FISA DE EVALUARE

SI
EVIDENTA

Nr:_________ DATA______________________

I. DATE PERSONALE ALE PACIENTULUI

NUME si PRENUME:
SEX:
VARSTA:
II. ANTECEDENTE HEREDO-COLATERALE____________________________________________________
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III.ANTECEDENTE PERSONALE_______________________________________________________________
BOLI CRONICE: ___________________________________________________________________________

IV.TRATAMENTE PE CARE LE URMEAZA PACIENTUL IN PREZENT:

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V.SIMPTOME: __________________________________________________________________________________
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VI.INVESTIGATII/ANALIZE LABORATOR:_______________________________________________________
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VII. EVALUARE/CONCLUZIE :__________________________________________________________________

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VIII. SE APLICA TRATAMENTUL PENTRU .......................................................................

TIMP DE .............../................ SEDINTE INCEPAND DIN DATA ____/____/______ PANA LA

DATA___/_____/_____
VARIANTA DE PROGRAM........................SEDINTE/SAPTAMANA.
IX. ALTE RECOMANDARI: ____________________________________________________________________
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X:
SUBSEMNATUL..............................................................................................................................susti
n ca toate informatiile referitoare la starea de sanatate, simptome, tratamente anterioare sau
prezente,alergii, boli cornice pe care le-am oferit sunt adevarate, am luat la cunostinta de
modalitatea de tratament,program,efecte secundare si sunt de acord cu toate si sustin ca nu sunt
bolnav de:
Afectiuni ale pielii - zone inrosite, inflamate sau infectate, epiderma sensibila sau lezata, eczema,
psoriasis, dermatitele, alte boligrave ale pielii, boli infecto-contagioase, hemoragii cerebrale
recente, premenstrual cu 1 zi, in timpul menstrei si postmenstrual cu 1 zi, boli sau leziuni cu
caracter hemoragic, infarct miocardic, emboli, angina pectorala, hipertensiune arteriala, cardiopatie
ischemica dureroasa, pneumonii , pleurezii, abcese pulmonare, tuberculoza, hemoptizie, apendicita ,
peritonita, hematom muscular, ruptura musculara sau alte traumatisme musculare majore, care
necesita ingrjire de specialitate, diaree, hemoragi interne, ulcere in faza active, inflamatii sau infectii
ale organelor urogenitale, dureri menstruale, boli varicoase in stadiul avansat, fracturi recente, boli
psihice cu caracter excesiv si confuzional, stari insotite de febra si agitatie, sarcina cu risc crescut de
pierdere, boli acute ale sisitemului endocrine, masajul se aplica dupa 2-3 ore de la servirea meselor
sau de alte boli de natura infecto-contagioasa, transmisibila sau care necesita un tratament de
specialitate si nu l-am urmat.
Data:________________ Numele
/Prenumele:__________________________
Semnatura
:____________________________
Concluziile observate in urma tratamentului:
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