria Especial de Protecc. Social
0110#STR0111#ALL#Secretaria Ejecutiva de Salud
0111#STR0112#ALL#INFORME TECNICO Y JUSTIFICATIVA INTERNACION
0112#STR0113#ALL#30-Principales signos y sintomasClinicos
0113#STR0114#ALL#31-Condiciones que justifican internac. 
0114#STR0115#ALL#32-Principales Result. de Pruebas Diagnosticas 
0115#STR0116#ALL#33-Diagnostico Inicial:
0116#STR0117#ALL#34-CID 10:
0117#STR0118#ALL#35-Clinica:
0118#STR0119#ALL#1-Quirurgica (  )
0119#STR0120#ALL#2-Obstetrica  (  )
0120#STR0121#ALL#3-Medica  (  )
0121#STR0122#ALL#4-F.P.T.  (  )
0122#STR0123#ALL#5-Psiquiatrica  (  )
0123#STR0124#ALL#6-Tisiopneumologica (  )
0124#STR0125#ALL#7-Pediatrica  (  )
0125#STR0126#ALL#8-Rehabilitacion (  )
0126#STR0127#ALL#9-Otros    (  )
0127#STR0128#ALL#36-Procedimiento Solicitado
0128#STR0129#ALL#37-Codigo Procedimiento:  
0129#STR0130#ALL#38-Medico Solicitante:
0130#STR0131#ALL#39-Director clinico
0131#STR0132#ALL#40-CPF de Medico Supervisor:
0132#STR0133#ALL#41-Medico Supervisor:
0133#STR0134#ALL#42-Fecha Autorizacion: 
0134#STR0135#ALL#Firma/Sello:      
0135#STR0136#ALL#INTERNACION
0136#STR0137#ALL#ALTA
0137#STR0138#ALL#NUEVO PROC. 
0138#STR0139#ALL#DIAS UTI AUT.
0139#STR0140#ALL#AC
0140#STR0141#ALL#PARTO
0141#STR0142#ALL#MO
0142#STR0143#ALL#Material/Medicamento
0143#STR0144#ALL#CID
0144#STR0145#ALL#CID II
0145#STR0146#ALL#ALA
0146#STR0147#ALL#TIPO
0147#STR0148#ALL#Dias/Procedimiento
0148#STR0149#ALL#CRM
0149#STR0150#ALL#SUMA TIPOS
0150#STR0151#ALL#ORTESIS/PROTESIS
0151#STR0152#ALL#EXAMEN
0152#STR0153#ALL#SADT
0153#STR0154#ALL#PROCEDIM.   
0154#STR0155#ALL#CTD.
0155#STR0156#ALL#Factura    
0156#STR0157#ALL#COD.
0157#STR0158#ALL#SUMA SADT
0158#STR0159#ALL#SUMA CANTIDAD  
0159#STR0160#ALL#SUMA CODIGO
0160#STR0161#ALL#SUMA CTD
0161#STR0162#ALL#SUMA SADT
0162#STR0163#ALL#FechaInst.
0163#STR0164#ALL#Nro.Dias
0164#STR0165#ALL#Fch Cambio
0165#STR0166#ALL#Firma     
0166#STR0167#ALL#LAUDO MEDICO PARA EMISION DE AIH
0167#STR0168#ALL#01-Numero de Laudo:
0168#STR0169#ALL#02-Numero de Autorizacion - PPI
0169#STR0170#ALL#03-Numero de Pedido de Vacante
0170#STR0171#ALL#04-Unidad de Origen:
0171#STR0172#ALL#05-Codigo
0172#STR0173#ALL#06-CNPJ N�.:
0173#STR0174#ALL#07-Unidad de Destino:
0174#STR0175#ALL#08-Codigo
0175#STR0176#ALL#09-CNPJ N�.:
0176#STR0177#ALL#10-Nombre del Paciente:
0177#STR0178#ALL#N� de Atencion
0178#STR0179#ALL#Edad:
0179#STR0180#ALL#11-Fecha de Nacimiento:
0180#STR0181#ALL#12-Sexo:
0181#STR0182#ALL#13-Direccion:
0182#STR0183#ALL#14-C p:
0183#STR0184#ALL#15-Municipio:
0184#STR0185#ALL#Barrio:
0185#STR0186#ALL#16-UF:
0186#STR0187#ALL#Tipo Doc.:
0187#STR0188#ALL#17-Numero de Documento:
0188#STR0189#ALL#18-Nombre del Responsable:
0189#STR0190#ALL#19-CPF Medico Solicitante:
0190#STR0191#ALL#20-Numero de Cama:
0191#STR0192#ALL#21-Sala N�:
0192#STR0193#ALL#22-Caracter de la internacion:
0193#STR0194#ALL#23-Fecha de la Internacion:
0194#STR0195#ALL#24-CPF Director Cl�nico:
0195#STR0196#ALL#25-Empleado de Contacto del Hospital
0196#STR0197#ALL#26-Caracter de la Solicitud
0197#STR0198#ALL#(  ) Alto Riesgo   (   ) Aislamiento  (   ) U.T.I.   (   ) SIDA   (   ) Otros  ___________________
0198#STR0199#ALL#Rellenar en caso de
0199#STR0200#ALL#Accidente de Transito
0200#STR0201#ALL#27-Causa Externa:
0201#STR0202#ALL#28-CNPJ de la Aseguradora:
0202#STR0203#ALL#29-N� de Billete:
0203#STR0204#ALL#30-Serie:
0204#STR0205#ALL#SUS - SISTEMA UNICO DE SALUD
0205#STR0206#ALL#Ministerio de Salud
0206#STR0207#ALL#GOBIERNO DEL ESTADO 
0207#STR0208#ALL#Secretaria Especial de Proteccion Social
0208#STR0209#ALL#Secretaria Ejecutiva de Salud
0209#STR0210#ALL#LAUDO TECNICO Y JUSTIFICACION DE INTERNACION
0210#STR0211#ALL#31-Principales Indicios y Sintomas Clinicos
0211#STR0212#ALL#32-Condiciones que justifican la Internacion
0212#STR0213#ALL#33-Principales Resultados de Pruebas Diagnosticas
0213#STR0214#ALL#34-Diagnostico Inicial:
0214#STR0215#ALL#35-CID del Diagnostico Inicial
0215#STR0216#ALL#36-Clinica:
0216#STR0217#ALL#1-Quirurgica  (  )
0217#STR0218#ALL#2-Obstetrica  (  )
0218#STR0219#ALL#3-Medica  (  )
0219#STR0220#ALL#4-F.P.T.  (  )
0220#STR0221#ALL#5-Psiquiatrica  (  )
0221#STR0222#ALL#6-Tisioneumologica  (  )
0222#STR0223#ALL#7-Pediatrica  (  )
0223#STR0224#ALL#8-Rehabilitacion   (  )
0224#STR0225#ALL#9-Otros   (  )
0225#STR0226#ALL#37-Cod. del Procedimiento:
0226#STR0227#ALL#Descripcion:
0227#STR0228#ALL#38-Situacion del Laudo
0228#STR0229#ALL#(   ) Anulado        (   ) Autorizado     (   ) Cambio de Procedimiento
0229#STR0230#ALL#39-Problema    (   ) Si      (   ) No                 40-Tipo
0230#STR0231#ALL#41-Fecha de la Emision:
0231#STR0232#ALL#42-Medico Solicitante:
0232#STR0233#ALL#43-Director Clinico:
0233#STR0234#ALL#44-Medico Supervisor:
0234#STR0235#ALL#Firma/Sello:
0235#STR0236#ALL#LAUDO MEDICO PARA EMISION DE AIH
0236#STR0237#ALL#01-Numero de Laudo:
0237#STR0238#ALL#02-Numero de Autorizacion - PPI
0238#STR0239#ALL#03-Numero do Pedido de Vacante
0239#STR0240#ALL#04-Unidad de Origen:
0240#STR0241#ALL#05-Codigo
0241#STR0242#ALL#06-CNPJ N�:
0242#STR0243#ALL#07-Unidad de Destino:
0243#STR0244#ALL#08-Codigo
0244#STR0245#ALL#09-CNPJ N�:
0245#STR0246#ALL#10-Nombre del Paciente:
0246#STR0247#ALL#N� de Atencion
0247#STR0248#ALL#Edad:
0248#STR0249#ALL#11-Fecha de Nacimiento:
0249#STR0250#ALL#12-Sexo:
0250#STR0251#ALL#13-Direccion:
0251#STR0252#ALL#14-Cp:
0252#STR0253#ALL#15-Municipio:
0253#STR0254#ALL#Barrio:
0254#STR0255#ALL#16-UF:
0255#STR0256#ALL#Tipo Doc.:
0256#STR0257#ALL#17-Numero de Documento:
0257#STR0258#ALL#18-Nombre del Responsable:
0258#STR0259#ALL#19-CPF Medico Solicitante:
0259#STR0260#ALL#20-Numero de Cama:
0260#STR0261#ALL#21-Sala N�:
0261#STR0262#ALL#22-Caracter de la internacion:
0262#STR0263#ALL#23-Fecha de la Internacion:
0263#STR0264#ALL#24-CPF Director Clinico:
0264#STR0265#ALL#25-Empleado de Contacto del Hospital
0265#STR0266#ALL#26-Caracter de la Solicitud
0266#STR0267#ALL#(  ) Auto Riesgo    (   ) Aislamiento   (   ) U.T.I.   (   ) SIDA   (   ) Otros ___________________
0267#STR0268#ALL#Rellenar en caso de
0268#STR0269#ALL#Accidente de Transito
0269#STR0270#ALL#27-Causa Externa:
0270#STR0271#ALL#28-CNPJ de la Aseguradora:
0271#STR0272#ALL#29-N� del Billete:
0272#STR0273#ALL#30-Serie:
0273#STR0274#ALL#SUS - SISTEMA UNICO DE SALUD
0274#STR0275#ALL#Ministerio de Salud
0275#STR0276#ALL#GOBIERNO DE ESTADO 
0276#STR0277#ALL#Secretaria Especial de Proteccion Social
