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881-34
Ficha Clínica
Data:___/____/_____
Nome:_____________________________________________________ Idade:________________
Endereço___________________________________CEP:________________Bairro:____________
Profissão:________________________________________________ Sexo: Fem ( ) Masc ( )
Est. Civil: __________________________ Escolaridade:__________________________________
Como chegou até nós: _____________________________________________________________
Queixa Principal:__________________________________________________________________
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Problema Emocional Qual?__________________________________________________________
( ) Dor Crônica ( ) Dor por trauma Quando teve início o problema? ____________________
Mulheres: Está grávida? ( )Sim ( )Não Se sim, de quanto tempo _____________ Quantas
gestações: _________ Está na menopausa ( )Sim ( )Não há quanto tempo?______________
DOR
1-Local da dor: ( )Cabeça ( )Occiptal ( )Temporal ( )Frontal ( )ATM ( )Sinusite
Hematológica ( ) Hepatológica ( )
25-Pratica Atividade Física ( ) Não ( )Sim Com Qual Frequência? ( )1-2 X/Semana
( )3-5x Semana ( ) Todos Os Dias Qual:_____________________________________________
26-Quantas refeições faz ao dia ( ) 1-2 ( ) 3-5 ( )+5
27-Quantos copos de água toma por dia (+/-300ml)? ( ) não tomo água ( ) 1-2 copos
( ) 3-4 ( ) 5-6 ( ) + de 7 copos
28- Qual seu peso: _______________ Altura:______________ IMC:_______________________
29- Quanto ao hábito intestinal? ( ) Todos os dias ( ) 1-2x/Semana ( ) Em dias
alternados ( ) 1 Semana ( ) Mais de 1 Semana
30- Quantas horas de sono por dia:_______________ A que hora vai dormir ______________
( ) Bruxismo ( ) Síndrome das Pernas Inquietas ( )Dificuldades para dormir ou
acorda no meio da noite ( ) Acorda com dor ( ) Acorda cansado ( ) Ronco e apneia
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