Ficha de Avaliação

Nome: _______________________________________________________________________________
Idade: ________ Nascimento: _________________ Sexo: ____________________________________
Endereço: _____________________________________________________________________________
Telefone Res.: (___) __________________________ Celular: (___) ______________________________
Profissão: ___________________________________________________ Há quantos anos? _________

Anamnese
Motivo da Consulta: _____________________________________________________________________
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HDA: ________________________________________________________________________________
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HDP: ________________________________________________________________________________
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Altura: ____________ Peso: ______________ Obs.: ________________________________________
É diabético? _____ Está grávida? _____ É cardíaco? _____ Sofre de pressão alta? _____ Fuma? ____
Usa marca passo? ______ Usa antidepressivos? _____ Usa analgésicos fortes? _____
Bebidas alcoólicas? ( ) não ( ) com frequência ( ) pouco
Doença crônica? (há muito tempo) _________________________________________________________
Doenças na família? ___________________________________________________________________
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Dor de cabeça forte e constante? ______ Outra dor? __________________________________________
Sente dores nos ossos? ______ Sente dores nas articulações? ______ Sente dores musculares? ________
Faz exercícios físicos? _____ Bebe bastante água? ______ Vida estressada? _______
Como se alimenta? ( ) pouco ( ) razoável ( ) muito ( ) mais do que deveria
Com que qualidade? ( ) mal ( ) regular ( ) boa ( ) me alimento muito bem
Que tipo de medicamento está usando agora? ________________________________________________
Com que objetivo?
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Estado Geral
Emocional: ____________________________________________________________________________
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Cardiorrespiratório: _____________________________________________________________________
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Digestivo: _____________________________________________________________________________
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Intestinal: _____________________________________________________________________________
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Urinário: ______________________________________________________________________________
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Dermatológico: _________________________________________________________________________
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Neurológico: ___________________________________________________________________________
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Exame Físico
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Avaliação Auricular

Inspeção (manchas, vascularização, escamações e alterações morfológicas)

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Palpação (alterações morfológicas, reação à dor, depressões, edemas e escamações)

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Conclusão
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CONSULTA Nº 1
Data ___/___/____ Hora: ___:___

Pontos Aplicados:

Objetivos desta aplicação:

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CONSULTA Nº 2
Data ___/___/____ Hora: ___:___

Pontos Aplicados:

Resposta clínica do paciente a aplicação anterior:

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Objetivos desta aplicação:

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