SPA ESPAÇO TERAPIA

FICHA DE ANAMNESE TERAPÊUTICA

Nome: Nasc.:____/____/_____

Idade: Signo: Est. Civil: Bairro:

CNS:

Endereço: Celular: ( )

Cidade: CEP: Tel. Residencial: ( )

Tel. Comercial: ( ) Email:

Profissão: Qto. Tempo:

Empresa Atual: Filhos: Religião:

Motivo da Consulta:

Já fez terapia antes: Qual: Obteve resultado satisfatório?

Pratica exercícios físicos ou esportes: Quais: É fumante?

Está tomando algum tipo de medicamento: Quais:

Como funciona o intestino: Apar. digestivo: Menst.Regular:

Menopausa: Qto tempo: Pílula: Cólicas:

* Obs: (olhar cor do rosto, veias dos olhos, cor e umidade da língua, pulso, olheiras, postura, se fica ansioso,
nervoso).

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

( ) Artrite ( )Tendinite ( ) Hipertensão ( ) Neurite ( ) Trombose ( ) Bursite

( ) Bursite ( ) Nódulos ( ) Traumatismo ( ) Tumor ( ) Fibromialgia ( ) Hepatite

( ) Câncer ( ) Feblite ( ) Escabiose ( ) Osteoporose ( ) Anemia ( ) Alergia

( ) Tireoidismo ( ) Artrose ( ) Problemas Cardíacos

( )Prob. Neurológicos ( ) Dilatação da Aorta ( ) Problemas Renais

( ) Outros - Quais:

Conclusão:

2 - Tratamentos terapêuticos energéticos a serem aplicados:

 SPA ESPAÇO TERAPIA

3 - Periodicidade: ( ) Diária ( ) Semanal ( ) Quinzenal ( ) Mensal

OBS:

(CONFIRMO SEREM VERDADEIRAS E DE MINHA INTEIRA RESPONSABILIDADE AS INFORMAÇÕES POR MIM

PRESTADAS)

Local:.................................................................................. Data:___/_______/_______.

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

Avaliação Postural
( ) Cifose ( ) Lordose ( )Escoliose
( ) Joelho ( ) Valgo ( ) Valro
( ) Pé Cavo ( ) Plano ( ) Normal
Observações: ____________________________________________________________________________
_______________________________________________________________________________________

TRATAMENTO

1ª sessão: (____/_____/_____) Conduta: _____________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________
 SPA ESPAÇO TERAPIA
2ª sessão: (____/_____/_____) Conduta: _____________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

3ª sessão: (____/_____/_____) Conduta: _____________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

4ª sessão: (____/_____/_____) Conduta: _____________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

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

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________
 SPA ESPAÇO TERAPIA
(____/_____/_____) Conduta: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

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

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________
 SPA ESPAÇO TERAPIA
(____/_____/_____) Conduta: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________

(____/_____/_____) Conduta: ______________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
Evolução: _______________________________________________________________________________