0277#STR0278#ALL#Secretaria Ejecutiva de Salud
0278#STR0279#ALL#Atencion Medica Ambulatoria
0279#STR0280#ALL#Unidad:
0280#STR0281#ALL#Direccion:
0281#STR0282#ALL#Paciente:
0282#STR0283#ALL#Edad:
0283#STR0284#ALL#Fecha Nacimiento:
0284#STR0285#ALL#Sexo:
0285#STR0286#ALL#Direccion:
0286#STR0287#ALL#Barrio:
0287#STR0288#ALL#Municipio:
0288#STR0289#ALL#Documento:
0289#STR0290#ALL#Direccion:
0290#STR0291#ALL#Medico:
0291#STR0292#ALL#CUENTA:   
0292#STR0293#ALL#                Fecha Atencion:   
0293#STR0294#ALL#PROCEDIMIENTO:
0294#STR0295#ALL#MOTIVO DE ATENCION:   
0295#STR0296#ALL#DESCRIP. SUMARIA DE EXAMEN CLINICO:
0296#STR0297#ALL#Diagnostico:
0297#STR0298#ALL#CID:
0298#STR0299#ALL#Modalidad de Atencion:  
0299#STR0300#ALL#___Clin    ___Ciru   ____Obst  ____Pedi   ___Psiq   ____Tisi   ____Odon
0300#STR0301#ALL#___Otro    ___Accidente en gral           ___Accidente de Trabajo
0301#STR0302#ALL#Medicac:  
0302#STR0303#ALL#___Prescrip.      ___Aplicada
0303#STR0304#ALL#Encaminamiento:
0304#STR0305#ALL#___P/ Resid   ___P/ Amb.Publico    ___Intern    ___Obito    ___Otros 
0305#STR0306#ALL# PULGAR 
0306#STR0307#ALL#   Sello y firma del profesional                  Fir de paciente/responsable    
0307#STR0308#ALL#CUENTA DE ATENCION MEDICA AMBULATORIA DE URGENCIA   
0308#STR0309#ALL#SERVICIOS PROFESIONAL:         1-Consulta       2-Inmovilizac.    3-Curativo
0309#STR0310#ALL#                               4-Peq.Cirugia    5-Otros           6-At.Odontologica
0310#STR0311#ALL#Descrip.del Procedimiento                                                         
0311#STR0312#ALL#RECURSOS COMPLEMENTAR. :       1-Exam. Lab.     2-Rayos X         3-Oxigenoterapia
0312#STR0313#ALL#                               4-Hemoterapia    5-Rehidratac.     6-Otros          
0313#STR0314#ALL#Descrip. de Procedimiento                 Codigo   |  Descrip. de Procedimiento                   Codigo 
0314#STR0315#ALL#MATERIAL. Y MEDICAMENTOS:      1-Material.      2-Medicamentos    3-Trasla.        
0315#STR0316#ALL#                               4-Otros                                             
0316#STR0317#ALL#Descrip. de Procedimiento                   Ctd    |  Descrip. de Procedimiento                     Ctd  
0317#STR0318#ALL#     Director responsable p/informac.                                  Firma del responsable             
0318#STR0319#ALL#   Rellene en forma legible todos los camposos bajo pena de no considerarse la atencion. Firme con X las
0319#STR0320#ALL#   cuadriculas precedidas de numeros marcando la alternativa. Son responsables por la inform. el medico u
0320#STR0321#ALL#   odontologo asistente y los directores de entidad conveniente o contratada. La declaracion  falsa  y/o
0321#STR0322#ALL#   fraude sujeta los infractores a las sanciones de articulos 171 y/o 298 del Codigo Penal
0322#STR0323#ALL#FORMULARIO DE PRESCRIPCION MEDICA
0323#STR0324#ALL#Paciente.: 
0324#STR0325#ALL#          Registro.: 
0325#STR0326#ALL#Convenio.: 
0326#STR0327#ALL#           Fecha..: 
0327#STR0328#ALL#           Hora.....: 
0328#STR0329#ALL#          Cama..: 
0329#STR0330#ALL#Medico...: 
0330#STR0331#ALL#ITEM
0331#STR0332#ALL#PRESCRIPCION
0332#STR0333#ALL#HORARIO
0333#STR0334#ALL#UTI
0334#STR0335#ALL#DEV
0335#STR0336#ALL#SOLICITUD DE PROCEDIMIENTOS
0336#STR0337#ALL#QUE NECESITAN AUTORIZACION PREVIA
0337#STR0338#ALL#Paciente.: 
0338#STR0339#ALL#Registro.: 
0339#STR0340#ALL#        Convenio.: 
0340#STR0341#ALL#Fecha.....: 
0341#STR0342#ALL#      Hora.....: 
0342#STR0343#ALL#          Cama..: 
0343#STR0344#ALL#Medico...: 
0344#STR0345#ALL#1-MATERIA (L)(ES) DE ALTO COSTO - Especificar:
0345#STR0346#ALL#2-CAMBIO DE PROCEDIMIENTO:
0346#STR0347#ALL#3-CONSULTA ESPECIALISTA - Especificar:
0347#STR0348#ALL#4-CONSULTA ESPECIALISTA - Especificar:
0348#STR0349#ALL#Justificacion:
0349#STR0350#ALL#Fecha:              Medico Solicitante:                     Auditor:
0350#STR0351#ALL#Para los siguientes Convenios, utilizar formularios propios
0351#STR0352#ALL#Amil (Examenes Especiales)
0352#STR0353#ALL#HapVida (Todos los examenes y procedimientos)
0353#STR0354#ALL#Sa�de Bradesco (Cambio de Procedimiento)
0354#STR0355#ALL#Petrobras (Procedimientos)
 

HSPAHR87_PT-BR.TRES

 0001#STR0001#ALL#Fichas de Atendimento
0002#STR0002#ALL#Fone: 
0003#STR0003#ALL# - Fax: 
0004#STR0004#ALL#CEP: 
0005#STR0005#ALL#Masculino
0006#STR0006#ALL#Feminino
0007#STR0007#ALL# - Fone: 
0008#STR0008#ALL#- CEP: 
0009#STR0009#ALL#Nome: 
0010#STR0010#ALL#DATA
0011#STR0011#ALL#HORA
0012#STR0012#ALL# - CNPJ: 
0013#STR0013#ALL#Certificado Fins Filantr�picos - Processo 44006.002144    97-02 - U PUB.-FED.DEC. 64.412-280469
0014#STR0014#ALL# de 
0015#STR0015#ALL#            Leito: 
0016#STR0016#ALL#FOLHA DE CONTROLE E BALAN�O H�DRICO
0017#STR0017#ALL#Data da Admiss�o: ____/____/____                                 Registro: 
0018#STR0018#ALL#SANGUE-PLASMA EXPANSORES
0019#STR0019#ALL#�GUA
0020#STR0020#ALL#SINAIS VITAIS
0021#STR0021#ALL#Admi-
0022#STR0022#ALL#Elimi-
0023#STR0023#ALL#Balan�o
0024#STR0024#ALL#nistrado
0025#STR0025#ALL#nado
0026#STR0026#ALL#Administrada
0027#STR0027#ALL#Eliminada
0028#STR0029#ALL#Oral
0029#STR0030#ALL#Perenteral
0030#STR0031#ALL#Urin�ria
0031#STR0032#ALL#Digest.
0032#STR0033#ALL#Outras
0033#STR0034#ALL#Tempe-
0034#STR0035#ALL#ratura
0035#STR0036#ALL#Pulso
0036#STR0037#ALL#Respi-
0037#STR0038#ALL#ra��o
0038#STR0039#ALL#Press�o
0039#STR0040#ALL#V.C.
0040#STR0041#ALL#Peso
0041#STR0042#ALL#Altura
0042#STR0043#ALL#C.A.
0043#STR0044#ALL#P.C.
0044#STR0045#ALL#P.T.
0045#STR0046#ALL#Hemogli
0046#STR0047#ALL#cotest
0047#STR0048#ALL#PROCEDIMENTOS ESPECIAIS
0048#STR0049#ALL#Procedimentos
0049#STR0050#ALL#Equipo PVC
0050#STR0051#ALL#Acess. Resp.
0051#STR0052#ALL#Acess. Nebul.
0052#STR0053#ALL#Cat. Nasal
0053#STR0054#ALL#Sng    Sne
0054#STR0055#ALL#Sonda Vesical
0055#STR0056#ALL#Traqueostomia
0056#STR0057#ALL#Intra Cath D
0057#STR0058#ALL#Intra Cath E
0058#STR0059#ALL#Flebotomia
0059#STR0060#ALL#Drenotor�cico
0060#STR0061#ALL#Entub. Traqueal
0061#STR0062#ALL#AUTORIZA��O
0062#STR0063#ALL#Eu, 
0063#STR0064#ALL#Autorizo o 
0064#STR0065#ALL#, a enviar
0065#STR0066#ALL#c�pias de documentos do meu prontu�rio, a auditoria do conv�nio,do qual fa�o
0066#STR0067#ALL#parte  relativas  ao  per�odo  em  que estive internado nesse hospital, para
0067#STR0068#ALL#efeito de an�lise m�dico-financeira.
