Professional Documents
Culture Documents
Data da Avaliao:____/____/____
Horrio:______________
1. Dados Pessoais
Nome:_____________________________________________ Estado civil:_______________ Filhos:________________
Sexo: ( )F ( )M Data Nascimento:____/___/___ Hora do nascimento:______________________ Cor: ________________
Endereo:________________________________________________________________________________________
Bairro:_______________________ Cidade:______________________________________UF:_____________________
Naturalidade:____________________________________________ Fone: ( )__________________________________
Escolaridade:__________________________________Profisso:____________________________________________
2. Histrico
Motivo da Consulta:_________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Hora que os sintomas pioram:__________________________________________________________________________
Antecedentes patolgicos, cirurgias:_____________________________________________________________________
________________________________________________________________________________________________
Cicatrizes:________________________________________________________________________________________
________________________________________________________________________________________________
Exames e tratamentos realizados:_______________________________________________________________________
Medico responsvel: _________________________________________________________________________________
Medicamentos em uso:_______________________________________________________________________________
Tabagista:
Etilista:
Drogas:
Atividade fsica:
( ) sim ( ) no
( ) sim ( ) no
( ) sim ( ) no
( ) sim ( ) no
quantidade:___________________________________________________________
quantidade: ___________________________________________________________
quantidade: ___________________________________________________________
qual:_____ ___________________________________________________________
3. Exame Fsico
Peso____________________________________
Altura__________________________________
ICM ___________________________________
P.A.____________________________________
Busto/peitoral_____________________________
Cintura______________________________________
Quadril______________________________________
Coxa________________________________________
Brao_______________________________________
Abdmen (S/I)________________________________
Cabea
( )Algia Frontal
( )Algia Orbital
( )Algia Temporal
( )Algia Occipital
Obs:_______________________________
__________________________________
__________________________________
( )Algia cervical
( )Algia torcica
( )Algia lombar
( )Algia sacral
( )Algia coxgena
Obs:__________________________
______________________________
______________________________
Ventral- Torcica
(
(
(
(
(
(
)
)
)
)
dorme bem
dorme pouco
Insnia
Letargia sonolncia
Obs.:______________________________
__________________________________
__________________________________
__________________________________
__________________________________
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Alimentao
( ) come muito
( ) come pouco
( ) sem apetite
( ) prefere alimentos quentes
( ) prefere alimentos frios
Obs_______________________________
__________________________________
Eliminao intestinal
( ) normal
( ) constipao
( ) diarria ativo
( ) diarria alimento no digerido
( ) fezes ftidas
( ) Melena
( ) fezes com muco
( ) fezes seca
( ) fezes fina como gua
( ) hemorridas
( ) borborigno
( )Dores migratrios
( )Hiperemia e edema
( )Varizes
( )Frio
( )Dores joelhos
Obs.:_________________________
_____________________________
(
(
(
(
(
Audio - Ouvidos
Tato Pele
( )Fraco
(
(
(
(
(
)Fraca
)Surdez
)Zumbido
)Otodinia dor
)Surdez Sbita
)Calor
)Hipodinamia
)Astenia
)Tendinite
)Tenso muscular
Obs.:___________________________
_______________________________
Paladar - Boca
( )Fraco
Olfato - Nariz
( )Fraco
( )Anosmia
Transpirao
( ) sua pouco
( ) suor frio
( ) no sua
( ) suor nas mos e ps
( ) sua muito
( ) suor noturno
( ) suor na cabea
Respiracao
( ) respirao fraca
( ) respirao forcada
( ) falta de ar
( ) dispnia
( ) suspiro
( ) tosse rouca
( ) tosse seca
( ) tosse clara
Disfunes gastro-intestinais
( ) halitose
( ) azia
( ) nuseas enjos
( ) gastrite
( ) constipao
( ) diarria
Obs___________________________
______________________________
Eliminao urinaria
( ) normal
( ) turva
( ) poliria
( ) oliguria
( ) espumante
( ) incontinncia
( ) Nicturia
( ) hematuria
Sede
( ) sem sede
( ) pouca sede
( ) muita sede
( ) preferncia por gua gelada
Obs_____________________________
______________________________
Menstruao
( ) fluxo normal
( )metrorragia
( ) amenorreia
( ) disminorreia
( ) ciclo irregular
( ) TPM
( ) menopausa
Obs.:___________________________
_______________________________
Sistema Reprodutor:
________________________________
______________________________
Averses:_______________________________________
Preferncias Palatais
____Doce(E/BP) ____cido(VB/F) ____Salgado(B/R) ____Amargo(ID/C) ____Picante(IG/P)
Obs.:_______________________________________________________________________________________________
Preferncias Climticas
____Outono(IG/P) ____Primavera(VB/F) ____Inverno(B/R) ____Vero(C/CS)
Obs.:________________________________________________________________________________________________
Agresso
____Umidade(BP/E) ____Frio(B/R) ____Vento(VB/F) ____Calor(C/ID) ____Secura(P/IG)
Obs.:________________________________________________________________________________________________
Quais so as emoes mais freqentes e em quais situaes elas surgem
____Raiva(VB/F) ____Tristeza(P/IG) ____Preocupao(BP/E) ____Medo(R/B) ____Alegria(C/IG)
Obs.:________________________________________________________________________________________________
5. Constitucional / tipologia
Cor do Rosto
____Vermelho(C/ID) ____Amarelo(BP/E) ____Branco(P/IG) ____Preto(R/B) ____Azul.(F/VB)
( ) face brilhante
( ) face opaca
( ) face amarelada
( ) face escurecida
( ) face plida
( ) pele seca
( ) face avermelhada
( ) pele mida
( ) face avermelhada ou azulada
Tipo de Face
( ) fogo ( ) terra ( ) metal ( ) gua ( ) madeira
Obs.:______________________________________________________________________
Cabelos:__________________________________________________________________
Dentes:________________________________________________________________________________
Unhas:_________________________________________________________________________________
Lbios:_________________________________________________________________________________
Voz:___________________________________________________________________________________
(
(
(
(
(
) fala alta
) fala baixo
) fala incoerente
) fala muito
) gagueira
( ) pouca fala
( ) sem fala
( ) afonia sbita
( ) rouquido, afonia gradual
Obs.: ____________________________________________________________________________________
Caractersticas ficicas
( ) tronco > membros ( ) membros> tronco
Tipologia Geral (postura):
6. Lngua
( ) YIN
( ) tronco = membros
( ) YANG
Cor:_________________________________Aspecto:_________________________
( ) plida e seca
( ) com saburra amarela
( ) plida e mida
( ) sem saburra
( ) vermelha
( ) denteada
( ) vermelha com reas avermelhadas
( ) prpura ou violacea
( ) ulcerada e vermelha
( ) grande
( ) com rachadura
( ) curta
( ) com saburra
7. Pulsologia
Direito
I-
Superficial IG
Profundo
P
II-
Superficial E
Profundo
BP
III-
Superficial TA
Profundo CS
Antes
Depois
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Esquerdo
I-
Superficial ID
Profundo C
II-
Superficial VB
Profundo F
III-
Superficial B
Profundo R
Antes
Depois
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8. Diagnstico
Meridiano Tendneo Muscular afetado?_________ Qual__________________________________________________
9. Concluso
Base Clnica para o tratamento / Pontos sistmicos/ vasos maravilhosos/ auriculo/ outros recursos
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Assinatura: _________________________________