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Ficha de anamnese para Terapia Floral

Nome:________________________________________________________________________
Data nascimento: ___/___/___
Endereo:_____________________________________________________________________
Bairro:_____________________Telefone:(____)______________________________________
email:________________________________________________________________________
Profisso:__________________ Estado civil:_________________________________________
Filhos:________________________________________________________________________
Padro corporal:
Atividade fsica regular? No ( ) Sim ( ) Qual? _______________________________________
Cirurgias?_____________________________________________________________________
Fraturas?_____________________________________________________________________
Dores?_______________________________________________________________________
Sade:
Pele ( )__________________ Ginecolgico / urolgico ( ) ___________________Endcrino ( )
__________________ Renal ( ) ___________________ Digestivo ________________ Circulao /
corao ( )__________________ Presso: ____________Respiratrio ( ) ____________________
sseo/coluna ( ) _____________________________ Funcionamento
intestinal:_______________Alergias( )_____________________Diabetes( ) ______________
Faz uso de algum mtodo contraceptivo? __________________________________________
Menopausa( ) Faz reposio hormonal?____________________________________________
Histrico oncolgico:________________________________
Doenas Anteriores:______________________________
Tratamentos Anteriores:_________________________________________________________
Atualmente faz acompanhamento mdico, psicolgico ou outra terapia?
_____________________________________________________________________________
Faz uso de alguma medicao?
______________________________________________________________________
Alimentao:
Apetite:___________________Legumes/verduras ____________ Frutas ____________ Massas
__________________ Carnes ___________ Leite_____________Frituras
__________Aucar___________________ Faz dieta ___________
Caf________________lcool:____________________Qtde de gua que ingere/dia
___________________________
VIDA (dia a dia)?
Nvel de stress ( ) baixo ( ) mdio ( ) alto Possui algum vcio?
______________________________________________
Nvel de ansiedade ( ) baixo ( ) mdio ( ) alto
Dorme bem?______________________________________________________________
Familiar
Quem mora com voc?_____________________________________________________

Convivncia? ( ) boa ( ) ruim ( ) conflituosa ( ) insatisfeito


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Profissional
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Relacionamento grupal no meio ambiente onde estuda ou trabalha? ( ) bom ( ) conflituoso ( ) pssimo
Gosta do que faz/estuda? ( ) sim ( ) no ( ) faz por necessidade / Satisfeito com salrio? ( ) sim ( ) no
Leitura ( ) muito ( ) pouco ( ) detesta
ltima vez que tirou frias
_________________________________________________________________________
Planejamento profissional/mdio
prazo:_______________________________________________________________
OBS.: ________________________________________________________________________
Social
Possui amigos?
____________________________________________________________________________
Sai para se divertir? ( ) sim ( ) no ( ) muito pouco ( ) raramente
Hobbies ( ) sim ( )
no__________________________________________________________________________
Religio ________________ ( ) freqentador assduo ( ) normal ( ) eventualmente
Costuma viajar? ( ) sim ( ) no
OBS.:
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1 Consulta Data __ / __ / __
Motivo / queixas do cliente:
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Avaliao geral / observaes
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2 Consulta Data __ / __ / __
Motivo / queixas do cliente:
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Avaliao geral / observaes /Sugestes/Frmula:
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3 Consulta Data __ / __ / __
Motivo / queixas do cliente:
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Avaliao geral / observaes /Sugestes/Frmula:
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4 Consulta Data __ / __ / __
Motivo / queixas do cliente:
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Avaliao geral / observaes /Sugestes/Frmula:
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5 Consulta Data __ / __ / __
Motivo / queixas do cliente:
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Avaliao geral / observaes /Sugestes/Frmula:
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