0068#STR0069#ALL#Nome:_____________________________________
0069#STR0070#ALL#R.G.:______________________
0070#STR0071#ALL#Laudo M�dico para SUS
0071#STR0072#ALL#Prontu�rio:
0072#STR0073#ALL#Hospital:
0073#STR0074#ALL#LAUDO M�DICO PARA EMISS�O DE AIH
0074#STR0075#ALL#1-C�digo de Autoriza��o:
0075#STR0076#ALL#2-Unidade de Origem:
0076#STR0077#ALL#3-CNPJ N�.:
0077#STR0078#ALL#4-Unidede de Destino:
0078#STR0079#ALL#5-CNPJ N�.:
0079#STR0080#ALL#6-Nome do Paciente:
0080#STR0081#ALL#7-Idade:
0081#STR0082#ALL#8-Data Nascimento:
0082#STR0083#ALL#9-Sexo:
0083#STR0084#ALL#10-Endere�o:
0084#STR0085#ALL#11-Bairro:
0085#STR0086#ALL#12-CEP:
0086#STR0087#ALL#13-Munic�pio:
0087#STR0088#ALL#14-UF:
0088#STR0089#ALL#15-Tipo Doc.:
0089#STR0090#ALL#16-N�mero do Documento:
0090#STR0091#ALL#17-Nome do Respons�vel.:
0091#STR0092#ALL#18-CPF M�dico Solicitante:
0092#STR0093#ALL#19-CPF Diretor Cl�nico:
0093#STR0094#ALL#20-N�mero do Leito:
0094#STR0095#ALL#21-Enfermaria N�.:
0095#STR0096#ALL#22-Car�ter da interna��o:
0096#STR0097#ALL#23-Data da Interna��o:
0097#STR0098#ALL#Preencher em caso de
0098#STR0099#ALL#Acidente de Tr�nsito
0099#STR0100#ALL#Acidente de Trabalho
0100#STR0101#ALL#24-Causa Externa:
0101#STR0102#ALL#25-CNPJ da Seguradora:
0102#STR0103#ALL#26-N�. do Bilhete:
0103#STR0104#ALL#27-S�rie:
0104#STR0105#ALL#28-Comunicado Acidentede Trabalho:
0105#STR0106#ALL#29-CNPJ do Empregador:
0106#STR0107#ALL#SUS - SISTEMA �NICO DE SA�DE
0107#STR0108#ALL#Minist�rio da Sa�de
0108#STR0109#ALL#GOVERNO DO ESTADO 
0109#STR0110#ALL#Secretaria Especial de Prote��o Social
0110#STR0111#ALL#Secretaria Executiva de Sa�de
0111#STR0112#ALL#LAUDO T�CNICO E JUSTIFICATIVA DA INTERNA��O
0112#STR0113#ALL#30-Principais Sinais e Sintomas Cl�nicos
0113#STR0114#ALL#31-Condi��es que justificam a Interna��o
0114#STR0115#ALL#32-Principais Resultados de Provas Diagn�sticas
0115#STR0116#ALL#33-Diagn�stico Inicial:
0116#STR0117#ALL#34-CID 10:
0117#STR0118#ALL#35-Cl�nica:
0118#STR0119#ALL#1-Cir�rgica  (  )
0119#STR0120#ALL#2-Obst�trica  (  )
0120#STR0121#ALL#3-M�dica  (  )
0121#STR0122#ALL#4-F.P.T.  (  )
0122#STR0123#ALL#5-Psiqui�trica  (  )
0123#STR0124#ALL#6-Tsiopneumol�gica  (  )
0124#STR0125#ALL#7-Pedi�trica  (  )
0125#STR0126#ALL#8-Reabilita��o   (  )
0126#STR0127#ALL#9-Outros   (  )
0127#STR0128#ALL#36-Procedimento Solicitado:
0128#STR0129#ALL#37-C�digo do Procedimento:
0129#STR0130#ALL#38-M�dico Solicitante:
0130#STR0131#ALL#39-Diretor Cl�nico:
0131#STR0132#ALL#40-CPF do M�dico Supervisor:
0132#STR0133#ALL#41-M�dico Supervisor:
0133#STR0134#ALL#42-Data da Autoriza��o:
0134#STR0135#ALL#Assintura/Carimbo:
0135#STR0136#ALL#INTERNA��O
0136#STR0137#ALL#ALTA
0137#STR0138#ALL#NOVO PROCED.
0138#STR0139#ALL#DIAS UTI AUT.
0139#STR0140#ALL#AC
0140#STR0141#ALL#PARTO
0141#STR0142#ALL#MO
0142#STR0143#ALL#Material/Medicamento
0143#STR0144#ALL#CID
0144#STR0145#ALL#CID II
0145#STR0146#ALL#ALA
0146#STR0147#ALL#TIPO
0147#STR0148#ALL#Dias/Procedimento
0148#STR0149#ALL#CRM
0149#STR0150#ALL#SOMA TIPOS
0150#STR0151#ALL#�RTESE E PR�TESE
0151#STR0152#ALL#EXAMES
0152#STR0153#ALL#SADT
0153#STR0154#ALL#PROCEDIMENTO
0154#STR0155#ALL#QTDE
0155#STR0156#ALL#Nota Fiscal
0156#STR0157#ALL#COD.
0157#STR0158#ALL#SOMA SADT
0158#STR0159#ALL#SOMA QUANTIDADE
0159#STR0160#ALL#SOMA C�DIGO
0160#STR0161#ALL#SOMA QTD
0161#STR0162#ALL#SOMA SADT
0162#STR0163#ALL#Data Inst.
0163#STR0164#ALL#N�. Dias
0164#STR0165#ALL#Data Troca
0165#STR0166#ALL#Assinatura
0166#STR0167#ALL#LAUDO M�DICO PARA EMISS�O DE AIH
0167#STR0168#ALL#01-N�mero do Laudo:
0168#STR0169#ALL#02-N�mero da Autoriza��o - PPI
0169#STR0170#ALL#03-N�mero do Pedido de Vaga
0170#STR0171#ALL#04-Unidade de Origem:
0171#STR0172#ALL#05-C�digo
0172#STR0173#ALL#06-CNPJ N�.:
0173#STR0174#ALL#07-Unidade de Destino:
0174#STR0175#ALL#08-C�digo
0175#STR0176#ALL#09-CNPJ N�.:
0176#STR0177#ALL#10-Nome do Paciente:
0177#STR0178#ALL#No. do Atendimento
0178#STR0179#ALL#Idade:
0179#STR0180#ALL#11-Data do Nascimento:
0180#STR0181#ALL#12-Sexo:
0181#STR0182#ALL#13-Endere�o:
0182#STR0183#ALL#14-Cep:
0183#STR0184#ALL#15-Munic�pio:
0184#STR0185#ALL#Bairro:
0185#STR0186#ALL#16-UF:
0186#STR0187#ALL#Tipo Doc.:
0187#STR0188#ALL#17-N�mero do Documento:
0188#STR0189#ALL#18-Nome do Respons�vel.:
0189#STR0190#ALL#19-CPF M�dico Solicitante:
0190#STR0191#ALL#20-N�mero do Leito:
0191#STR0192#ALL#21-Enfermaria N�.:
0192#STR0193#ALL#22-Car�ter da interna��o:
0193#STR0194#ALL#23-Data da Interna��o:
0194#STR0195#ALL#24-CPF Diretor Cl�nico:
0195#STR0196#ALL#25-Funcion�rio de Contato do Hospital
0196#STR0197#ALL#26-Car�ter da Solicita��o
0197#STR0198#ALL#(  ) Auto Risco    (   ) Isolamento   (   ) U.T.I.   (   ) AIDS   (   ) Outros ___________________
0198#STR0199#ALL#Preencher em caso de
0199#STR0200#ALL#Acidente de Tr�nsito
0200#STR0201#ALL#27-Causa Externa:
0201#STR0202#ALL#28-CNPJ da Seguradora:
0202#STR0203#ALL#29-N�. do Bilhete:
0203#STR0204#ALL#30-S�rie:
0204#STR0205#ALL#SUS - SISTEMA �NICO DE SA�DE
0205#STR0206#ALL#Minist�rio da Sa�de
0206#STR0207#ALL#GOVERNO DO ESTADO 
0207#STR0208#ALL#Secretaria Especial de Prote��o Social
0208#STR0209#ALL#Secretaria Executiva de Sa�de
0209#STR0210#ALL#LAUDO T�CNICO E JUSTIFICATIVA DA INTERNA��O
0210#STR0211#ALL#31-Principais Sinais e Sintomas Cl�nicos
0211#STR0212#ALL#32-Condi��es que justificam a Interna��o
0212#STR0213#ALL#33-Principais Resultados de Provas Diagn�sticas
0213#STR0214#ALL#34-Diagn�stico Inicial:
0214#STR0215#ALL#35-CID do Diagn�stico Inicial
0215#STR0216#ALL#36-Cl�nica:
0216#STR0217#ALL#1-Cir�rgica  (  )
0217#STR0218#ALL#2-Obst�trica  (  )
0218#STR0219#ALL#3-M�dica  (  )
0219#STR0220#ALL#4-F.P.T.  (  )
0220#STR0221#ALL#5-Psiqui�trica  (  )
0221#STR0222#ALL#6-Tsiopneumol�gica  (  )
0222#STR0223#ALL#7-Pedi�trica  (  )
0223#STR0224#ALL#8-Reabilita��o   (  )
0224#STR0225#ALL#9-Outros   (  )
0225#STR0226#ALL#37-C�d. do Procedimento:
0226#STR0227#ALL#Descri��o:
0227#STR0228#ALL#38-Situa��o do Laudo
0228#STR0229#ALL#(   ) Cancelado      (   ) Autorizado     (   ) Mudan�a de Procedimento
0229#STR0230#ALL#39-Problema    (   ) Sim     (   ) N�o                40-Tipo
0230#STR0231#ALL#41-Data da Emiss�o:
0231#STR0232#ALL#42-M�dico Solicitante:
0232#STR0233#ALL#43-Diretor Cl�nico:
0233#STR0234#ALL#44-M�dico Supervisor:
0234#STR0235#ALL#Assinatura/Carimbo:
0235#STR0236#ALL#LAUDO M�DICO PARA EMISS�O DE AIH
0236#STR0237#ALL#01-N�mero do Laudo:
0237#STR0238#ALL#02-N�mero da Autoriza��o - PPI
0238#STR0239#ALL#03-N�mero do Pedido de Vaga
