FICHA DE ANAMNESE

1) Dados gerais do paciente:

Nome:__________________________________________________________________________
Idade:______ Sexo______ Data de Nasc:___/___/___ Profisso:___________________________
Estado Civil:___________________ Filhos: ( )________________________________________
End: ___________________________________________________________________________
Tel:______________________________ e-mail:_______________________________________
QP:_________________________________ HD:_______________________________________
HMA:___________________________________________________________________________
________________________________________________________________________________
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2) Avaliao do paciente:
Sinais Vitais: PA:_________ FC:________ T:_______ Peso:_______ Alt:______ IMC:_______
Diabetes( )

Hipertenso Arterial ( )

Tabagismo ( )

Alcoolismo ( )

Cirurgias( ) _____________________________________________________________________
Exerccios Fsicos( ) ___________________________ Freqncia: ________________________
Problemas respiratrios( ) ________________________ Alergia( )________________________

3) Distrbios:
Digesto( )

Cibras( )

Convulses( )

Fibromialgia( )

Ansiedade( )

Depresso( )

Outros:__________________________________________________________________________

4) Avaliao Postural
Cifose( ) Lordose( ) Escoliose( ) Joelho: Valgo( ) Varo( ) P:Cavo( ) Plano( ) Normal( )
Observaes: _____________________________________________________________________
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5) Observaes Gerais:____________________________________________________________
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6) Objetivo Principal: _____________________________________________________________
________________________________________________________________________________

7) Conduta: _____________________________________________________________________
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Nome: _________________________________________________ RG: _____________________

Ciente:__________________________________________________________________________
Massoterapeuta: __________________________________________________________________
Catanduva SP Data:___/___/___
TRATAMENTO

1 sesso(___/___/___) Conduta:____________________________________________________
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Evoluo:_______________________________________________________________________
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2 sesso(___/___/___) Conduta:____________________________________________________
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Evoluo:_______________________________________________________________________
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3 sesso(___/___/___) Conduta:____________________________________________________
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Evoluo:_______________________________________________________________________
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4 sesso(___/___/___) Conduta:____________________________________________________
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Evoluo:_______________________________________________________________________
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Observaes Adicionais: __________________________________________________________
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Massoterapeuta:____________________________________________________
Auxiliar:___________________________________________________________