CADASTRO PARA MASSOTERAPIA
Propaganda
Rua Túlio Jaime Nº 115, Vila Borges – Rio Verde – GO. Cel.: (064) 8409-1463 – 9293-6739 E-mail: [email protected] FRANCISCO CARLOS SILVA RAMOS TÉCNICO EM ESTÉTICA FÁCIAL E CORPORAL MASSOTERAPIA RELAXANTE FICHA DE ANAMNESE 1° - Dados gerais do paciente: Nome:__________________________________________________________________________ Idade:______ Sexo______ Data de Nasc:___/___/___ Profissão:___________________________ Estado Civil:___________________ Filhos: ( )________________________________________ End: ___________________________________________________________________________ Tel:______________________________ e-mail:_______________________________________ QP:_________________________________ HD:_______________________________________ HMA:___________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 2° - Avaliação do paciente: Sinais Vitais: PA:_________ FC:________ T:_______ Peso:_______ Alt:______ IMC:_______ Diabetes ( ) Hipertensão Arterial ( ) Tabagismo ( ) Alcoolismo ( ) Cirurgias ( ) _____________________________________________________________________ Exercícios Físicos ( ) ___________________________ Freqüência: ________________________ Problemas respiratórios ( ) ________________________ Alergia( )________________________ 3° - Distúrbios: Digestão ( ) Rua Túlio Jaime Nº 115, Vila Borges – Rio Verde – GO. Cel.: (064) 8409-1463 – 9293-6739 E-mail: [email protected] Cãibras( ) Convulsões( ) Fibromialgia( ) Ansiedade( ) Depressão( ) Outros:__________________________________________________________________________ 4° - Avaliação Postural Cifose( ) Lordose( ) Escoliose( ) Joelho: Valgo( ) Varo( ) Pé:Cavo( ) Plano( ) Normal( ) Observações: _____________________________________________________________________ ________________________________________________________________________________ 5° - Observações Gerais:____________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 6° - Objetivo Principal: _____________________________________________________________ ________________________________________________________________________________ 7° - Conduta: _____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Rua Túlio Jaime Nº 115, Vila Borges – Rio Verde – GO. Cel.: (064) 8409-1463 – 9293-6739 E-mail: [email protected] Nome: _________________________________________________ RG: _____________________ Ciente:__________________________________________________________________________ Massoterapeuta: __________________________________________________________________ Rio Verde – GO, Data:___/___/___ TRATAMENTO 1ª sessão (___/___/___) Conduta:____________________________________________________ ________________________________________________________________________________ Evolução:_______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Rua Túlio Jaime Nº 115, Vila Borges – Rio Verde – GO. Cel.: (064) 8409-1463 – 9293-6739 E-mail: [email protected] 2ª sessão (___/___/___) Conduta:____________________________________________________ ________________________________________________________________________________ Evolução:_______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 3ª sessão (___/___/___) Conduta:____________________________________________________ ________________________________________________________________________________ Evolução:_______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 4ª sessão (___/___/___) Conduta:____________________________________________________ ________________________________________________________________________________ Evolução:_______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Observações Adicionais: __________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Massoterapeuta:____________________________________________________ Auxiliar:___________________________________________________________ Observações:_____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Rua Túlio Jaime Nº 115, Vila Borges – Rio Verde – GO. Cel.: (064) 8409-1463 – 9293-6739 E-mail: [email protected] ________________________________________________________________________________ ________________________________________________________________________________ (Enviar para o E-mail descrito acima para avaliação e inicio de seções)
