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FICHA DE ANAMNESE 
 
1- DADOS DO PACIENTE 
Nome:_________________________________________________________________ 
Nascimento: ___/___/___ idade: ____sexo: __________nacionalidade:___________ 
Estado civil:______________ filhos: ( ) ________ idade:_______________________ 
Religião: _________________ profissão:_____________________________________ 
Bairro:_________________________________________________________________ 
Cidade: ______________________ estado: _________ UF: ____CEP:______________ 
Telefone: ____________ celular: ( ) __________ e-mail:_______________________ 
CPF: ___________________RG:________________ órgão emissor: _______________ 
 
 
Em caso de emergência 
Nome: __________________________ contato: _______________________________ 
Médico:_________________________ contato: _______________________________ 
Convenio: _______________________ cartão: ________________________________ 
hospital:_______________________________________________________________ 
 
Queixa principal: ________________________________________________________ 
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2- AVALIAÇÃO DO PACIENTE 
Sinais vitais PA: FC: T: Peso: Altura: 
Diabetes ( ) Tabagismo ( ) Próteses dentárias ( ) Epilepsia ( ) Varizes ( ) 
Lesões ( ) Hipertensão arterial ( ) Hipotensão arterial ( ) Colesterol ( ) 
Faz ou já fez algum tratamento médico? S ( ) N ( ) quais: _____________________ 
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Tem antecedente oncológico? S ( ) N ( ) 
Antecedente familiar: ____________________________________________________ 
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Já fez tratamento estético? S ( ) N ( ) quais:________________________________ 
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Toma algum remédio? S ( ) N ( ) quais: ___________________________________ 
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Pratica exercícios físicos? S ( ) N ( ) frequência: 
_____________________________ 
Ingere água com frequência? S ( ) N ( ) 
Tem a alimentação balanceada? S ( ) N ( ) 
Ingere álcool? S ( ) N ( ) frequência: ______________________________________ 
Usa drogas ilícitas? S ( ) N ( ) 
Tem alguma alergia? S ( ) N ( ) quais:_____________________________________ 
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Tem alguma doença transmissível? S ( ) N ( ) 
É gestante ou amamenta? S ( ) N ( ) 
Usa anticoncepcional? S ( ) N ( ) 
Ciclo menstrual regular? S ( ) N ( ) 
Presença de metais: S ( ) N ( ) 
Tem algum problema ortopédico? S ( ) N ( ) 
É portador de marca passo? S ( ) N ( ) 
Tem sensibilidade a dor? S ( ) N ( ) 
 
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