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Ficha de Inscrio e Sondagem

Nome:____________________________________________________________________________________
Sexo:_______ Idade:________ Estado Civil:________________________
Endereo:__________________________________________________________________________________
Tel. Res.:_______________________ Tel. com: ______________________ Cel.:___________________________
Data de nascimento: _______________________ e-mail: ________________________________________________
Filhos:________ Quantos: __________________
Atividade Profissional:_________________________________________________________________________
Fuma? ( ) Quanto?_____________________ Outros vcio:___________________________________________
Pratica esporte? _____________________ Freqncia: _______________________________________________
Horas de sono: _____________________ Freqncia: _______________________________________________
Distrbios do sono, Insnia ( ) Apnia ( ) Inconstncia ( ) Bruxismo ( ) Suor noturno ( ) Sede noturna ( )
Mico
noturna
(
)
Outros:
__________________________________________________________________________
Hbitos alimentares (ex: vegetariano, carnvoro, alimentos industrializados, etc.), freqncia e quantidade de
lquidos:
________________________________________________________________________________________________
_________________________________________________________________________________________
Disfunes:
Sistema Urinrio:____________________________________________________________________________
Sistema Digestivo:___________________________________________________________________________
Sistema Respiratrio:_________________________________________________________________________
Sistema Emocional:__________________________________________________________________________
Observaes:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
_________________________________________________________________________________________
( ) Dores ( ) Cimbras ( ) Cansao ( ) Dormncia Onde?_____________________________________________
_________________________________________________________________________________________
( ) Raiva ( ) Ressentimento ( ) Inveja (Madeira)
( ) Alegria ( ) Euforia ( ) Razo ( )Conscincia ( ) Raciocinio (Fogo)
( ) Angstia ( ) Melancolia ( ) Tristeza ( ) Humilhao ( ) Depresso (Metal)
( ) Medo ( ) Autoritarismo ( ) Insegurana ( ) Pavor ( ) Vontade (gua)
( ) Mgoa ( ) Cime ( ) Obsesso ( ) Preocupao ( ) Memria (Terra)
DIU ( ) Diafragma ( ) Prteses ( ) Onde? ______________________________________________________
Cncer
(
)
Onde?
__________________________
Gestante
(
)
Quanto
tempo?_______________________________
Hrnia de disco (
) Localizao: ___________________ Bico de papagaio (
) Localizao:
_______________________
Trombose Venosa ( ) Hipertenso arterial ( ) Hipotenso arterial ( )
Osteoporose ( ) Inflamaes ( ) Infeces ( ) Onde? ________________________________________________
Distrbios da medula e da cauda eqina ( ) Bloqueios sseos que limita a amplitude de movimento ( )

Artrite reumatide ( ) Doenas degenerativa ( ) Qual?_________________________________________________


Distrbios cardacos (
) Qual? ______________________________ Contuses (
) Onde?
_______________________
Luxaes ( ) Onde? ____________________________ Tores ( ) Onde? ___________________ Erupes ( )
Acne ( ) Urticria ( ) Varizes( ) Quisto( ) Verrugas( ) Hematomas ( ) Onde? _________________ Alergia (
) a que? _________________________________________________________________________________________
Perodo menstrual, dias ______________________ Irregular ( ) Regular ( ) Atrasos ( )
Clicas, menstrual ( ) Estomacal ( ) Renal ( )
Problemas respiratrios ( ) Quais? __________________________________________________________________
Secrees, sudorese excessiva ( ) Urinria, problemas ( ) Quais (ardor, dores, muito, pouco, regularidade, cor
etc.)?_____________________________________________ Fezes ( dores, quantidade, regularidade, forma, cor,
etc.) ____________________________ Doenas transmissveis (
) Qual, quanto tempo e
tratamento?________________
J teve alguma infeco ( ) Qual e a quanto tempo? ______________________________
(F) ( ) Voz triste ( ) (P) Urgncia ( ) (E) Volumosa ( )
(R) Sumida ( ) (IG) Alongada ( ) (E) Rpida ( )
Coluna:
( ) Normal
( ) Cifose
( ) Escoliose
( ) Lordose
Cirurgias, qual e tempo? ________________________________________________________________________
Acidentes, quais e tempo? ______________________________________________________________________
Fraturas
recentes,
Onde
e
quanto
tempo?
______________________________________________________________
Dor
aguda,
Onde?
________________________
Contraturas
musculares,
onde?________________________________
Toma
algum
medicamento,
qual?_____________________________________________________________________
Porque est aqui? (Detalhar motivos):
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
_________________________________________________________________________________________
Outros desequilbrios: ________________________________________________________________________
________________________________________________________________________________________________
____________________________________________________________________________________________

__________________________________
Cliente

Data:

/
___________________________________
Guilherme Elias

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