FICHA DE ANAMNESE - VENTOSATERAPIA

Nome:_____________________________________________________________________________________

Idade:_______________________ Profissão: ____________________________

Telefone: ( )_____________-_______________ Data: ________________________________

Queixa Principal (motivo da procura do tratamento) :

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AVALIAÇÃO GERAL

SABORES

( ) Amargo-Fo ( ) Doce-Te ( ) Picante-Me ( ) Salgado-Ag ( ) Azedo/ácido-Ma

Padrão de Deficiência dos Cinco elementos: ____________________________________________________

EMOÇÕES
( ) Ansiedade ( ) Preocupação ( ) Tristeza ( ) Medo/Insegurança ( ) Raiva/mágoa

ASPECTOS GERAIS

1. DOENÇA CRÔNICA– uso de medicamento : _ ________________________________________________

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2. SONO:_______________________________________________________________________________
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3. FUNCÕES INTESTINAIS: ______________________________________________________________
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4. DIGESTÃO:____________________________________________________________________________
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5. CEFALÉIA:_____________________________________________________________________________
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Informações Adicionais:
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Objetivos de Tratamento:
Físico:

Energético:

Psíquico:

Esquema de tratamento:
Região:

Meridiano de energia:

Observaçôes:
SESSÃO Nº _____ DATA: / /

Resposta clínica do paciente da aplicação anterior:

Objetivo desta aplicação: