This document contains an anamnesis form for patients at the Shen Ti clinic. The form collects information about a patient's personal details, medical history, symptoms, and lifestyle habits related to digestion, excretion, sleep, respiration, senses, and more. It aims to gather a comprehensive picture of a patient's constitution and current health complaints to inform their acupuncture treatment.

1. Clínica SHEN TI
Dra Luciene Helena da Silva
Biomédica Acupunturista - CRBM 11943
R Brilhante, 71 – Jd dos Camargos – Barueri, SP
IPESSP – INSTITUTO DE PESQUISA E EDUCAÇÃO EM SAÚDE DE SÃO PAULO
TRABALHO DE ACUPUNTURA
LUCIENE HELENA DA SILVA
MARÇO - 2015
SÃO PAULO

2. Clínica SHEN TI
Dra Luciene Helena da Silva
Biomédica Acupunturista - CRBM 11943
R Brilhante, 71 – Jd dos Camargos – Barueri, SP
SHEN TI
ANAMNESE
Nome:_______________________________________________________________________
Idade:_________________ Sexo:______________ EstadoCivil:_____________________
Profissão:_____________________________________________________________________
Endereço:____________________________________________________________________
CirurgiasRealizadas:____________________________________________________________
Alergiaamedicamentos:________________________________________________________
Se mulher:
Quantidade e Tipode Partos:_____________________________________________________
DUM: (data da últimamenstruação) _______________________________________________
TPM: (vontade de morreroumatar?) ______________________________________________
Menstruaçãoregular:___________________________________________________________
Menopausada:________________________________________________________________
1- Doençade Base?
_______________________________________________________________________
_______________________________________________________________________
Local da dor?
_______________________________________________________________________
_______________________________________________________________________
Tipoda dor?
Pontiaguda,Tensional,Latejante, outras_____________________________________
_______________________________________________________________________
_______________________________________________________________________
Hematomas?___________________________________________________________
______________________________________________________________________
Inchaço?_______________________________________________________________
_______________________________________________________________________

3. Clínica SHEN TI
Dra Luciene Helena da Silva
Biomédica Acupunturista - CRBM 11943
R Brilhante, 71 – Jd dos Camargos – Barueri, SP
Tempoda dor, recente ouantiga? __________________________________________
_______________________________________________________________________
_______________________________________________________________________
Horário da dor? _________________________________________________________
_______________________________________________________________________
2- Principal sentimentoque descrevesuapersonalidade?
Preocupado/Triste / Irritado/ Tímido/ Alegre (excesso=incoveniente)
_______________________________________________________________________
_______________________________________________________________________
3- Transpiração:
Muito ouPouco?________________________________________________________
_______________________________________________________________________
Horário:_______________________________________________________________
Local: _________________________________________________________________
_______________________________________________________________________
4- Preferênciaporalimentos:
Quente ouFrio?_________________________________________________________
_______________________________________________________________________
Doce,Salgado,Amargo,Picante ouÁcido?____________________________________
_______________________________________________________________________
Horário:_______________________________________________________________
5- Sede:
Geralmente maisde diaoude noite?________________________________________
_______________________________________________________________________
Horário:_______________________________________________________________
Tipo:insaciável oubasta?_________________________________________________
_______________________________________________________________________
6- Comoé a sua Digestão?
Normal,Sensaçãode Vazioou de Empachamento?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Sente sonoapósrefeições? ________________________________________________
_______________________________________________________________________
_______________________________________________________________________
7- Excreções:
- Urina:
Mais de dia ou maisde noite?______________________________________________
_______________________________________________________________________

4. Clínica SHEN TI
Dra Luciene Helena da Silva
Biomédica Acupunturista - CRBM 11943
R Brilhante, 71 – Jd dos Camargos – Barueri, SP
Cheironormal ouforte?__________________________________________________
_______________________________________________________________________
Cor: amareloclaro,amareloescuro,outras?__________________________________
_______________________________________________________________________
Dor ao urinar?_________________________________________________________
_______________________________________________________________________
- Fezes:
Todosos dias?__________________________________________________________
_______________________________________________________________________
Quantasvezesaodia? ____________________________________________________
_______________________________________________________________________
Formatode “charutinho”,“bolinha”ou“pastosa”?_____________________________
_______________________________________________________________________
Cor: (claraou escura?)____________________________________________________
_______________________________________________________________________
8- Respiração:
Ofegante /Curta / Normal?________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Apresentadificuldade pararespirar?________________________________________
______________________________________________________________________
______________________________________________________________________
9- Sono:
Dorme bemou apresentadificuldadeparadormir?_____________________________
_______________________________________________________________________
_______________________________________________________________________
Insônia:________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Precisalevantaranoite?__________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Horário:_______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Muitossonhos?_________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Bonsou ruins?___________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

5. Clínica SHEN TI
Dra Luciene Helena da Silva
Biomédica Acupunturista - CRBM 11943
R Brilhante, 71 – Jd dos Camargos – Barueri, SP
Apnéia?_______________________________________________________________
_______________________________________________________________________
______________________________________________________________________
Faz usode algummedicamentoparadormir?Qual?____________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
10- Sentidos:
- Visão/Olhos:
Vermelhos?____________________________________________________________
_______________________________________________________________________
Fotofobia?_____________________________________________________________
_______________________________________________________________________
- Audição/Ouvidos:
Surdez?________________________________________________________________
_______________________________________________________________________
Zumbido?______________________________________________________________
_______________________________________________________________________
- Olfação/ Nariz:
Secreções?_____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Dificuldade psentircheiros?_______________________________________________
_______________________________________________________________________
_______________________________________________________________________
- Paladar/ Boca:
Geralmente apresentagostoamargo,azedo,metálico,doce ousalgadona boca?____
_______________________________________________________________________
_______________________________________________________________________
- Tato / Sensação:
Transpiração?___________________________________________________________
_______________________________________________________________________
Horário?_______________________________________________________________
_______________________________________________________________________
Queimaduras?__________________________________________________________
_______________________________________________________________________
Anomalias/deformidade?________________________________________________
______________________________________________________________________