CONSULTÓRIO DE MEDICINA NATURAL E TRADICIONAL

“ALEGRIA DA MAMÔ
BAIRRO CAMPO ESCOLA
SAPÚ BITA – CAMPO
TEL: 943 234 869

Ficha de inscrição Nº _____/_________ Data________/________/_________

Nome do Cliente _________________________________________________________
Data de nascimento______/_____________/_______
Sexo: Masculino Feminino
Endereço_________________________________________________________________
Bairro ___________________________________________________________________
Município________________________________________________________________
Distrito __________________________________________________________________
Cidade___________________________________________________________________
Telefone______________________________/___________________________________
Telefone/ Acompanhante_____________________/______________________________

Histórico
Alimentação:______________________________________________________________
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Eventual :________________________________________________________________
Dieta Alimentar
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Usa ou usou drogas? _______________
Quais____________________________________________________________________
Faz alguma terapia? ________________
Qual_____________________________________________________________________
Doença de infância_________________________________________________________
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Queixas do desequilíbrio orgânico
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Observações______________________________________________________________
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Cidade de_____________ aos ________/________/___________________

O TERAPEUTA
_______________________
ANTÓNIO MAWA
(ALEGRIA DA MAMÃ)
 CONSULTÓRIO DE MEDICINA NATURAL E TRADICIONAL
“ALEGRIA DA MAMÔ
BAIRRO CAMPO ESCOLA
SAPÚ BITA – CAMPO
TEL: 943 234 869

Ficha de Atendimento Nº _____/_________ Data________/_______/________

Nome Completo___________________________________________________________
Data de nascimento______/______/____________
Local de residência_________________________________________________________
Sexo___________________ Tel__________________________

Avaliação de qualidade de vida

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Recomendações a terapia
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Continuação das recomendações a terapia
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Luanda, aos _______/__________/___________

O TERAPEUTA

____________________
ANTÓNIO MAWA
(ALEGRIA DA MAMÃ)
TEL : 943 234 869