Ficha de anamnese para Terapia Floral

Nome:________________________________________________________________________
Data nascimento: ___/___/___
Endereço:_____________________________________________________________________
Bairro:_____________________Telefone:(____)______________________________________
email:________________________________________________________________________
Profissão:__________________ Estado civil:_________________________________________
Filhos:________________________________________________________________________

Padrão corporal:
Atividade física regular? Não ( ) Sim ( ) Qual? _______________________________________
Cirurgias?_____________________________________________________________________
Fraturas?_____________________________________________________________________
Dores?_______________________________________________________________________

Saúde:
Pele ( )__________________ Ginecológico / urológico ( ) ___________________Endócrino ( )
__________________ Renal ( ) ___________________ Digestivo ________________ Circulação /
coração ( )__________________ Pressão: ____________Respiratório ( ) ____________________
Ósseo/coluna ( ) _____________________________ Funcionamento
intestinal:_______________Alergias( )_____________________Diabetes( ) ______________
Faz uso de algum método contraceptivo? __________________________________________
Menopausa( ) Faz reposição hormonal?____________________________________________
Histórico oncológico:________________________________
Doenças Anteriores:______________________________
Tratamentos Anteriores:_________________________________________________________
Atualmente faz acompanhamento médico, psicológico ou outra terapia?
_____________________________________________________________________________
Faz uso de alguma medicação?
______________________________________________________________________

Alimentação:
Apetite:___________________Legumes/verduras ____________ Frutas ____________ Massas
__________________ Carnes ___________ Leite_____________Frituras
__________Açucar___________________ Faz dieta ___________
Café________________Álcool:____________________Qtde de água que ingere/dia
___________________________
VIDA (dia a dia)?
Nível de stress ( ) baixo ( ) médio ( ) alto Possui algum vício?
______________________________________________
Nível de ansiedade ( ) baixo ( ) médio ( ) alto
Dorme bem?______________________________________________________________
Familiar
Quem mora com você?_____________________________________________________
Convivência? ( ) boa ( ) ruim ( ) conflituosa ( ) insatisfeito
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Profissional
_____________________________________________________________________________

Relacionamento grupal no meio ambiente onde estuda ou trabalha? ( ) bom ( ) conflituoso ( ) péssimo
Gosta do que faz/estuda? ( ) sim ( ) não ( ) faz por necessidade / Satisfeito com salário? ( ) sim ( ) não
Leitura ( ) muito ( ) pouco ( ) detesta
Última vez que tirou férias
_________________________________________________________________________
Planejamento profissional/médio
prazo:_______________________________________________________________
OBS.: ________________________________________________________________________

Social
Possui amigos?
____________________________________________________________________________
Sai para se divertir? ( ) sim ( ) não ( ) muito pouco ( ) raramente
Hobbies ( ) sim ( )
não__________________________________________________________________________
Religião ________________ ( ) freqüentador assíduo ( ) normal ( ) eventualmente
Costuma viajar? ( ) sim ( ) não
OBS.:
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1º Consulta Data __ / __ / __
Motivo / queixas do cliente:
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Avaliação geral / observações

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2º Consulta Data __ / __ / __
Motivo / queixas do cliente:
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Avaliação geral / observações /Sugestões/Fórmula:

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3º Consulta Data __ / __ / __

Motivo / queixas do cliente:

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Avaliação geral / observações /Sugestões/Fórmula:

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4º Consulta Data __ / __ / __
Motivo / queixas do cliente:
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Avaliação geral / observações /Sugestões/Fórmula:

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5º Consulta Data __ / __ / __

Motivo / queixas do cliente:

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Avaliação geral / observações /Sugestões/Fórmula:

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