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Nome: Amanda Machado; Caroline Siqueira; Paloma Gonalves e Selen

Karoline

AVALIAO DE ACUPUNTURA E MEDICINA TRADICIONAL CHINESA

Paciente:_______________________________________________________
Endereo:______________________________________________________
Telefone
Res.
__________________
Cel
_________________
Email:__________________________________________________________
Nascimento ______/_______/_______ Idade _______
Profisso _________________________________________
QUEIXA PRINCIPAL:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
HISTRIA DA DOENA ATUAL
Quando e como iniciou? Desenvolvimento da patologia? O que piora e o
que melhora a sintomatologia?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
HISTRIA PATOLGICA PREGRESSA
Doenas anteriores:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Cirurgias:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Alergias:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

HISTRIA FAMILIAR - relao em famlia, doenas de antepassados.


_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
DOR: ( ) SIM ( ) NO Local: _____________________________________
O que alivia: ____________________________________________________
O que piora: ____________________________________________________
CALOR OU FRIO: ( ) SIM ( ) NO Quando: _________________________
FEBRE: ( ) SIM ( ) NO Valor: ___________________________________
SEDE: ( ) MUITA ( ) POUCA ( ) PREFERENCIA POR GELADO
( ) PREFERENCIA POR QUENTE OBS: _____________________________
FOME: ( ) MUITA ( ) POUCA ( ) PREFERENCIA ______________________
TRANSPIRAO: ( ) MUITA ( ) POUCA Local:_______________________
PELE: ( ) CICATRIZ ( ) LCERA ( ) ABSCESSOS ( ) INCHAOS
( ) MASSA LOCAL _______________________________________________
Sono e sonhos: ( ) INSONIA Tipo: ________________________________
RONCO: ( ) APNIA ( ) BRUXISMO ( ) PERNAS INQUIETAS ____________
CABEA:
Dor,
tipo
e
local:
_______________________________________________________________
_______________________________________________________________
SENTIDOS: ( ) Tontura ( ) Zumbido ( ) Baixa audio ( )Baixa viso
( ) perda do paladar
Sinais Vitais: PA:_________ FC:________ T:_______
Peso:_______ Alt:______ IMC:_______
Diabetes( )

Hipertenso Arterial ( ) Tabagismo ( )

Alcoolismo ( )

Exerccios Fsicos ( ) Freqncia: __________________________________


Problemas respiratrios ( ) _______________________________________
Alergia ( )______________________________________________________