Scribd Logo
Upload

Welcome to Scribd!

  • Pesquisa Saúde Visual

    Uploaded by

    Fabricio Mendes
    4 views1 page

    Original Title

    Pesquisa Saúde visual

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    4 views1 page

    Pesquisa Saúde Visual

    Uploaded by

    Fabricio Mendes

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    ůĂƐƐŝĮĐĂĕĆŽĚĂWĞƐƋƵŝƐĂ ůĂƐƐŝĮĐĂĕĆŽĚĂWĞƐƋƵŝƐĂ

    ( )Q ( )F ( )Q ( )F
    Pesquisa de Saúde Visual na cidade de ___________ Pesquisa de Saúde Visual na cidade de ___________
    Pesquisador: ________________________________ Pesquisador: ________________________________
    1: Nome: ______________________________________________ 1: Nome: ______________________________________________
    Ϯ͗ĂŝƌƌŽ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺWƌŽĮƐƐĆŽ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Ϯ͗ĂŝƌƌŽ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺWƌŽĮƐƐĆŽ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
    3: Telefone 1:_______________ Telefone 2: _________________ 3: Telefone 1:_______________ Telefone 2: _________________
    ϰ͗sŽĐġƵƐĂſĐƵůŽƐ͍ ;Ϳ^ŝŵ ;ͿEąŽ ϰ͗sŽĐġƵƐĂſĐƵůŽƐ͍ ;Ϳ^ŝŵ ;ͿEąŽ
    4.1 Se sim... Dioptria: _____________________________________ 4.1 Se sim... Dioptria: _____________________________________
    ;ͿDŝŽƉŝĂ ;Ϳ,ŝƉĞƌŵĞƚƌŽƉŝĂ ;ͿƐƟŐŵĂƟƐŵŽ ;ͿWƌĞƐďŝŽƉŝĂ ;ͿDŝŽƉŝĂ ;Ϳ,ŝƉĞƌŵĞƚƌŽƉŝĂ ;ͿƐƟŐŵĂƟƐŵŽ ;ͿWƌĞƐďŝŽƉŝĂ
    ϰ͘Ϯ^ĞŶĆŽ͘͘͘͘dĞŵĂůŐƵŵĂĚŝĮĐƵůĚĂĚĞƉĂƌĂĞŶdžĞƌŐĂƌ͍ ϰ͘Ϯ^ĞŶĆŽ͘͘͘͘dĞŵĂůŐƵŵĂĚŝĮĐƵůĚĂĚĞƉĂƌĂĞŶdžĞƌŐĂƌ͍
    ;ͿEĆŽĞŶdžĞƌŐŽďĞŵĚĞůŽŶŐĞ;ͿEĆŽĞŶdžĞƌŐŽďĞŵĚĞƉĞƌƚŽ ;ͿEĆŽĞŶdžĞƌŐŽďĞŵĚĞůŽŶŐĞ;ͿEĆŽĞŶdžĞƌŐŽďĞŵĚĞƉĞƌƚŽ
    ;ͿEĆŽĞŶdžĞƌŐŽďĞŵĚĞůŽŶŐĞĞĚĞƉĞƌƚŽ;ͿEĆŽƚĞŶŚŽƉƌŽďůĞŵĂƐ ;ͿEĆŽĞŶdžĞƌŐŽďĞŵĚĞůŽŶŐĞĞĚĞƉĞƌƚŽ;ͿEĆŽƚĞŶŚŽƉƌŽďůĞŵĂƐ
    ϱ͗YƵĂůĨŽŝĂƐƵĂƷůƟŵĂŝĚĂĂŽŽŌĂůŵŽůŽŐŝƐƚĂ͍DĠĚŝĐŽ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ϱ͗YƵĂůĨŽŝĂƐƵĂƷůƟŵĂŝĚĂĂŽŽŌĂůŵŽůŽŐŝƐƚĂ͍DĠĚŝĐŽ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
    ;ͿфϲŵĞƐĞƐ;ͿϲŵĞƐĞƐĂϭĂŶŽ;ͿхϭĂŶŽ;ͿхϮĂŶŽƐ;ͿEƵŶĐĂĨƵŝ ;ͿфϲŵĞƐĞƐ;ͿϲŵĞƐĞƐĂϭĂŶŽ;ͿхϭĂŶŽ;ͿхϮĂŶŽƐ;ͿEƵŶĐĂĨƵŝ
    ϲ͗KƋƵĞƚĞŝŵƉĞĚĞĚĞŝƌĂŽŽŌĂůŵŽůŽŐŝƐƚĂ͍ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ϲ͗KƋƵĞƚĞŝŵƉĞĚĞĚĞŝƌĂŽŽŌĂůŵŽůŽŐŝƐƚĂ͍ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
    ;ͿWƌĞĕŽ;ͿdĞŵƉŽ;ͿŽŶĮĂŶĕĂ;ͿĐŚŽƋƵĞŶĆŽƉƌĞĐŝƐŽ ;ͿWƌĞĕŽ;ͿdĞŵƉŽ;ͿŽŶĮĂŶĕĂ;ͿĐŚŽƋƵĞŶĆŽƉƌĞĐŝƐŽ
    ϳ͗ƐƚĄĐŽŵĂƌĞĐĞŝƚĂĞŵŵĆŽƐ͍;Ϳ^ŝŵ;ͿEĆŽ ϳ͗ƐƚĄĐŽŵĂƌĞĐĞŝƚĂĞŵŵĆŽƐ͍;Ϳ^ŝŵ;ͿEĆŽ
    ϴ͗:ĄĨĞnjĂĐŽŵƉƌĂĚŽMĐƵůŽƐ͍;Ϳ^ŝŵ;ͿEĆŽsĂůŽƌ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ϴ͗:ĄĨĞnjĂĐŽŵƉƌĂĚŽMĐƵůŽƐ͍;Ϳ^ŝŵ;ͿEĆŽsĂůŽƌ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
    ϵ͗DĠĚŝĐŽĚĞWƌĞĨĞƌġŶĐŝĂ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ϵ͗DĠĚŝĐŽĚĞWƌĞĨĞƌġŶĐŝĂ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

    ŐĞŶĚĂĚŽ͍;Ϳ^ŝŵ;ͿEĆŽ YƵĞŵůŝŐŽƵ͍ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ŐĞŶĚĂĚŽ͍;Ϳ^ŝŵ;ͿEĆŽ YƵĞŵůŝŐŽƵ͍ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ


    EǑ'ƵŝĂ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺ YƚLJĚĞ>ŝŐĂĕƁĞƐ͗;Ϳϭdž;ͿϮdž;Ϳϯdž EǑ'ƵŝĂ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺ YƚLJĚĞ>ŝŐĂĕƁĞƐ͗;Ϳϭdž;ͿϮdž;Ϳϯdž
    DĠĚŝĐŽ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ŶǀŝŽĚĞDĞŶƐĂŐĞŵ͗;Ϳ DĠĚŝĐŽ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ŶǀŝŽĚĞDĞŶƐĂŐĞŵ͗;Ϳ
    Data:_________________ ŽŵƉĂƌĞĐĞƵ͍;Ϳ^ŝŵ;ͿEĆŽ Data:_________________ ŽŵƉĂƌĞĐĞƵ͍;Ϳ^ŝŵ;ͿEĆŽ
    Hora:_________________ ŽŵƉƌŽƵ͍;Ϳ^ŝŵ;ͿEĆŽ Hora:_________________ ŽŵƉƌŽƵ͍;Ϳ^ŝŵ;ͿEĆŽ

    You might also like