Professional Documents
Culture Documents
Paciente ______________________________________________________________________
Endereço_____________________________________________________________________
Telefone Celular________________ E-mail __________________________________________
Nascimento ______/_______/19______
( ) Diabetes
( ) Gravidez
( ) Cardíaco
( ) Hipertenso
( ) Fumante
( ) Utiliza antidepressivos
( ) Utiliza analgésicos
( ) algum outro medicamento em uso. Qual? ____________________________________
para: _____________________________________________________________________
Dores:
( ) músculos
( ) outras dores :
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RUBRICA DO TERAPEUTA ASSINATURA DO PACIENTE
Pontos aplicados:
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Finalidade:
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Pontos aplicados:
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Finalidade:
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