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1. Terapia Fonoaudiológica:
Não ( ) Sim ( )
Há ______ meses Durante________ meses
Pelo motivo _______________________________________________________________
Parou por alta ( ) outro motivo ______________________________________
2. Aparelho ortodôntico:
Nunca usou ( ) já usou ( )
Tipo ____________________________________________________________________
Há _______ meses por __________ meses
Parou por alta ( ) outro motivo ______________________________________
Usa tipo _________________________________________________ Há ________ meses
Ortodontista ______________________________________ Telefone: ________________
3. Terapia Psicológica:
Não ( ) Sim ( )
Há ______ meses durante _______ meses
Pelo motivo_______________________________________________________________
Parou por alta ( ) outro motivo_______________________________________
HISTÓRIA
SONO
ALIMENTAÇÃO
SAÚDE GERAL
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