FICHA DE ANAMNESE

1°) Dados gerais do paciente:

Nome:__________________________________________________________________________
Idade:______ Sexo______ Data de Nasc:___/___/___ Profissão:___________________________
Estado Civil:___________________ Filhos: ( )________________________________________
End: ___________________________________________________________________________
Tel:______________________________ e-mail:_______________________________________
QP:_________________________________ HD:_______________________________________
HFami:__________________________________________________________________________
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2°) Avaliação do paciente:

Sinais Vitais: PA: _________________________ FC:________________ T:_________________
Peso:______________ Alt:________________ IMC:________________
Diabetes ( ) Hipertensão Arterial ( ) Tabagismo ( ) Alcoolismo ( )
Cirurgias ( ) _____________________________________________________________________
Exercícios Físicos ( ) ___________________________ Frequência: _______________________
Problemas respiratórios ( ) ________________________ Alergia( )________________________

3°) Distúrbios:
Digestão ( ) Cãibras( ) Convulsões( ) Fibromialgia( ) Ansiedade( ) Depressão( )
Outros:__________________________________________________________________________

4°) Avaliação Postural

Hipercifose ( ) / Hiperlordose C( ) L( ) / Escoliose C( ) S( ) / Retificação C( ) T( ) L( )
Joelho: Valgo( ) Varo( ) Pé: Cavo( ) Plano( ) Normal( )
Observações: _____________________________________________________________________
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5°) Observações Gerais:____________________________________________________________

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6°) Objetivo Principal: _____________________________________________________________
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7°) Conduta: _____________________________________________________________________

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Nome: _________________________________________________ RG: _____________________

Ciente:__________________________________________________________________________

Massoterapeuta: __________________________________________________________________

________________ – AP Data:___/___/___
 TRATAMENTO

1ª sessão(___/___/___) Conduta:____________________________________________________

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Evolução:_______________________________________________________________________

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2ª sessão(___/___/___) Conduta:____________________________________________________

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Evolução:_______________________________________________________________________

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3ª sessão(___/___/___) Conduta:____________________________________________________

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Evolução:_______________________________________________________________________

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Observações Adicionais: __________________________________________________________

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Massoterapeuta:____________________________________________________
Auxiliar:___________________________________________________________