PARA USO DA SNTESE MEDICINAS ALTERNATIVAS

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Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

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SINTESE MEDICINAS ALTERNATIVAS

INVENTRIO HOLSTICO DE SADE
DADOS PESSOAIS
Data:
Nome
:
Idade:

Nascimento:

N de filhos:
Endereo:
Bairr
o:
Local de
Trabalho:
Fone resid.:
Celula
r:
E-maill:

Estado civil:

Idade:
N
Cidade:

Compl.:
CEP:

Funo:
Fone trab.:

Home page:
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HOLOSSINTESE

Procure responder s questes que se seguem conforme sua percepo e

intuio.
Elas permitiro a voc uma reflexo abrangente sobre si mesmo
facilitando a compreenso de seu momento evolutivo, suas peculiaridades
e singularidades.
Permitir tambm de maior compreenso de suas demandas, sua
realidade, seu tratamento e medicao
.Se necessrio pode acrescentar informaes adicionais no verso das
pginas ou durante sua entrevista.
Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

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Obrigado, boa sorte!

PRIORIDADES DE TRATAMENTO
1

Est ou esteve em algum tratamento? (

) No. ( ) Sim. Cite-os

PARA SEU USO

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Apresenta alguma sndrome? ( )No.( ) Sim. Qual(is)?

PARA SEU USO
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Passou por alguma cirurgia? ( ) No. ( ) Sim. Quais? H quanto tempo?

PARA SEU USO
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Pratica alguma atividade fsica? (

) No. ( ) Sim. Quais?

PARA SEU USO

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Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com

Em relao aos medicamentos em uso, favor anotar qual voc utiliza a seguir,
nos subsistemas que seguem abaixo.

AVALIACAO DOS SUB SISTEMAS

RESPIRATRIO
( )Alergias
( )Entupimento nasal
( )Adenide
( )Tosse seca
( )Falta de ar
( )Tosse produtiva
( )Falta de flego
( )Pneumonias
( )Sinusite
( )Outros
( )Bronquite
Medicamentos____________________________
( )Asma
________________________________________
( )Sangramento nasal
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PARA SEU USO:____________________________________________________________________________________________
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PELE
(
(
(
(
(
(

)Acne
)Herpes
)Vitiligo
)Espinhas
)Manchas
)Escamao

(
(
(
(
(
(

)Caspa
)Verrugas
)Sudorese excessiva
)Micoses
)Coceira
)Psorase

( )Urticria
( )Outros
Medicamentos__________
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PARA SEU USO:____________________________________________________________________________________________

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DIGESTRIO
( )Aftas
( )Dor de garganta
( )Gengivite

( )Rouquido
( )Mau hlito
( )Dificuldade de engolir

( )Hrnia
( )Aumento de peso
( )Obesidade

Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com

(
(
(
(
(

)Esofagite
)Hemorragia
)Afonia
)Queimao
)Gases

(
(
(
(
(

)Gastrite
)lcera
)Emagrecimento
)Anorexia
)Compulso

(
(
(
(
(

)Vmitos
)Enjo de viagem
)Digesto lenta
)Cirurgias
)Outros

PARA SEU USO:____________________________________________________________________________________________

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DIFICULDADES DIGESTIVAS
(
(
(
(

)Gorduras
)Bebidas
)Queijos
)Peixes

(
(
(
(

)Leite
)Temperos
)Ovos
)Mariscos

( )Outros
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PARA SEU USO:____________________________________________________________________________________________

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INTESTINOS
(
(
(
(
(
(

)Priso de ventre
)Plipo
)Colite
)Divertculos
) Diarrias
)Clicas

(
(
(
(
(
(

)Pontadas
)Hemorridas
)Coceiras
)Vermes
)Sangramentos
)Outros

Medicamentos__________
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PARA SEU USO:____________________________________________________________________________________________

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EXCRETRIO
(
(
(
(
(
(

)Clculo renal
)Insuficincia renal
)Nefrite
)Hematria( Sangue na urina)
)Disria( Dificuldade em urinar)
)Polaciria(Aumento volume de urina)

(
(
(
(
(

)Nictria( Eliminao de urina a noite)

)Anria( Pouca urina)
)Presena de dor regio abdominal
)Incontinncia urinria
)Outros

Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com

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Medicamentos___________________________
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PARA SEU USO:____________________________________________________________________________________________

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CIRCULATRIO
(
(
(
(
(

)Presso alta
)Presso baixa
)Taquicardia
)Arritmias(Falhas)
)Hemorragias

(
(
(
(

)Dormncia nas mos

)Rigidez na nuca
)Formigamento
)Outros

Medicamentos__________
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PARA SEU USO:____________________________________________________________________________________________

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CIRCULATRIO / SANGUE
Tipo Sanguneo
( )Anemia
( )Glicose
( )Triglicrides
( )Hemorragias

Ultima data de
exames:________________________________
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( )Outros_____________________________

PARA SEU USO:____________________________________________________________________________________________

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SADE DA CRIANA
Adoecimentos do 1 ano de vida
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Adoecimentos dos primeiros 3 anos de vida
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Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com

________________________________________________________________________________
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Adoecimento de 4 a 7 anos
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Peculiaridades da Gestao
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(
(
(
(
(
(
(
(
(
(
(

)Dentio
)Crescimento
)Linguagem
)Cimes
)Altismo
)Esquizofrenia
)Isolamento
)Atraso desenvolvimento motor
)Atraso escolar
)Leucemia
)Distrofia Muscular

