Ficha de anamnese para Terapia Floral

 Nome:___________________
 Nome:______________________________
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Data nascimento: ___/___/___ 
Endereço:_____________________________________________________________________ 
Bairro:_____________________Telefone:(____)______________________________________ 
email:_____________________
email:________________________________
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________________________
_______________________
________________ 
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Profissão:__________________
Profissão:__________________ Estado civil:______________________
civil:__________________________________
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Filhos:___________________
Filhos:_______________________________
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Padrão corporal:
tividade f!sica re"#lar$ Não ( ) %im ( ) &#al$ ______________________
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'ir#r"ias$_______________
'ir#r"ias$___________________________
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________ 
Frat#ras$__________________
Frat#ras$_____________________________
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Dores$_______________________________________________________________________ 

%ade:
Pele ( )__________________
)__________________ inecol*"ico / #rol*"ico ( ) ___________________End*crino
___________________End*crino ( )
 __________________
 __________________ +enal
+enal ( ) ___________________
___________________ Di"estivo
Di"estivo ________________
________________ 'irc#lação
'irc#lação /
coração ( )__________________
)__________________ Pressão: ____________+espirat*rio
____________+espirat*rio ( ) ____________________
____________________
,sseo/col#na ( ) ______________________
_____________________________
_______ F#ncionamento
intestinal:_______________ler"
intestinal:_______________ler"ias(
ias( )_____________________Dia-
)_____________________Dia-etes(
etes( ) ______________
______________
Fa. #so de al"#m mtodo contraceptivo$ ______________________
__________________________________
____________________ 
________ 
0enopa#sa( ) Fa. reposição hormonal$________________________
hormonal$____________________________________
____________________ 
________ 
1ist*rico oncol*"ico:_______________
oncol*"ico:___________________________
_________________ 
_____ 
Doenças nteriores:______________
nteriores:__________________________
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Tratamentos nteriores:_________________________________________________________ 
t#almente fa. acompanhamento mdico2 psicol*"ico o# o#tra terapia$
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________ 
Fa. #so de al"#ma medicação$
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limentação:
petite:___________________3e
petite:___________________3e"#mes/verd#ras
"#mes/verd#ras ____________ Fr#tas ____________
____________ 0assas
 __________________
 __________________ 'arnes
'arnes ___________
___________ 3eite_____________Frit#ras
3eite_____________Frit#ras
 __________ç#car_______
 __________ç#car___________________
____________ Fa. Fa. dieta ___________
___________
'af________________4lcool:_
'af________________4lcool:____________
___________________&tde
________&tde de 5"#a 6#e in"ere/dia
 _______________________
 ___________________________ ____
78D (dia a dia)$
 N!vel de stress ( ) -ai9o
-ai9o ( ) mdio ( ) alto Poss#i
Poss#i al"#m v!cio$
 _______________________
 __________________________________
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____________ 
 N!vel de ansiedade
ansiedade ( ) -ai9o ( ) mdio ( ) alto
alto
Dorme -em$______________________________________________________________ 
Familiar 
&#em mora com voc$_____________________________________________________
 'onvivncia$ ( ) -oa ( ) r#im ( ) conflit#osa ( ) insatisfeito
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Profissional
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+elacionamento "r#pal no meio am-iente onde est#da o# tra-alha$ ( ) -om ( ) conflit#oso ( ) pssimo

osta do 6#e fa./est#da$ ( ) sim ( ) não ( ) fa. por necessidade / %atisfeito com sal5rio$ ( ) sim ( ) não

3eit#ra ( ) m#ito ( ) po#co ( ) detesta

;ltima ve. 6#e tiro# frias
 _________________________________________________________________________ 
Plane<amento profissional/mdio
 pra.o:_______________________________________________________________ 
=B%>: ________________________________________________________________________ 

%ocial
Poss#i ami"os$
 ____________________________________________________________________________ 
%ai para se divertir$ ( ) sim ( ) não ( ) m#ito po#co ( ) raramente
1o--ies ( ) sim ( )
não__________________________________________________________________________ 
+eli"ião ________________ ( ) fre6?entador ass!d#o ( ) normal ( ) event#almente
'ost#ma via<ar$ ( ) sim ( ) não
=B%>:
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@A 'ons#lta Data __ / __ / __ 

0otivo / 6#ei9as do cliente:
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valiação "eral / o-servaçes

/%#"estes/F*rm#la:_________________________________________________________________ 
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CA 'ons#lta Data __ / __ / __
0otivo / 6#ei9as do cliente:
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valiação "eral / o-servaçes /%#"estes/F*rm#la:

 _________________________________________________________________________________ 
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A 'ons#lta Data __ / __ / __

0otivo / 6#ei9as do cliente:

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valiação "eral / o-servaçes /%#"estes/F*rm#la:

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A 'ons#lta Data __ / __ / __ 

0otivo / 6#ei9as do cliente:
 _________________________________________________________________________
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 _________________________________________________________________________________ 
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 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
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valiação "eral / o-servaçes /%#"estes/F*rm#la:

 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
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 _________________________________________________________ 

A 'ons#lta Data __ / __ / __

0otivo / 6#ei9as do cliente:

 _________________________________________________________________________
 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
 _________________________________________________________________________________ 
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valiação "eral / o-servaçes /%#"estes/F*rm#la:

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