Nome:_________________________________________________________________
Data de nascimento:_____________ Telefone:_________________________________
Indicação:______________________________________________________________
Motivo Principal
Emocional /Dores / Tratamento estético:______________________________________
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Avaliação Física
Facial:_________________________________________________________________
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Corporal (dores, problema em articulações): __________________________________
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Características Fisiológicas
Percepção dos órgãos dos sentidos:__________________________________________
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Sono:__________________________________________________________________
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Atividade física:_________________________________________________________
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Hábitos alimentares (preferências, intolerância, temperatura, apetite):_______________
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Hábitos de hidratação (líquidos ingeridos, quantidade e característica da água):_______
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Funcionamento dos sistemas:
Tegumentar:____________________________________________________________
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Respiratório:____________________________________________________________
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Digestório:_____________________________________________________________
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Genito-urinário:_________________________________________________________
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Circulatório:____________________________________________________________
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