FICHA DE ANAMNESE

FICHA DE ANAMNESE1) Dados gerais do paciente:

Nome:__________________________________________________________________________ Idade:______ Sexo______ Data de Nasc:___/___/___ Profisso:___________________________

Estado Civil:___________________ Filhos: ( )________________________________________

End: ___________________________________________________________________________

Tel:______________________________ e-mail:_______________________________________

QP:_________________________________ HD:_______________________________________

HMA:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2) Avaliao do paciente:

Sinais Vitais: PA:_________ FC:________ T:_______ Peso:_______ Alt:______ IMC:_______

Diabetes( ) Hipertenso Arterial ( ) Tabagismo ( ) Alcoolismo ( )

Cirurgias( ) _____________________________________________________________________

Exerccios Fsicos( ) ___________________________ Freqncia: ________________________

Problemas respiratrios( ) ________________________ Alergia( )________________________

3) Distrbios:

Digesto( ) Cibras( ) Convulses( ) Fibromialgia( ) Ansiedade( ) Depresso( )

Outros:__________________________________________________________________________

4) Avaliao Postural

Cifose( ) Lordose( ) Escoliose( ) Joelho: Valgo( ) Varo( ) P:Cavo( ) Plano( ) Normal( )

Observaes: _____________________________________________________________________

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5) Observaes Gerais:____________________________________________________________

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6) Objetivo Principal: _____________________________________________________________

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7) Conduta: _____________________________________________________________________

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Nome: _________________________________________________ RG: _____________________ Ciente:__________________________________________________________________________

Massoterapeuta: __________________________________________________________________

Catanduva SP Data:___/___/___

TRATAMENTO1 sesso(___/___/___) Conduta:____________________________________________________

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Evoluo:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2 sesso(___/___/___) Conduta:____________________________________________________

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Evoluo:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3 sesso(___/___/___) Conduta:____________________________________________________

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Evoluo:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4 sesso(___/___/___) Conduta:____________________________________________________

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Evoluo:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Observaes Adicionais: __________________________________________________________

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Massoterapeuta:____________________________________________________

Auxiliar:___________________________________________________________