0239#STR0240#ALL#04-Unidade de Origem:
0240#STR0241#ALL#05-C�digo
0241#STR0242#ALL#06-CNPJ N�.:
0242#STR0243#ALL#07-Unidade de Destino:
0243#STR0244#ALL#08-C�digo
0244#STR0245#ALL#09-CNPJ N�.:
0245#STR0246#ALL#10-Nome do Paciente:
0246#STR0247#ALL#No. do Atendimento
0247#STR0248#ALL#Idade:
0248#STR0249#ALL#11-Data do Nascimento:
0249#STR0250#ALL#12-Sexo:
0250#STR0251#ALL#13-Endere�o:
0251#STR0252#ALL#14-Cep:
0252#STR0253#ALL#15-Munic�pio:
0253#STR0254#ALL#Bairro:
0254#STR0255#ALL#16-UF:
0255#STR0256#ALL#Tipo Doc.:
0256#STR0257#ALL#17-N�mero do Documento:
0257#STR0258#ALL#18-Nome do Respons�vel.:
0258#STR0259#ALL#19-CPF M�dico Solicitante:
0259#STR0260#ALL#20-N�mero do Leito:
0260#STR0261#ALL#21-Enfermaria N�.:
0261#STR0262#ALL#22-Car�ter da interna��o:
0262#STR0263#ALL#23-Data da Interna��o:
0263#STR0264#ALL#24-CPF Diretor Cl�nico:
0264#STR0265#ALL#25-Funcion�rio de Contato do Hospital
0265#STR0266#ALL#26-Car�ter da Solicita��o
0266#STR0267#ALL#(  ) Auto Risco    (   ) Isolamento   (   ) U.T.I.   (   ) AIDS   (   ) Outros ___________________
0267#STR0268#ALL#Preencher em caso de
0268#STR0269#ALL#Acidente de Tr�nsito
0269#STR0270#ALL#27-Causa Externa:
0270#STR0271#ALL#28-CNPJ da Seguradora:
0271#STR0272#ALL#29-N�. do Bilhete:
0272#STR0273#ALL#30-S�rie:
0273#STR0274#ALL#SUS - SISTEMA �NICO DE SA�DE
0274#STR0275#ALL#Minist�rio da Sa�de
0275#STR0276#ALL#GOVERNO DO ESTADO 
0276#STR0277#ALL#Secretaria Especial de Prote��o Social
0277#STR0278#ALL#Secretaria Executiva de Sa�de
0278#STR0279#ALL#Atendimento Medico Ambulatorial
0279#STR0280#ALL#Unidade:
0280#STR0281#ALL#Endere�o:
0281#STR0282#ALL#Paciente:
0282#STR0283#ALL#Idade:
0283#STR0284#ALL#Data Nascimento:
0284#STR0285#ALL#Sexo:
0285#STR0286#ALL#Endere�o:
0286#STR0287#ALL#Bairro:
0287#STR0288#ALL#Municipio:
0288#STR0289#ALL#Documento:
0289#STR0290#ALL#Endere�o:
0290#STR0291#ALL#M�dico:
0291#STR0292#ALL#CONTA:   
0292#STR0293#ALL#                Data Atendimento: 
0293#STR0294#ALL#PROCEDIMENTO:
0294#STR0295#ALL#MOTIVO DO ATENDIMENTO:
0295#STR0296#ALL#DESCRI��O SUMARIA DO EXAME CL�NICO:
0296#STR0297#ALL#Diagn�stico:
0297#STR0298#ALL#CID:
0298#STR0299#ALL#Natureza do Atendimento:
0299#STR0300#ALL#___Clin    ___Ciru   ____Obst  ____Pedi   ___Psiq   ____Tisi   ____Odon
0300#STR0301#ALL#___Outro   ___Acidente em geral           ___Acidente de Trabalho
0301#STR0302#ALL#Medica��o:
0302#STR0303#ALL#___Prescrita      ___Aplicada
0303#STR0304#ALL#Encaminhamento:
0304#STR0305#ALL#___P/ Resid   ___P/ Amb.Publico    ___Intern    ___Obito    ___Outros
0305#STR0306#ALL# POLEGAR
0306#STR0307#ALL#   Carimbo e ass. do profissional                 Ass do paciente/responsavel    
0307#STR0308#ALL#CONTA DO ATENDIMENTO M�DICO AMBULATORIAL DE URG�NCIA
0308#STR0309#ALL#SERVI�OS PROFISSIONAIS:        1-Consulta       2-Imobiliza��o    3-Curativo
0309#STR0310#ALL#                               4-Peq.Cirurgia   5-Outros          6-At.Odontologico
0310#STR0311#ALL#Descri��o do Procedimento                                                         
0311#STR0312#ALL#RECURSOS COMPLEMENTARES:       1-Exame Lab      2-Raios X         3-Oxigenoterapia
0312#STR0313#ALL#                               4-Hemoterapia    5-Rehidrata��o    6-Outros         
0313#STR0314#ALL#Descri��o do Procedimento                 C�digo   |  Descri��o do Procedimento                   C�digo 
0314#STR0315#ALL#MATERIAIS E MEDICAMENTOS:      1-Materiais      2-Medicamentos    3-Remo��o        
0315#STR0316#ALL#                               4-Outros                                            
0316#STR0317#ALL#Descri��o do Procedimento                   Qtd    |  Descri��o do Procedimento                     Qtd  
0317#STR0318#ALL#     Diretor responsavel p/ informa��o                                 Assinatura do responsavel         
0318#STR0319#ALL#   Preencha legivelmente todos os campos sob pena de nao ser considerado o atendimento. Assinale com X as
0319#STR0320#ALL#   quadriculas precedidas de n�meros marcando a alternativa. S�o responsaveis pela informa��o o m�dico ou
0320#STR0321#ALL#   odontologo assistente e os diretores da entidade conveniente ou contratada.  A declara��o  falsa  e/ou
0321#STR0322#ALL#   fraude sujeita os infratores as san��es dos artigos 171 e/ou 298 do C�digo Penal
0322#STR0323#ALL#FORMUL�RIO DE PRESCRI��O M�DICA
0323#STR0324#ALL#Paciente.: 
0324#STR0325#ALL#          Registro.: 
0325#STR0326#ALL#Convenio.: 
0326#STR0327#ALL#           Data..: 
0327#STR0328#ALL#           Hora.....: 
0328#STR0329#ALL#          Leito..: 
0329#STR0330#ALL#M�dico...: 
0330#STR0331#ALL#ITEM
0331#STR0332#ALL#PRESCRI��O
0332#STR0333#ALL#HOR�RIO
0333#STR0334#ALL#UTI
0334#STR0335#ALL#DEV
0335#STR0336#ALL#SOLICITA��O DE PROCEDIMENTOS
0336#STR0337#ALL#QUE NECESSITAM AUTORIZA��O PR�VIA
0337#STR0338#ALL#Paciente.: 
0338#STR0339#ALL#Registro.: 
0339#STR0340#ALL#        Convenio.: 
0340#STR0341#ALL#Data.....: 
0341#STR0342#ALL#      Hora.....: 
0342#STR0343#ALL#          Leito..: 
0343#STR0344#ALL#M�dico...: 
0344#STR0345#ALL#1-MAT�RIA (L)(IS) DE ALTO CUSTO - Especificar:
0345#STR0346#ALL#2-MUDAN�A DE PROCEDIMENTO:
0346#STR0347#ALL#3-CONSULTA ESPECIALISTA - Especificar:
0347#STR0348#ALL#4-CONSULTA ESPECIALISTA - Especificar:
0348#STR0349#ALL#Justificativa:
0349#STR0350#ALL#Data:               M�dico Solicitante:                     Auditor:
0350#STR0351#ALL#Para os Convenios abaixo, utilizar formul�rios proprios
0351#STR0352#ALL#Amil (Exames Especiais)
0352#STR0353#ALL#HapVida (Todos os exames e procedimentos)
0353#STR0354#ALL#Sa�de Bradesco (Mudan�a de Procedimento)
0354#STR0355#ALL#Petrobras (Procedimentos)
 

HSPAHR87_PT-PT.TRES

 0001#STR0001#ALL#Fichas De Atendimento
0002#STR0002#ALL#Telefone: 
0003#STR0003#ALL# - fax: 
0004#STR0004#ALL#C�digo postal: 
0007#STR0007#ALL# - telefone: 
0008#STR0008#ALL#- c�digo postal: 
0010#STR0010#ALL#Data
0011#STR0011#ALL#Hora
0012#STR0012#ALL# � nr. contrib.: 
0013#STR0013#ALL#Certificado fins filantr�picos - processo 44006.002144    97-02 - u pub.-fed.dec. 64.412-280469
0015#STR0015#ALL#            cama: 
0016#STR0016#ALL#Folha De Controlo E Balan�o H�drico
0017#STR0017#ALL#Data da admiss�o: ____/____/____                                 registo: 
0018#STR0018#ALL#Sangue-plasma Expansores
0019#STR0019#ALL#�gua
0020#STR0020#ALL#Sinais Vitais
0024#STR0024#ALL#Nistrado
0025#STR0025#ALL#Nado
0034#STR0035#ALL#Ratura
0037#STR0038#ALL#Ra��o
0039#STR0040#ALL#V.c.
