FICHA DE ANAMNESE TERAPÊUTICA

Nome: Nasc.:____/____/_____
Idade: Signo: Est. Civil: Bairro:
Endereço: Celular: ( )
Cidade: CEP: Tel. Residencial: ( )
Tel. Comercial: ( ) Email:
Profissão: Qto. Tempo:
Empresa Atual: Filhos: Religião:
Motivo da Consulta:
Já fez terapia antes: Qual: Obteve resultado satisfatório?
Pratica exercícios físicos ou esportes: Quais: É fumante?
Está tomando algum tipo de medicamento: Quais:
Como funciona o intestino: Apar. digestivo: Menst.Regular:
Menopausa: Qto tempo: Pílula: Cólicas:
* Obs: (olhar cor do rosto, veias dos olhos, cor e umidade da língua, pulso, olheiras, postura, se fica ansioso,
nervoso).

1 - Marque com um (X) se você tiver algum dos problemas abaixo:

( ) Artrite ( )Tendinite ( ) Hipertensão ( ) Neurite ( ) Trombose ( ) Bursite
( ) Bursite ( ) Nódulos ( ) Traumatismo ( ) Tumor ( ) Fibromialgia ( ) Hepatite
( ) Câncer ( ) Feblite ( ) Escabiose ( ) Osteoporose ( ) Anemia ( ) Alergia
( ) Tireoidismo ( ) Artrose ( ) Problemas Cardíacos
( )Prob. Neurológicos ( ) Dilatação da Aorta ( ) Problemas Renais
( ) Outros - Quais:

Conclusão:

2 - Tratamentos terapêuticos energéticos a serem aplicados:

3 - Periodicidade: ( ) Diária ( ) Semanal ( ) Quinzenal ( ) Mensal

OBS:

(CONFIRMO SEREM VERDADEIRAS E DE MINHA INTEIRA RESPONSABILIDADE AS INFORMAÇÕES POR MIM

PRESTADAS)
Local:.................................................................................. Data:___/_______/_______.

Ass:.......................................................................................
Avaliação Postural
( ) Cifose ( ) Lordose ( )Escoliose
( ) Joelho ( ) Valgo ( ) Valro
( ) Pé Cavo ( ) Plano ( ) Normal
Observações: ____________________________________________________________________________
_______________________________________________________________________________________

TRATAMENTO

1ª sessão: (____/_____/_____) Conduta: _____________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

2ª sessão: (____/_____/_____) Conduta: _____________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

3ª sessão: (____/_____/_____) Conduta: _____________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

4ª sessão: (____/_____/_____) Conduta: _____________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________
(____/_____/_____) Conduta: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________
(____/_____/_____) Conduta: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________
(____/_____/_____) Conduta: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________