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 ( ) altoDorme bem?______________________________________________________________FamiliarQuem mora com você?_____________________________________________________

Convivência? ( ) boa ( ) ruim ( ) conflituosa ( ) insatisfeito _____________________________________________________________________________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.: ________________________________________________________________________

SocialPossui amigos? ____________________________________________________________________________Sai para se divertir? ( ) sim ( ) não ( ) muito pouco ( ) raramente Hobbies ( ) sim ( ) não__________________________________________________________________________Religião ________________ ( ) freqüentador assíduo ( ) normal ( ) eventualmenteCostuma viajar? ( ) sim ( ) nãoOBS.: _____________________________________________________________________________

1º Consulta Data __ / __ / __Motivo / queixas do cliente: _________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Avaliação geral / observações /Sugestões/Fórmula:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2º Consulta Data __ / __ / __ Motivo / queixas do cliente: _________________________________________________________________________ _________________________________________________________________________________

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Avaliação geral / observações /Sugestões/Fórmula: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3º Consulta Data __ / __ / __

Motivo / queixas do cliente: _________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Avaliação geral / observações /Sugestões/Fórmula: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4º Consulta Data __ / __ / __Motivo / queixas do cliente: _________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Avaliação geral / observações /Sugestões/Fórmula: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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5º Consulta Data __ / __ / __

Motivo / queixas do cliente: _________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Avaliação geral / observações /Sugestões/Fórmula: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________