0042#STR0043#ALL#C.a.
0043#STR0044#ALL#P.c.
0044#STR0045#ALL#P.t.
0046#STR0047#ALL#Cotest
0047#STR0048#ALL#Procedimentos Especiais
0049#STR0050#ALL#Equipa Pvc
0059#STR0060#ALL#Drenotor�xico
0061#STR0062#ALL#Autoriza��o
0065#STR0066#ALL#C�pias de documentos do meu prontu�rio, � auditoria do acordo,do qual fa�o
0066#STR0067#ALL#Parte,  relativas  ao  per�odo  em  que estive internado nesse hospital, para
0067#STR0068#ALL#Efeito de an�lise m�dico-financeira.
0069#STR0070#ALL#R.g.:______________________
0070#STR0071#ALL#Relat�rio m�dico para sus
0073#STR0074#ALL#Relat�rio M�dico Para Emiss�o De Aih
0074#STR0075#ALL#1-c�digo de autoriza��o:
0075#STR0076#ALL#2-unidade De Origem:
0076#STR0077#ALL#3-nr. Contrib.:
0077#STR0078#ALL#4-unidede De Destino:
0078#STR0079#ALL#5-nr. Contrib.:
0079#STR0080#ALL#6-nome Do Paciente:
0080#STR0081#ALL#7-idade:
0081#STR0082#ALL#8-data De Nascimento:
0082#STR0083#ALL#9-sexo:
0083#STR0084#ALL#10-morada:
0084#STR0085#ALL#11-localidade:
0085#STR0086#ALL#12-c�digo postal:
0086#STR0087#ALL#13-concelho:
0087#STR0088#ALL#14-distrito:
0088#STR0089#ALL#15-tipo Doc.:
0089#STR0090#ALL#16-n�mero do documento:
0090#STR0091#ALL#17-nome do respons�vel.:
0091#STR0092#ALL#18-nr. contrib. m�dico solicitante:
0092#STR0093#ALL#19-nr. contrib director cl�nico:
0093#STR0094#ALL#20-n�mero da cama:
0094#STR0095#ALL#21-enfermaria Nr.:
0095#STR0096#ALL#22-car�cter do internamento:
0096#STR0097#ALL#23-data do internamento:
0098#STR0099#ALL#Acidente De Tr�nsito
0099#STR0100#ALL#Acidente De Trabalho
0100#STR0101#ALL#24-causa Externa:
0101#STR0102#ALL#25-nr. Contrib. Da Seguradora:
0102#STR0103#ALL#26-nr. Do Bilhete:
0103#STR0104#ALL#27-s�rie:
0104#STR0105#ALL#28-comunicado Acidente De Trabalho:
0105#STR0106#ALL#29-nr. Contrib. Do Empregador:
0106#STR0107#ALL#Sus - sistema �nico de sa�de
0107#STR0108#ALL#Minist�rio Da Sa�de
0108#STR0109#ALL#Governo do distrito 
0109#STR0110#ALL#Secretaria especial de protec��o social
0110#STR0111#ALL#Secretaria executiva de sa�de
0111#STR0112#ALL#Relat�rio T�cnico E Justificativa Do Internamento
0112#STR0113#ALL#30-principais sinais e sintomas cl�nicos
0113#STR0114#ALL#31-condi��es que justificam o internamento
0114#STR0115#ALL#32-principais resultados de provas diagn�sticas
0115#STR0116#ALL#33-diagn�stico inicial:
0116#STR0117#ALL#34-cid 10:
0117#STR0118#ALL#35-cl�nica:
0118#STR0119#ALL#1-cir�rgica  (  )
0119#STR0120#ALL#2-obst�trica  (  )
0120#STR0121#ALL#3-m�dica  (  )
0121#STR0122#ALL#4-f.p.t.  (  )
0122#STR0123#ALL#5-psiqui�trica  (  )
0123#STR0124#ALL#6-tsiopneumol�gica  (  )
0124#STR0125#ALL#7-pedi�trica  (  )
0125#STR0126#ALL#8-reabilita��o   (  )
0126#STR0127#ALL#9-outros   (  )
0127#STR0128#ALL#36-procedimento Solicitado:
0128#STR0129#ALL#37-c�digo do procedimento:
0129#STR0130#ALL#38-m�dico solicitante:
0130#STR0131#ALL#39-director cl�nico:
0131#STR0132#ALL#40-nr. contrib. do m�dico supervisor:
0132#STR0133#ALL#41-m�dico supervisor:
0133#STR0134#ALL#42-data da autoriza��o:
0134#STR0135#ALL#Assintura/carimbo:
0135#STR0136#ALL#Internamento
0136#STR0137#ALL#Alta
0137#STR0138#ALL#Novo Proced.
0138#STR0139#ALL#Dias Uci Aut.
0139#STR0140#ALL#Ac
0140#STR0141#ALL#Parto
0141#STR0142#ALL#Mo
0142#STR0143#ALL#Material/medicamento
0143#STR0144#ALL#Cid
0144#STR0145#ALL#Cid Ii
0145#STR0146#ALL#Ala
0146#STR0147#ALL#Tipo
0147#STR0148#ALL#Dias/procedimento
0148#STR0149#ALL#Crm
0149#STR0150#ALL#Soma Tipos
0150#STR0151#ALL#Ortese e pr�tese
0151#STR0152#ALL#Exames
0152#STR0153#ALL#Sadt
0153#STR0154#ALL#Procedimento
0154#STR0155#ALL#Qtde
0155#STR0156#ALL#Factura
0156#STR0157#ALL#C�d.
0157#STR0158#ALL#Soma Sadt
0158#STR0159#ALL#Soma Quantidade
0159#STR0160#ALL#Soma c�digo
0160#STR0161#ALL#Soma Qtd
0161#STR0162#ALL#Soma Sadt
0163#STR0164#ALL#Nr. Dias
0166#STR0167#ALL#Relat�rio M�dico Para Emiss�o De Aih
0167#STR0168#ALL#01-n�mero do relat�rio:
0168#STR0169#ALL#02-n�mero da autoriza��o - ppi
0169#STR0170#ALL#03-n�mero do pedido de vaga
0170#STR0171#ALL#04-unidade De Origem:
0171#STR0172#ALL#05-c�digo
0172#STR0173#ALL#06-nr. Contrib.:
0173#STR0174#ALL#07-unidade De Destino:
0174#STR0175#ALL#08-c�digo
0175#STR0176#ALL#09-nr. Contrib.:
0176#STR0177#ALL#10-nome Do Paciente:
0177#STR0178#ALL#Nr. De Atendimento
0179#STR0180#ALL#11-data De Nascimento:
0180#STR0181#ALL#12-sexo:
0181#STR0182#ALL#13-morada:
0182#STR0183#ALL#14-c�digo postal:
0183#STR0184#ALL#15-concelho:
0184#STR0185#ALL#Localidade:
0185#STR0186#ALL#16-distrito:
0187#STR0188#ALL#17-n�mero do documento:
0188#STR0189#ALL#18-nome do respons�vel.:
0189#STR0190#ALL#19-nr. contrib. m�dico solicitante:
0190#STR0191#ALL#20-n�mero da cama:
0191#STR0192#ALL#21-enfermaria Nr.:
0192#STR0193#ALL#22-car�cter do internamento:
0193#STR0194#ALL#23-data do internamento:
0194#STR0195#ALL#24-nr. contrib. director cl�nico:
0195#STR0196#ALL#25-empregado de contacto do hospital
0196#STR0197#ALL#26-car�cter da solicita��o
0197#STR0198#ALL#(  ) auto risco    (   ) isolamento   (   ) u.c.i.   (   ) aids   (   ) outros ___________________
0199#STR0200#ALL#Acidente De Tr�nsito
0200#STR0201#ALL#27-causa Externa:
0201#STR0202#ALL#28-nr. Contrib. Da Seguradora:
0202#STR0203#ALL#29-nr. Do Bilhete:
0203#STR0204#ALL#30-s�rie:
0204#STR0205#ALL#Sus - sistema �nico de sa�de
0205#STR0206#ALL#Minist�rio Da Sa�de
0206#STR0207#ALL#Governo do distrito 
0207#STR0208#ALL#Secretaria especial de protec��o social
0208#STR0209#ALL#Secretaria executiva de sa�de
0209#STR0210#ALL#Relat�rio T�cnico E Justificativa Do Internamento
0210#STR0211#ALL#31-principais sinais e sintomas cl�nicos
0211#STR0212#ALL#32-condi��es que justificam o internamento
0212#STR0213#ALL#33-principais resultados de provas diagn�sticas
0213#STR0214#ALL#34-diagn�stico inicial:
0214#STR0215#ALL#35-cid do diagn�stico inicial
0215#STR0216#ALL#36-cl�nica:
0216#STR0217#ALL#1-cir�rgica  (  )
0217#STR0218#ALL#2-obst�trica  (  )
0218#STR0219#ALL#3-m�dica  (  )
0219#STR0220#ALL#4-f.p.t.  (  )
0220#STR0221#ALL#5-psiqui�trica  (  )
0221#STR0222#ALL#6-tsiopneumol�gica  (  )
0222#STR0223#ALL#7-pedi�trica  (  )
0223#STR0224#ALL#8-reabilita��o   (  )
0224#STR0225#ALL#9-outros   (  )
0225#STR0226#ALL#37-c�d. do procedimento:
0227#STR0228#ALL#38-situa��o do relat�rio
0228#STR0229#ALL#(   ) cancelado      (   ) autorizado     (   ) mudan�a de procedimento
0229#STR0230#ALL#39-problema    (   ) sim     (   ) n�o                40-tipo
0230#STR0231#ALL#41-data da emiss�o:
0231#STR0232#ALL#42-m�dico solicitante:
0232#STR0233#ALL#43-director cl�nico:
