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Ficha de Anamnese Massagem[1]

Ficha de Anamnese Massagem[1]

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Publicado porGeovana Alves

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Published by: Geovana Alves on Apr 02, 2013
Direitos Autorais:Attribution Non-commercial

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09/05/2013

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Ficha de Anamnese

Nome:___________________________________________________Nasc:______________
Endereço:___________________________________________________________________
Bairro:_____________________Cep:______________E-mail:________________________
Dados da Massagem:
( ) Estética______________________________ ( ) Relaxante_______________________
( ) Desportiva___________________________ ( ) Idosos__________________________
Prodto !tili"ado# ( ) $im ( ) N%o &al#_____________________________________
'( reali"o massa)em anteriormente# ( ) $im ( ) N%o &al#________________________
Contra- indicações:
( ) *ravide"# &antos meses# _________________________________________________
( ) Caso de c+ncer na ,am-lia# &em#____________ &to tempo# _____________________
( ) .l)m para,so o pla/eta implantados# 0nde#________________________________
( ) Reali"o al)ma cirr)ia# 0nde#________________&to tempo#___________________
( ) 1ipertens%o o 1ipotens%o# P.: _____________________________________________
( ) 2enstraç%o com ,lxo alto# &to tempo# ______________________________________
( ) 2ioma#
( ) !sa DI!#
( ) Cisto no ov(rio o em al)ma otra (rea#______________________________________
( ) .l)m tipo de 3érnia# &al# ________________________________________________
( ) 2arca passo#
( ) .l)ma ,ratra recente# 0nde#______________________________________________
( ) .l)m corte o mac3cado# 0nde# __________________________________________
( ) .l)m processo de de)eneraç%o 4ssea o msclar# &al# ________________________
( ) 5a" so de medicamento# &al# ____________________ P/#______________________
( ) Reali"ando al)m tipo de tratamento# &al#____________________________________
Hábitos:
( ) 5ma# ( ) Be6e# ________________________________________________________
( ) Be6e ()a diariamente# &tos copos em média# _________________________________
( ) 5a" exerc-cios ,-sicos# &al periodicidade# ____________________________________
( ) 7ra6al3a# Em /e# _______________________Estda# 0 /e#____________________
Informações Adicionais:
___________________________________________________________________________
___________________________________________________________________________
Declaro para os devidos fins que as respostas prestadas por mim nesta ficha são
expressamente verdadeiras e estou ciente de todo procedimento que será realizado.
8ocal______________________ Dta: ___9____9_____
.ss: do cliente: ______________________________________________________________
PERIMETRIA
Data / / / / / / / / / / / / / / / / / / / /
Peso
Braço D
Braço E
Busto
Cintura alta
Cintura umbigo
Cintura baixa
Coxa alta D
Coxa alta E
Coxa baixa D
Coxa baixa E
Panturrilha
Ass. do cliente
06servaç:es:________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

do cliente / / / / / / / / / / / / / / / / / / / / Observações:________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ .PERIMETRIA Data Peso Braço D Braço E Busto Cintura alta Cintura umbigo Cintura baixa Coxa alta D Coxa alta E Coxa baixa D Coxa baixa E Panturrilha Ass.

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