Ficha de Anamnese

1. Dados Pessoais

Nome: _______________________________________________________________ Data da Avaliação:____/____/____

Data de Nascimento: ____/____/____ Hora do Nascimento: ____:____ Sexo : ( ) F ( ) M Ponto Aberto: ____________
Naturalidade: _______________________ Escolaridade: _______________________Profissão: ____________________
Telefone (fixo): ______________ Telefone (celular): ______________ E-mail: ___________________________________
Endereço: _____________________________________________ Bairro: ______________ Cidade/UF: ______________

2. Histórico

Queixa Principal:
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Queixas secundárias:
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Medicações:
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Cirurgias:
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Cicatriz/Tatuagem: ( ) Sim ( ) Não
Locais:____________________________________________________________________________________________
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3. Preferências

Palatais Climáticas Relação com: Emoções

( )Doce (BP/E) ( ) Outono (IG/P) ( ) Umidade (BP/E) ( ) Raiva (VB/F)
( ) Ácido (VB/F) ( ) Primavera (VB/F) ( ) Vento (VB/F) ( ) Alegria (CS/C)
( ) Salgado (B/R) ( ) Inverno (B/R) ( ) Secura (IG/P) ( ) Tristeza (IG/P)
( ) Amargo (ID/C) ( ) Verão (CS/C) ( ) Frio (B/R) ( ) Medo (B/R)
( ) Picante (IG/P) Obs.: ( ) Calor (CS/C) ( ) Preocupação (E/BP)
Desejos: Obs.: Obs.:

Aversões:
 4. Exame Físico
Peso: Altura: Nariz/Garganta (P):
Olhos (F): Dentes (R): Digestão (E/BP):
Transpiração (TA-S/M/I): Urina (R): Sono:
Fezes (IG – H=3 a 5 M= 1 a2): Voz (P): Menstruação (R):
Sistema Reprodutor (R):

5. Tipologia

Postura: ( ) Yin ( )Yang

Infância e Puberdade Adulto

Características físicas:

Psico-comportamental:

Sintomatologia:

Cor da face: ( )Vermelho (C/CS) ( ) Amarelo (E/BP) ( ) Branco (P/IG) ( ) Preto (R/B) ( )Azul/Esverdeado (F/VB)

6. Pulsologia

1ª 2ª 3ª 4ª 5ª 6ª 7ª 8ª 9ª 10ª
Direito ___/___ ___/___ ___/___ ___/___ ___/___ ___/___ ___/___ ___/___ ___/___ ___/___
Superficial IG
Profundo P
Superficial E
Profundo BP
Superficial TA
Profundo CS
Esquerdo
Superficial ID
Profundo C
Superficial VB
Profundo F
Superficial B
Profundo R
Marido/Esposa

7. Língua

( ) Pálida e seca (def. de Xue) ( ) Ulcerada e vermelha (ascenção do fogo do C)

( ) Pálida e úmida (def. Yang Qi) ( ) Púrpura ou violácea (estase do Xue)
Cor ( ) Vermelha pálida (normal) ( ) Vermelha com saburra (calor cheio)
( ) Vermelha (calor / def. Yin Qi) ( ) Vermelha escura (desarmonia grave)
( ) Vermelha com áreas avermelhadas (estag. de Xue) ( ) Vermelha sem saburra (calor vazio, def. Yin)
( ) Com saburra branca em excesso (frio interno)
Saburra ( ) Com saburra amarelada (calor interno)
( ) Sem saburra (insuf. do Qi E ou R – def. Yin)
( ) Com fissuras (calor excessivo, def. Yin Qi do R)
Forma ( ) Denteada (umidade, def. Qi BP)
( ) Edemaciada/Inchada (umidade em BP / def. Yang Qi)
( ) Levemente úmida (normal)
Umidade ( ) Umidade ausente (liq. Corpóreos
( ) Umidade em excesso (def. Yin)
Local ( ) Aquecedor inferior (R)
( ) Aquecedor superior (P/C)
Afetado ( ) Aquecedor médio (B/E)
8. Vasos Maravilhosos:
( ) ID3 – B62 (aguda) ( ) TA5 – VB41 (subaguda) ( ) P7 – R6 (crônica) ( ) CS6 – BP4 (psíquico)

9. Evolução:
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