Ficha de anamnese para Terapia Floral
Nome:___________________ Nome:______________________________ _______________________ _______________________ _______________________ ___________________ _______ Data nascimento: ___/___/___ Endereço:_____________________________________________________________________ Bairro:_____________________Telefone:(____)______________________________________ email:_____________________ email:________________________________ _______________________ ________________________ _______________________ ________________ _____ Profissão:__________________ Profissão:__________________ Estado civil:______________________ civil:__________________________________ ___________________ _______ Filhos:___________________ Filhos:_______________________________ _______________________ _______________________ _______________________ __________________ _______ Padrão corporal: tividade f!sica re"#lar$ Não ( ) %im ( ) &#al$ ______________________ _________________________________ _________________ ______ 'ir#r"ias$_______________ 'ir#r"ias$___________________________ _______________________ _______________________ _______________________ ___________________ ________ Frat#ras$__________________ Frat#ras$_____________________________ _______________________ _______________________ _______________________ _________________ _____ Dores$_______________________________________________________________________ %ade: Pele ( )__________________ )__________________ inecol*"ico / #rol*"ico ( ) ___________________End*crino ___________________End*crino ( ) __________________ __________________ +enal +enal ( ) ___________________ ___________________ Di"estivo Di"estivo ________________ ________________ 'irc#lação 'irc#lação / coração ( )__________________ )__________________ Pressão: ____________+espirat*rio ____________+espirat*rio ( ) ____________________ ____________________ ,sseo/col#na ( ) ______________________ _____________________________ _______ F#ncionamento intestinal:_______________ler" intestinal:_______________ler"ias( ias( )_____________________Dia)_____________________Dia-etes( etes( ) ______________ ______________ Fa. #so de al"#m mtodo contraceptivo$ ______________________ __________________________________ ____________________ ________ 0enopa#sa( ) Fa. reposição hormonal$________________________ hormonal$____________________________________ ____________________ ________ 1ist*rico oncol*"ico:_______________ oncol*"ico:___________________________ _________________ _____ Doenças nteriores:______________ nteriores:__________________________ ________________ ____ Tratamentos nteriores:_________________________________________________________ t#almente fa. acompanhamento mdico2 psicol*"ico o# o#tra terapia$ _______________________ __________________________________ _______________________ _______________________ _______________________ ____________________ ________ Fa. #so de al"#ma medicação$ _______________________ __________________________________ _______________________ _______________________ _______________________ ______________ limentação: petite:___________________3e petite:___________________3e"#mes/verd#ras "#mes/verd#ras ____________ Fr#tas ____________ ____________ 0assas __________________ __________________ 'arnes 'arnes ___________ ___________ 3eite_____________Frit#ras 3eite_____________Frit#ras __________ç#car_______ __________ç#car___________________ ____________ Fa. Fa. dieta ___________ ___________ 'af________________4lcool:_ 'af________________4lcool:____________ ___________________&tde ________&tde de 5"#a 6#e in"ere/dia _______________________ ___________________________ ____ 78D (dia a dia)$ N!vel de stress ( ) -ai9o -ai9o ( ) mdio ( ) alto Poss#i Poss#i al"#m v!cio$ _______________________ __________________________________ _______________________ ____________ N!vel de ansiedade ansiedade ( ) -ai9o ( ) mdio ( ) alto alto Dorme -em$______________________________________________________________ Familiar &#em mora com voc$_____________________________________________________
'onvivncia$ ( ) -oa ( ) r#im ( ) conflit#osa ( ) insatisfeito _____________________________________________________________________________ Profissional _____________________________________________________________________________ +elacionamento "r#pal no meio am-iente onde est#da o# tra-alha$ ( ) -om ( ) conflit#oso ( ) pssimo osta do 6#e fa./est#da$ ( ) sim ( ) não ( ) fa. por necessidade / %atisfeito com sal5rio$ ( ) sim ( ) não 3eit#ra ( ) m#ito ( ) po#co ( ) detesta ;ltima ve. 6#e tiro# frias _________________________________________________________________________ Plane
: ________________________________________________________________________ %ocial Poss#i ami"os$ ____________________________________________________________________________ %ai para se divertir$ ( ) sim ( ) não ( ) m#ito po#co ( ) raramente 1o--ies ( ) sim ( ) não__________________________________________________________________________ +eli"ião ________________ ( ) fre6?entador ass!d#o ( ) normal ( ) event#almente 'ost#ma via: _____________________________________________________________________________ @A 'ons#lta Data __ / __ / __ 0otivo / 6#ei9as do cliente: _________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ valiação "eral / o-servaçes /%#"estes/F*rm#la:_________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________ CA 'ons#lta Data __ / __ / __ 0otivo / 6#ei9as do cliente: _________________________________________________________________________ _________________________________________________________________________________
_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ valiação "eral / o-servaçes /%#"estes/F*rm#la: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _______________________________________________________ A 'ons#lta Data __ / __ / __ 0otivo / 6#ei9as do cliente: _________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ valiação "eral / o-servaçes /%#"estes/F*rm#la: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________ A 'ons#lta Data __ / __ / __ 0otivo / 6#ei9as do cliente: _________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________ valiação "eral / o-servaçes /%#"estes/F*rm#la: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________ A 'ons#lta Data __ / __ / __ 0otivo / 6#ei9as do cliente: _________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ valiação "eral / o-servaçes /%#"estes/F*rm#la: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _______________________________________________________
