FICHA DE ANAMNESE CLÍNICA

DADOS PESSOAIS:

NOME: _______________________________________________________________________________

DATA DE NASCIMENTO: _________________________________________________________________

ENDEREÇO: _______________________________________________CEP: ________________________

BAIRRO: _____________________ CIDADE: ______________________ESTADO: ___________________

TELEFONES: ( ) ________________________________________________________________________

E-MAIL: ___________________________________________ INSTAGRAM: _______________________

PROFISSÃO: _______________________________ESTADO CIVIL: _______________________________

COMO CONHECEU A SKIN HEALTH? _______________________________________________________

QUEIXA:
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HÁBITOS DIÁRIOS:

UTILIZAÇÃO DE COSMÉTICOS: ____________________________________________________________

EXPOSIÇÃO AO SOL: ___________________ USA LENTES DE CONTATO: __________________________

TABAGISMO: _____________ CIGARROS AO DIA: ____________________________________________

INGERE BEBIDA ALCOÓLICA: _________ QUANTIDADE E FREQUÊNCIA: ___________________________

FUNCIONAMENTO INTESTINAL: __________________________________________________________

QUALIDADE DO SONO: ______________________QTAS HORAS DE SONO: ________________________

INGESTÃO DE LIQUIDO AO DIA: ___________________________________________________________

LÍQUIDO QUE MAIS CONSOME: ___________________________________________________________

REFEIÇÕES AO DIA: _____________________________________________________________________

O QUE MAIS COME DURANTE O DIA: _______________________________________________________

ATIVIDADE FÍSICA: __________________________ FREQUÊNCIA: _______________________________

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 HISTÓRICO CLÍNICO:

TRATAMENTO MÉDICO ATUAL: ___________________________________________________________

MEDICAMENTO EM USO: ________________________________________________________________

ALERGIA: ________________________QUAL: _______________________________________________

PORTADOR DE MARCAPASSO: ___________________ALTERAÇÕES CARDÍACAS: ___________________

HIPERTENSÃO ARTERIAL: _________ MEDICAMENTO: ________________________________________

HIPOTENSÃO ARTERIAL: __________ MEDICAMENTO: ________________________________________

DESMAIOS: _______________ EPLEPSIA: _________________ PSICOPATIA: _______________________

DIABETES: ________________ MEDICAMENTO: _____________________________________________

QUELÓIDE OU CICATRIZ HIPERTRÓFICA: ____________________________________________________

DISTÚRBIO CIRCULATÓRIO: ___________ MEDICAMENTO: ____________________________________

TROMBOSE/EMBOLIA: ______________ MEDICAMENTO: _____________________________________

DISTÚRBIO RENAL: _________________ MEDICAMENTO: _____________________________________

DISTÚRBIO HEPÁTICO: ______________ MEDICAMENTO: _____________________________________

DISTÚRBIO GASTROINTESTINAL: __________________________________________________________

DISTÚRBIO HORMONAL: ________________________________________________________________

ESTRESSE: ____________________________________________________________________________

ANTECEDENTES ONCOLÓGICOS: __________________________________________________________

HÉRNIA UMBILICAL: ____________________________________________________________________

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 EXCLUSIVO PARA MULHERES:

USA ANTICONCEPCIONAL? _______________________________________________________________

USA DIU? QUAL? _______________________________________________________________________

DATA DA ÚLTIMA MENSTRUAÇÃO: ________________________________________________________

PRETENDE ENGRAVIDAR NOS PRÓXIMOS 6 MESES: ___________________________________________

GESTAÇÕES: __________________________________________________________________________

TIPO DE PARTO: _______________________________________________________________________

HISTÓRICO CIRÚRGICO:

CIRURGIA PLÁSTICA: ____________________________________________________________

OUTRAS CIRURGIAS: ____________________________________________________________

IMPLANTE METÁLICO: __________________________________________________________

HISTÓRICO ESTÉTICO:

TRATAMENTO PARA GORDURA LOCALIZADA: _______________________________________

TRATAMENTO PARA CELULITE: ___________________________________________________

TRATAMENTO PARA ESTRIAS: ____________________________________________________

TRATAMENTO PARA FLACIDEZ PELE: ______________________________________________

TRATAMENTO PARA MANCHAS: __________________________________________________

TRATAMENTO PARA CICATRIZ: ___________________________________________________

TRATAMENTO PARA REJUVENESCIMENTO: _________________________________________

DECLARO QUE TODAS AS INFORMAÇÕES ACIMA SÃO VERDADEIRAS, NÃO CABENDO A PROFISSIONAL
E/OU CLÍNICA À RESPONSABILIDADE POR INFORMAÇÕES OMITIDAS

PACIENTE: ______________________________________RG: ___________________________

DATA: _________________________________________ CPF: __________________________

EVOLUÇÃO CLÍNICA:

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@bandodacami

Gerson Neto - falagersao@gmail.com - IP: 45.160.124.240