0233#STR0234#ALL#44-m�dico supervisor:
0234#STR0235#ALL#Assinatura/carimbo:
0235#STR0236#ALL#Relat�rio M�dico Para Emiss�o De Aih
0236#STR0237#ALL#01-n�mero do relat�rio:
0237#STR0238#ALL#02-n�mero da autoriza��o - ppi
0238#STR0239#ALL#03-n�mero do pedido de vaga
0239#STR0240#ALL#04-unidade De Origem:
0240#STR0241#ALL#05-c�digo
0241#STR0242#ALL#06-nr. Contrib.:
0242#STR0243#ALL#07-unidade De Destino:
0243#STR0244#ALL#08-c�digo
0244#STR0245#ALL#09-nr. Contrib.:
0245#STR0246#ALL#10-nome Do Paciente:
0246#STR0247#ALL#Nr. De Atendimento
0248#STR0249#ALL#11-data De Nascimento:
0249#STR0250#ALL#12-sexo:
0250#STR0251#ALL#13-morada:
0251#STR0252#ALL#14-c�digo postal:
0252#STR0253#ALL#15-concelho:
0253#STR0254#ALL#Localidade:
0254#STR0255#ALL#16-distrito:
0256#STR0257#ALL#17-n�mero do documento:
0257#STR0258#ALL#18-nome do respons�vel.:
0258#STR0259#ALL#19-nr. contrib. m�dico solicitante:
0259#STR0260#ALL#20-n�mero da cama:
0260#STR0261#ALL#21-enfermaria Nr.:
0261#STR0262#ALL#22-car�cter do internamento:
0262#STR0263#ALL#23-data do internamento:
0263#STR0264#ALL#24-nr. contrib. director cl�nico:
0264#STR0265#ALL#25-empregado de contacto do hospital
0265#STR0266#ALL#26-car�cter da solicita��o
0266#STR0267#ALL#(  ) auto risco    (   ) isolamento   (   ) u.c.i.   (   ) aids   (   ) outros ___________________
0268#STR0269#ALL#Acidente De Tr�nsito
0269#STR0270#ALL#27-causa Externa:
0270#STR0271#ALL#28-nr. Contrib. Da Seguradora:
0271#STR0272#ALL#29-nr. Do Bilhete:
0272#STR0273#ALL#30-s�rie:
0273#STR0274#ALL#Sus - sistema �nico de sa�de
0274#STR0275#ALL#Minist�rio Da Sa�de
0275#STR0276#ALL#Governo do distrito 
0276#STR0277#ALL#Secretaria especial de protec��o social
0277#STR0278#ALL#Secretaria executiva de sa�de
0278#STR0279#ALL#Atendimento M�dico Ambulatorial
0280#STR0281#ALL#Morada:
0283#STR0284#ALL#Data De Nascimento:
0285#STR0286#ALL#Morada:
0286#STR0287#ALL#Localidade:
0287#STR0288#ALL#Concelho:
0289#STR0290#ALL#Morada:
0290#STR0291#ALL#M�dico:
0291#STR0292#ALL#Conta:   
0292#STR0293#ALL#                data do atendimento: 
0293#STR0294#ALL#Procedimento:
0294#STR0295#ALL#Motivo Do Atendimento:
0295#STR0296#ALL#Descri��o Sum�ria Do Exame Cl�nico:
0297#STR0298#ALL#Cid:
0298#STR0299#ALL#Natureza Do Atendimento:
0299#STR0300#ALL#___cl�n    ___ciru   ____obst  ____pedi   ___psiq   ____tisi   ____odon
0300#STR0301#ALL#___outro   ___acidente Em Geral           ___acidente De Trabalho
0302#STR0303#ALL#___prescrita      ___aplicada
0304#STR0305#ALL#___p/ resid   ___p/ amb.p�blico    ___intern    ___�bito    ___outros
0305#STR0306#ALL# Polegar
0306#STR0307#ALL#   carimbo e ass. do profissional                 ass do paciente/respons�vel    
0307#STR0308#ALL#Conta Do Atendimento M�dico Ambulatorial De Urg�ncia
0308#STR0309#ALL#Servi�os profissionais:        1-consulta       2-imobiliza��o    3-curativo
0309#STR0310#ALL#                               4-peq.cirurgia   5-outros          6-at.odontol�gico
0310#STR0311#ALL#Descri��o do procedimento                                                         
0311#STR0312#ALL#Recursos complementares:       1-exame lab      2-raios-x         3-oxigenoterapia
0312#STR0313#ALL#                               4-hemoterapia    5-rehidrata��o    6-outros         
0313#STR0314#ALL#Descri��o do procedimento                 c�digo   |  descri��o do procedimento                   c�digo 
0314#STR0315#ALL#Materiais e medicamentos:      1-materiais      2-medicamentos    3-remo��o        
0315#STR0316#ALL#                               4-outros                                            
0316#STR0317#ALL#Descri��o do procedimento                   qtd    |  descri��o do procedimento                     qtd  
0317#STR0318#ALL#     director respons�vel p/ informa��o                                 assinatura do respons�vel         
0318#STR0319#ALL#   preencha de forma leg�vel todos os campos sob pena de n�o ser considerado o atendimento. assinale com x as
0319#STR0320#ALL#   quadriculas precedidas de n�meros marcando a alternativa. s�o respons�veis pela informa��o o m�dico ou
0320#STR0321#ALL#   odontolista assistente e os directores da entidade conveniente ou contratada.  a declara��o  falsa  e/ou
0321#STR0322#ALL#   fraude sujeita os infractores �s san��es previstas nos artigos 171 e/ou 298 do c�digo penal
0322#STR0323#ALL#Formul�rio de prescri��o m�dica
0324#STR0325#ALL#          registo.: 
0325#STR0326#ALL#Acordo.: 
0326#STR0327#ALL#           data..: 
0327#STR0328#ALL#           hora.....: 
0328#STR0329#ALL#          cama..: 
0330#STR0331#ALL#Elemento
0331#STR0332#ALL#Prescri��o
0332#STR0333#ALL#Hor�rio
0333#STR0334#ALL#Uti
0334#STR0335#ALL#Dev
0335#STR0336#ALL#Solicita��o De Procedimentos
0336#STR0337#ALL#Que Necessitam Autoriza��o Pr�via
0338#STR0339#ALL#Registo.: 
0339#STR0340#ALL#        acordo.: 
0341#STR0342#ALL#      hora.....: 
0342#STR0343#ALL#          cama..: 
0344#STR0345#ALL#1-material(�is) de alto custo - especificar:
0345#STR0346#ALL#2-mudan�a de procedimento:
0346#STR0347#ALL#3-consulta Especialista - Especificar:
0347#STR0348#ALL#4-consulta Especialista - Especificar:
0349#STR0350#ALL#Data:               m�dico solicitante:                     auditor:
0350#STR0351#ALL#Para os acordos abaixo, utilizar formul�rios pr�prios
0351#STR0352#ALL#Amil (exames Especiais)
0352#STR0353#ALL#Hapvida (todos os exames e procedimentos)
0353#STR0354#ALL#Sa�de Bradesco (mudan�a De Procedimento)
0354#STR0355#ALL#Petrobras (procedimentos)
 

HSPAHR87_RU.TRES

 0001#STR0001#ALL#Attendance Forms
0002#STR0002#ALL#���.: 
0003#STR0003#ALL# - Fax: 
0004#STR0004#ALL#ZipCd:
0005#STR0005#ALL#���.
0006#STR0006#ALL#���.  
0007#STR0007#ALL# -Phone: 
0008#STR0008#ALL#-ZipC: 
0009#STR0009#ALL#���: 
0010#STR0010#ALL#����
0011#STR0011#ALL#TIME
0012#STR0012#ALL# - CNPJ: 
0013#STR0013#ALL#Philantropy Purposes Certificate - Process 44006.002144    97-02 - UPUB.-FED.DEC. 64.412-280469
0014#STR0014#ALL# ��  
0015#STR0015#ALL#              Bed: 
0016#STR0016#ALL#CONTROL SHEET AND HYDRAULIC BALANCE
0017#STR0017#ALL#Admission Date: ______/____/____                                 Registro: 
0018#STR0018#ALL#BLOOD-PLASMA EXPANSORS  
0019#STR0019#ALL#WATER
0020#STR0020#ALL#VITAL SIGNS
0021#STR0021#ALL#Admi-
0022#STR0022#ALL#Dele-
0023#STR0023#ALL#������ 
0024#STR0024#ALL#nistrated
0025#STR0025#ALL#ted
0026#STR0026#ALL#Managed     
0027#STR0027#ALL#�������
0028#STR0029#ALL#Oral
0029#STR0030#ALL#Parenteral
0030#STR0031#ALL#Urinary
0031#STR0032#ALL#Digest.
