CENTRO DE FORMAO PROFISSIONAL LEDUC

Clnica Escola de Terapias Corporais

Rua Comendador Clementino, 243 Centro Manaus- AM
Fone: 3232-5178
www.centroleduc.com.br
FICHA DE AVALIAO MASSOTERPICA
1) DADOS GERAIS:
Nome:__________________________________________________________________________
Idade:______ Sexo______ Data de Nasc:___/___/___ Profisso:___________________________
End: ___________________________________________________________________________
Tel:______________________________ e-mail:_______________________________________
PA:____x____mmHG Peso:_______ Alt.:______ IMC:_______
2) OBJETIVO PRINCIPAL:__________________________________________________
________________________________________________________________________________
3) HISTRICO DE DOENAS ATUAIS
Diabetes( ) Hipertenso Arterial( ) Dor na Coluna( ) Dores Musculares( ) Dores Articulares( )
Problemas Cardacos( ) Problemas Vasculares ( ) Perfil Lipdico( ) Tabagismo ( ) Alcoolismo ( )
Cirurgias( ) Depresso( ) Dislipidemias( ) Outros( ). Especifique:

________________________________________________________________________________
Exerccios Fsicos( ) ___________________________ Freqncia: ________________________
Problemas respiratrios( ) ________________________ Alergia( )________________________
4) HISTRICO FAMILIAR
Problemas Respiratrios( ) Cardiovasculares( ) Hipertenso( ) Obesidade e Dislipidemias( ) Outros( )
Especifique:_____________________________________________________________________________

5) Atualmente realiza algum tratamento:

( ) Tratamento Mdico: Dr. (a) _______________ Fone: _____________________
( ) Tratamento Fisioteraputico: Dr.(a) _____________ Fone: _________________
( ) Outro tratamento __________________________________________________
Observaes:
________________________________________________________________________________
6) Faz uso de medicao? No( ) Sim( ), especifique:_______________________________
7) ANOTAES GERAIS
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

CENTRO DE FORMAO PROFISSIONAL LEDUC

Clnica Escola de Terapias Corporais
Rua Comendador Clementino, 243 Centro Manaus- AM
Fone: 3232-5178
www.centroleduc.com.br
8) INSPEO FSICA

OBSERVAES: ________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
9) CONDUTA:_______________________________________________________________
________________________________________________________________________________
Termo de Consentimento
de minha escolha receber a terapia, com a qual concordo plenamente. Relatei todos os
problemas de sade dos quais estou ciente e informarei a meu terapeuta sobre quaisquer mudanas
no meu estado de sade, pois daro base para interveno de massoterapia.
Nome: _________________________________________________ RG: _____________________
Ciente:__________________________________________________________________________
Terapeuta Responsvel:_____________________________________________________________
Manaus-AM Data:___/___/___

CENTRO DE FORMAO PROFISSIONAL LEDUC

Clnica Escola de Terapias Corporais
Rua Comendador Clementino, 243 Centro Manaus- AM
Fone: 3232-5178
www.centroleduc.com.br
FICHA DE EVOLUO - TRATAMENTO
Sesso N___ (___/___/___) Conduta:________________________________________________
Evoluo:_______________________________________________________________________
________________________________________________________________________________
Assinatura Cliente:_______________________________________________________________

Sesso N___ (___/___/___) Conduta:________________________________________________

Evoluo:_______________________________________________________________________
________________________________________________________________________________
Assinatura Cliente:_______________________________________________________________

Sesso N___ (___/___/___) Conduta:________________________________________________

Evoluo:_______________________________________________________________________
________________________________________________________________________________
Assinatura Cliente:_______________________________________________________________

Sesso N___ (___/___/___) Conduta:________________________________________________

Evoluo:_______________________________________________________________________
________________________________________________________________________________
Assinatura Cliente:_______________________________________________________________

Observaes Adicionais: __________________________________________________________

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