Anamnese Florais.docx

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 _____________________________________________________________________________ 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.: _____________________________________________________________________________ 1º Consulta Data __ / __ / __ Motivo / queixas do cliente: _________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ Avaliação geral / observações /Sugestões/Fórmula:_________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________ 2º Consulta Data __ / __ / __ Motivo / queixas do cliente: _________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ 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: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

_________________________________________________________ 5º Consulta Data __ / __ / __ Motivo / queixas do cliente: _________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _____________________________________________________ Avaliação geral / observações /Sugestões/Fórmula: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _______________________________________________________