0032#STR0033#ALL#������
0033#STR0034#ALL#Temper
0034#STR0035#ALL#-ature
0035#STR0036#ALL#Pulse
0036#STR0037#ALL#Respi-
0037#STR0038#ALL#ration
0038#STR0039#ALL#Pressure
0039#STR0040#ALL#V.C.
0040#STR0041#ALL#Wght
0041#STR0042#ALL#���.  
0042#STR0043#ALL#C.A.
0043#STR0044#ALL#P.C.
0044#STR0045#ALL#P.T.
0045#STR0046#ALL#Hemogli
0046#STR0047#ALL#cotest
0047#STR0048#ALL#SPECIAL PROCEDURES
0048#STR0049#ALL#��������� 
0049#STR0050#ALL#Equipm PVC
0050#STR0051#ALL#Brth. Access
0051#STR0052#ALL#Nebul. Access
0052#STR0053#ALL#Nasal Cath
0053#STR0054#ALL#Bld    Sne
0054#STR0055#ALL#Vesical Cath.
0055#STR0056#ALL#Tracheostomy
0056#STR0057#ALL#Intra Cath D
0057#STR0058#ALL#Intra Cath E
0058#STR0059#ALL#Flebotomy
0059#STR0060#ALL#Thoraxdrain
0060#STR0061#ALL#Tracheo Tube
0061#STR0062#ALL#AUTHORIZATION
0062#STR0063#ALL#I,  
0063#STR0064#ALL#Authorize  
0064#STR0065#ALL#, to send
0065#STR0066#ALL# a copy of my dossier documents, to the Health Care Auditing
0066#STR0067#ALL#, of which I am part  relating to the period I was confined in
0067#STR0068#ALL#this hospital, to carry out financial-medicine analysis.
0068#STR0069#ALL#Name:_____________________________________
0069#STR0070#ALL#I.D.:______________________
0070#STR0071#ALL#Medical Report for SUS
0071#STR0072#ALL#Dossier:   
0072#STR0073#ALL#Hospital:
0073#STR0074#ALL#MEDICAL REPORT FOR AIH ISSUEING 
0074#STR0075#ALL#1-Authorization Code:   
0075#STR0076#ALL#2-Source Unit:      
0076#STR0077#ALL#3-CNPJ No.:
0077#STR0078#ALL#4-Target Unit:       
0078#STR0079#ALL#5-CNPJ No.:
0079#STR0080#ALL#6-Patient Name:    
0080#STR0081#ALL#7-Age:  
0081#STR0082#ALL#8-Birthdate:      
0082#STR0083#ALL#9-Gend:
0083#STR0084#ALL#10-Address: 
0084#STR0085#ALL#11-Zone:  
0085#STR0086#ALL#12-ZCd:
0086#STR0087#ALL#13-District: 
0087#STR0088#ALL#14-St:
0088#STR0089#ALL#15-Doc. Type:
0089#STR0090#ALL#16-Document Number:    
0090#STR0091#ALL#17-Responsible Name:    
0091#STR0092#ALL#18-Req. Doctor CPF:       
0092#STR0093#ALL#19-Clinical Dir. CPF:  
0093#STR0094#ALL#20-Bed Number:     
0094#STR0095#ALL#21-Infirmary Numb.
0095#STR0096#ALL#22-Confinement Character:
0096#STR0097#ALL#23-Confinement Date:  
0097#STR0098#ALL#In case of a Car    
0098#STR0099#ALL#Accident, fill out  
0099#STR0100#ALL#Working Accident    
0100#STR0101#ALL#24-External Cause:
0101#STR0102#ALL#25-Insurance CNPJ:    
0102#STR0103#ALL#26-Title Number:  
0103#STR0104#ALL#27-Series:
0104#STR0105#ALL#28-Working Accident Note:         
0105#STR0106#ALL#29-Employer CNPJ:     
0106#STR0107#ALL#SUS - SINGLE HEALTH SYSTEM
0107#STR0108#ALL#Ministry of Health 
0108#STR0109#ALL#STATE GOVERNMENT  
0109#STR0110#ALL#Special Department for Social Protect.
0110#STR0111#ALL#Executive Health Department
0111#STR0112#ALL#CONFINEMENT JUSTIFICATION AND MEDICAL REPORT
0112#STR0113#ALL#30-Clinical Main Signs and Indications  
0113#STR0114#ALL#31-Conditions which justify Confinement 
0114#STR0115#ALL#32-Diagnostical Exams Main Results             
0115#STR0116#ALL#33-Initial Diagnoses:  
0116#STR0117#ALL#34-ICD 10:
0117#STR0118#ALL#35-Clinic: 
0118#STR0119#ALL#1-Surgical   (  )
0119#STR0120#ALL#2-Obstetrics  (  )
0120#STR0121#ALL#3-Medical (  )
0121#STR0122#ALL#4-F.P.T.  (  )
0122#STR0123#ALL#5-Psychiatrical (  )
0123#STR0124#ALL#6-Phtisiological    (  )
0124#STR0125#ALL#7-Pediatrics  (  )
0125#STR0126#ALL#8-Rehabilitation (  )
0126#STR0127#ALL#9-Others   (  )
0127#STR0128#ALL#36-Requested Procedure:    
0128#STR0129#ALL#37-Procedure Code:        
0129#STR0130#ALL#38-Requit. Doctor:    
0130#STR0131#ALL#39-Clinical Dir.:  
0131#STR0132#ALL#40-Supervisor Doctor CPF:   
0132#STR0133#ALL#41-Supervisor Doctor:
0133#STR0134#ALL#42-Authorization Date: 
0134#STR0135#ALL#Signature/Stamp:  
0135#STR0136#ALL#CONFINEMENT:
0136#STR0137#ALL#DSCH
0137#STR0138#ALL#NEW PROCED. 
0138#STR0139#ALL#AUT. ICU DAYS
0139#STR0140#ALL#AC
0140#STR0141#ALL#DELIVERY
0141#STR0142#ALL#MO
0142#STR0143#ALL#Material/Medicine   
0143#STR0144#ALL#ICD
0144#STR0145#ALL#ICD II
0145#STR0146#ALL#WNG
0146#STR0147#ALL#��� 
0147#STR0148#ALL#Days/Procedure   
0148#STR0149#ALL#SMB
0149#STR0150#ALL#TYPES SUM 
0150#STR0151#ALL#ORTHESE AND PROTHESE
0151#STR0152#ALL#EXAMS 
0152#STR0153#ALL#SADT
0153#STR0154#ALL#PROCEDURE   
0154#STR0155#ALL#�-��:
0155#STR0156#ALL#��.���.
0156#STR0157#ALL#��� 
0157#STR0158#ALL#SADT SUM 
0158#STR0159#ALL#QUANTITY SUM   
0159#STR0160#ALL#CODE SUM   
0160#STR0161#ALL#QTY SUM 
0161#STR0162#ALL#SADT SUM 
0162#STR0163#ALL#Inst. Date
0163#STR0164#ALL#No. Days
0164#STR0165#ALL#���� ���.  