( )Dores do crescimento
( )Dermatite
( )Desidratao
( )Hidrocefalia
( )Varismo e Valgismo
( )Anemia
( )Outros
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PARA SEU USO:____________________________________________________________________________________________

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PATOLOGIAS INFANTIS
(
(
(
(
(
(
(

)Sarampo
)Catapora
)Coqueluche
)Alergias
)Pneumonias
)Bronquite
)Dislexia

(
(
(
(
(

)Rubola
)Caxumba
)Diarria
)Meningite
)Outros___________________

PARA SEU USO:____________________________________________________________________________________________

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SISTEMA HEPTICO
( )Boca amarga

( )Boca seca

( )Vmitos biliares

Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com

( )Clculos biliares
( )Extrao de Vescula
______________________
( )Clica heptica
( )Outros
___________________
( )Clica biliar
______________________
( )Hepatite
PARA SEU USO:____________________________________________________________________________________________
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MSCULO ESQUELTICO
Dores na coluna

( )Cervical

( )Costas

Desvio na coluna
( ) Escoliose ( ) Cifose (

( )Lombar

) Lordose

( )Paralisias
( )Joelho
( )Quadris
( )Tornozelos
( )Mos
( )Dedos
( )Pernas
( ) Ccix

PARA SEU USO:____________________________________________________________________________________________

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MSCULOS
(
(
(
(
(
(

)Atrofias
)Cimbras
)Estiramentos
)Luxaes
)Traumatismos
)Cirurgias

( )Tenso
( )Fraqueza
( )Dor
( )Distenso muscular
( )Ndulos
( )Rigidez

( )Flacidez
( )Outros
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PARA SEU USO:____________________________________________________________________________________________

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RGOS DOS SENTIDOS

Viso (

) No. ( ) Sim. Quais?

Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com

PARA SEU USO:

_________________________________________________________________________________________
Olfato ( ) No. ( ) Sim. Quais? 3
PARA SEU USO
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Paladar ( ) No. ( ) Sim. Quais?

PARA SEU USO
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Tato ( )No. ( ) Sim. Quais?
PARA SEU USO
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SISTEMA NEUROLGICO
( )Convulses
( )Disritmia
( )Tremores
( )Epilepsia
( )Sonolncia
( )Aneurisma
( )Paralisia
( )Estafa

(
(
(
(
(
(
(
(

)Bruxismo
)Neurose
)Delrios
)Enxaquecas
)Esquecimento
)Zumbido
)Pesadelo
)Insnia

( )Sonambulismo
( )Desmaios
( )Concentrao
( )Outros
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PARA SEU USO:____________________________________________________________________________________________

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SNDROMES
(
(
(
(
(
(
(

)Pnico
)West
)Down
)Parkinson
)Rett
)Turner
)AIDS

( )Marfan
( )Outros
Medicamentos___________________________
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PARA SEU USO:____________________________________________________________________________________________

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Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com

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SISTEMA IMUNOLGICO
(
(
(
(
(

)Alergias
)Irritaes
)Infeces recorrentes
)Herpes Labial
)Stress

(
(
(
(
(

)Gripe
)Amdalas/garganta
)ngua
)Ndulos
)Inflamao

( )Furnculo
( )Outros
Medicamentos__________
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PARA SEU USO:____________________________________________________________________________________________

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PERFIL EXISTENCIAL
Que sentimentos e emoes voc experimenta
cotidianamente?
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(

)Queixume
)Mau-humor
)Inflexibilidade
)Arrogncia
)Repulsa ao sexo
)Trauma
)Manipulao
)dio
)Dificuldade com crticas
)Protelao
)Vtima
)Melancolia
)Exausto
)Repetio de erros
)Choro preso
)Vergonha
)Sem objetivos
)Sem direo
)Confuso
)Negao do corpo
)Detalhismo
)Mania de doena
)Inveja
)Pessimismo
)Auto-represso

( )Intolerncia
( )Falta de foco
( )Sonhador
( )Medo do desconhecido
( )Medo de multides
( )Medo de perdas
( )Medo de morte
( )Medo da solido
( )Medo do futuro
( )Crueldade
( )Teimosia
( )Tristeza
( )Ansiedade
( )Agressividade
( )Rispidez
( )Falta de Confiana
( )Desalento
( )Egosmo
( )Ingenuidade
( )Crueldade
( )Insatisfao
( )Descontentamento
( )Negligncia consigo
mesma
( )Passividade

(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(

)Rebeldia
)Auto Conteno
)Desdobramentos
)Cime
)Carncia
)Mgoa
)Culpa
)Desnimo
)Angstia
)Irritao
)Timidez
)Ressentimento
)Depresso
)Raiva
)Desconfiana
)Indiferena
)Indeciso
)Insegurana
)Descrena
)Autoritarismo
)Desespero
)Preguia
)Apatia
)Outros ____________

Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com

PARA SEU USO:____________________________________________________________________________________________

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AUTO DESENHO
Voc tem na seqncia trs paginas em branco. Voc deve desenhar nelas a partir da sua auto
percepo trs desenhos de voc mesmo, de frente de costas e de lado;
Eles so importantes para visualizar os caminhos que se abrem para voc no processo
teraputico.
Use lpis, sem usar borracha.

Rua 06 de janeiro,127 2 andar Centro Acesita/Timteo/MG 35.180-030 - telefax: (31) 3849-1039 - e-mail:

sintesecuidardesi@gmail.com