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FICHA DE ANAMNESE TERAPUTICA

Nome:

Nasc.:____/____/_____

Idade:

Signo:

Est. Civil:

Bairro:

Endereo:

Celular: (

Cidade:
Tel. Comercial: (

CEP:
)

Tel. Residencial: (

Email:

Profisso:

Qto. Tempo:

Empresa Atual:

Filhos:

Religio:

Motivo da Consulta:
J fez terapia antes:

Qual:

Obteve resultado satisfatrio?

Pratica exerccios fsicos ou esportes:

Quais:

Est tomando algum tipo de medicamento:


Como funciona o intestino:

fumante?
Quais:

Apar. digestivo:

Menst.Regular:

Menopausa:
Qto tempo:
Plula:
Clicas:
* Obs: (olhar cor do rosto, veias dos olhos, cor e umidade da lngua, pulso, olheiras, postura, se fica ansioso,
nervoso).

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


( ) Artrite

( )Tendinite

( ) Hipertenso

( ) Neurite

( ) Trombose

( ) Bursite

( ) Bursite

( ) Ndulos

( ) Traumatismo

( ) Tumor

( ) Fibromialgia

( ) Hepatite

( ) Cncer

( ) Feblite

( ) Anemia

( ) Alergia

( ) Escabiose

( ) Osteoporose

( ) Tireoidismo

( ) Artrose

( ) Problemas Cardacos

( )Prob. Neurolgicos

( ) Dilatao da Aorta

( ) Problemas Renais

( ) Outros - Quais:
Concluso:

2 - Tratamentos teraputicos energticos a serem aplicados:

3 - Periodicidade:

( ) Diria

( ) Semanal

( ) Quinzenal

( ) Mensal

OBS:
(CONFIRMO SEREM VERDADEIRAS E DE MINHA INTEIRA RESPONSABILIDADE AS INFORMAES POR MIM
PRESTADAS)
Local:..................................................................................

Data:___/_______/_______.

Ass:.......................................................................................

Avaliao Postural
( ) Cifose
( ) Lordose
( )Escoliose
( ) Joelho
( ) Valgo
( ) Valro
( ) P Cavo
( ) Plano
( ) Normal
Observaes: ____________________________________________________________________________
_______________________________________________________________________________________

TRATAMENTO
1 sesso: (____/_____/_____) Conduta: _____________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evoluo: _______________________________________________________________________________
2 sesso: (____/_____/_____) Conduta: _____________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evoluo: _______________________________________________________________________________
3 sesso: (____/_____/_____) Conduta: _____________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evoluo: _______________________________________________________________________________
4 sesso: (____/_____/_____) Conduta: _____________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evoluo: _______________________________________________________________________________
(____/_____/_____) Conduta: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evoluo: _______________________________________________________________________________
(____/_____/_____) Conduta: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evoluo: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________


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

(____/_____/_____) Conduta: ______________________________________________________________


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