0165#STR0166#ALL#�������  
0166#STR0167#ALL#MEDICAL REPORT TO ISSUE AIH     
0167#STR0168#ALL#01-Report number:  
0168#STR0169#ALL#02-Authorization number - PPI 
0169#STR0170#ALL#03-No. of Request for Vcncy
0170#STR0171#ALL#04-Origin unit:      
0171#STR0172#ALL#05-Code  
0172#STR0173#ALL#06-CNPJ No.:
0173#STR0174#ALL#07-Destination unit:  
0174#STR0175#ALL#08-Code  
0175#STR0176#ALL#09-CNPJ No.:
0176#STR0177#ALL#10-Patient name:    
0177#STR0178#ALL#Attendance number 
0178#STR0179#ALL#Age:  
0179#STR0180#ALL#11-Date of birth:     
0180#STR0181#ALL#12-Sex: 
0181#STR0182#ALL#13-Address: 
0182#STR0183#ALL#14-ZIP:
0183#STR0184#ALL#15-City:     
0184#STR0185#ALL#Distr.:
0185#STR0186#ALL#16-St:
0186#STR0187#ALL#Doc. Type:
0187#STR0188#ALL#17-Document number:    
0188#STR0189#ALL#18-Responsible's name:  
0189#STR0190#ALL#19-Requesting Doctor's CPF
0190#STR0191#ALL#20-Bed number:     
0191#STR0192#ALL#21-Policlinic No.:
0192#STR0193#ALL#22-HospitalizationPurpose
0193#STR0194#ALL#23-Hospitalizat. Date:
0194#STR0195#ALL#24-ClinicalDirectorCPF:
0195#STR0196#ALL#25-Hospital's Contact Employee       
0196#STR0197#ALL#26-Purpose of Request    
0197#STR0198#ALL#(  ) Self-Risk     (   ) Isolation    (   ) I.C.U.   (   ) AIDS   (   ) Other  ___________________
0198#STR0199#ALL#Fill out in case of 
0199#STR0200#ALL#Transit Accident    
0200#STR0201#ALL#27-ExternalCause:
0201#STR0202#ALL#28-Insurer's CNPJ no.:
0202#STR0203#ALL#29-Ticket Number: 
0203#STR0204#ALL#30-Series
0204#STR0205#ALL#SUS - UNIQUE HEALTH SYSTEM
0205#STR0206#ALL#Ministry of Health 
0206#STR0207#ALL#STATE GOVERNMENT  
0207#STR0208#ALL#Special Social Protection Secretary   
0208#STR0209#ALL#Executive Health Secretary   
0209#STR0210#ALL#TECHNICAL REPORT JUSTIFYING HOSPITALIZATION
0210#STR0211#ALL#31-Main Signals and Clinical Symptoms   
0211#STR0212#ALL#32-Conditions justifying Hospitalization
0212#STR0213#ALL#33-Main Results of Diagnostic Examinations     
0213#STR0214#ALL#34-Initial Diagnosis:  
0214#STR0215#ALL#35-Initial Diagnosys CID     
0215#STR0216#ALL#36-Clinic: 
0216#STR0217#ALL#1-Surgical   (  )
0217#STR0218#ALL#2-Obstetrical (  )
0218#STR0219#ALL#3-Doctor  (  )
0219#STR0220#ALL#4-F.P.T.  (  )
0220#STR0221#ALL#5-Psychiatric   (  )
0221#STR0222#ALL#6-Tsiopneumonologic (  )
0222#STR0223#ALL#7-Pediatric   (  )
0223#STR0224#ALL#8-Rehabilitation (  )
0224#STR0225#ALL#9-Other    (  )
0225#STR0226#ALL#37-Procedure Code:      
0226#STR0227#ALL#��������: 
0227#STR0228#ALL#38-Report Status    
0228#STR0229#ALL#(   ) Cancelled      (   ) Authorized     (   ) Change of Procedure    
0229#STR0230#ALL#39-Problem     (   ) Yes     (   ) No                 40-Type
0230#STR0231#ALL#41-Date of Issue:  
0231#STR0232#ALL#42-Requesting Doctor: 
0232#STR0233#ALL#43-Clinical Doctor:
0233#STR0234#ALL#44-Supervising Doctor
0234#STR0235#ALL#Signature/Stamp:   
0235#STR0236#ALL#MEDICAL REPORT TO ISSUE AIH     
0236#STR0237#ALL#01-Report Number:  
0237#STR0238#ALL#02-Authorization Number - PPI 
0238#STR0239#ALL#03-Request Number for Vcncy
0239#STR0240#ALL#04-Origin Unit:      
0240#STR0241#ALL#05-Code  
0241#STR0242#ALL#06-CNPJ No.:
0242#STR0243#ALL#07-Destination Unit:  
0243#STR0244#ALL#08-Code  
0244#STR0245#ALL#09-CNPJ No.:
0245#STR0246#ALL#10-Patient Name:    
0246#STR0247#ALL#Attendance number 
0247#STR0248#ALL#Age:  
0248#STR0249#ALL#11-Date of Birth:     
0249#STR0250#ALL#12-Sex: 
0250#STR0251#ALL#13-Address: 
0251#STR0252#ALL#14-ZIP:
0252#STR0253#ALL#15-City:     
0253#STR0254#ALL#Distric
0254#STR0255#ALL#16-St:
0255#STR0256#ALL#Doc. Type:
0256#STR0257#ALL#17-Document Number:    
0257#STR0258#ALL#18-Responsible's Name:  
0258#STR0259#ALL#19-RequestingDoctor's CPF:
0259#STR0260#ALL#20-Bed Number:     
0260#STR0261#ALL#21-Policlinic No.:
0261#STR0262#ALL#22-HospitalizationPurpose
0262#STR0263#ALL#23-Date of Hospitaliz:
0263#STR0264#ALL#24-ClinicalDirectorCPF:
0264#STR0265#ALL#25-Hospital's Contact Employee       
0265#STR0266#ALL#26-Purpose of Request    
0266#STR0267#ALL#(  ) Self-Risk     (   ) Isolation    (   ) I.C.U.   (   ) AIDS   (   ) Other  ___________________
0267#STR0268#ALL#Fill out in case of 
0268#STR0269#ALL#Transit Accident    
0269#STR0270#ALL#27-External Cause
0270#STR0271#ALL#28-Insurer's CNPJ:    
0271#STR0272#ALL#29-Ticket Number: 
0272#STR0273#ALL#30-Series
0273#STR0274#ALL#SUS - SINGLE HEALTH SYSTEM  
0274#STR0275#ALL#Ministery of Health
0275#STR0276#ALL#GOVERNMENT OF STATE
0276#STR0277#ALL#Special Social Protection Secretary   
0277#STR0278#ALL#Executive Health Secretary   
0278#STR0279#ALL#Policlinic Medical Attendance  
0279#STR0280#ALL#����:
0280#STR0281#ALL#�����:  
0281#STR0282#ALL#Patient: 
0282#STR0283#ALL#Age:  
0283#STR0284#ALL#Date of Birth:  
0284#STR0285#ALL#Sex: 
0285#STR0286#ALL#�����:  
0286#STR0287#ALL#Distric
0287#STR0288#ALL#�����:   
0288#STR0289#ALL#Document: 
0289#STR0290#ALL#�����:  
0290#STR0291#ALL#Doctor:
0291#STR0292#ALL#ACCOUNT: 
0292#STR0293#ALL#                Date of Attend.:  
0293#STR0294#ALL#PROCEDURE:   
0294#STR0295#ALL#REASON FOR ATTENDANCE:
0295#STR0296#ALL#SUMMARY DESCRIPT. OF CLINICAL EXAM:
0296#STR0297#ALL#Diagnosis:  
0297#STR0298#ALL#ICD:
0298#STR0299#ALL#Nature of Attendance:   
0299#STR0300#ALL#___Clin    ___Surg   ____Obst  ____Pedi   ___Psic   ____Tisi   ____Odon
0300#STR0301#ALL#___Other   ___General accident            ___OccupationalAccident
0301#STR0302#ALL#Medication
0302#STR0303#ALL#___Prescribed     ___Applied 
0303#STR0304#ALL#Transfer:      
0304#STR0305#ALL#___To Resid   ___P/ Pub.Policl.    ___Hospit    ___Death    ___Other 
0305#STR0306#ALL# THUMB  
0306#STR0307#ALL#   Profissional's stamp and sign.                 Patient's/Responsible's sign.  
0307#STR0308#ALL#URGENCY POLICLINICAL MEDICAL ATTENDANCE BILL        
0308#STR0309#ALL#PROFESSIONAL SERVICES:         1-Consultation   2-Imobilization   3-Curative
0309#STR0310#ALL#                               4-Small Surgery  5-Other           6-Odontol.Attend.
0310#STR0311#ALL#Description of Procedure                                                          
0311#STR0312#ALL#SUPPLEMENTARY RESOURCES:       1-Lab Exam       2-X-ray           3-Oxigentherapy 
0312#STR0313#ALL#                               4-Hemotherapy    5-Rehydration     6-Other          
0313#STR0314#ALL#Description of Procedure                  Code     |  Description of Procedure                    Code   
0314#STR0315#ALL#MATERIAL AND MEDICINES:        1-Material       2-Medicines       3-Removal        
0315#STR0316#ALL#                               4-Other                                             
0316#STR0317#ALL#Description of Procedure                    Qty    |  Description of Procedure                      Qty  
0317#STR0318#ALL#     Director responsible for information                              Responsible's signature           
0318#STR0319#ALL#   Fill out clearly every field under penalty of attendance not being considered. Check with an X       
0319#STR0320#ALL#   the grids presided by numbers ticking the alternative. Responsible for said information: doctor or    
0320#STR0321#ALL#   odontologist assistant and directors of the healthcare or contracted entity. False statement and/or   
0321#STR0322#ALL#   fraud makes infractors liable to sanctions of sections 171 and/or 298 of the Criminal Code 
0322#STR0323#ALL#MEDICAL PRESCRIPTION FORM      
0323#STR0324#ALL#Patient..: 
0324#STR0325#ALL#          Record...: 
0325#STR0326#ALL#Healthcare 
0326#STR0327#ALL#           Date..: 
0327#STR0328#ALL#           Time.....: 
0328#STR0329#ALL#          Bed....: 
0329#STR0330#ALL#Doctor...: 
0330#STR0331#ALL#���.
0331#STR0332#ALL#PRESCRIPT.
0332#STR0333#ALL#TIME   
0333#STR0334#ALL#ICU
0334#STR0335#ALL#DEV
0335#STR0336#ALL#REQUEST FOR PROCEDURES      
0336#STR0337#ALL#THAT NEED PRIOR AUTHORIZATION    
0337#STR0338#ALL#Patient..: 
0338#STR0339#ALL#Record...: 
0339#STR0340#ALL#       Healthcare: 
0340#STR0341#ALL#Date.....: 
0341#STR0342#ALL#      Time.....: 
0342#STR0343#ALL#          Bed....: 
0343#STR0344#ALL#Doctor...: 
0344#STR0345#ALL#1-HIGH COST MATERIAL - Specify:               
0345#STR0346#ALL#2-CHANGE OF PROCEDURE:    
0346#STR0347#ALL#3-APPOINTMENT SPECIALIST - Specify:   
0347#STR0348#ALL#4-APPOINTMENT SPECIALIST - Specify:   
0348#STR0349#ALL#Justification:
0349#STR0350#ALL#Date:               Requesting Doctor:                      Auditor:
0350#STR0351#ALL#For Healthcares below, use own forms                   
0351#STR0352#ALL#AMIL (Special Exams)   
0352#STR0353#ALL#HapVida (All exams and procedures)       
0353#STR0354#ALL#Sa�de Bradesco (Change of Procedure)    
0354#STR0355#ALL#PETROBRAS (Procedures)