Therapeutic service formPedro Dias2023-10-23T14:42:17+00:00 Therapeutic service form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastBirth datePlace of Birth:LayoutWeight: (kg)Hight (cm)OccupationCurrent residenceMain complaintsHow long have you been having these problems?These problems are?StableFluctuatingAre gradually improvingGradually worseningRapidly improvingRapidly worseningWhat factors aggravating your problems?Do you suffer from:FluCoughHyperacidityFrequent headachesIf the answer is yes, since when and to what extent?Do you feel good when you get up in the morning?If not, do you feel heavy, unwell, or have body aches?And how long have you felt this way?Do you have bowel movements daily?YesNoThe stool is usually:SoftAverageHardAny problems (pain, burning, etc.) during evacuation?Do you feel any discomfort when urinating?Any family history of health problems similar to yours?Please list the main illnesses and previous surgeries you have had.What type of weather do you feel most uncomfortable in?HotColdRainyCold and wetYour skin has a predominant tendency:DryOilyMediumMixed (certain areas oily and others dry)List the medications you are taking:Your diet is:Strictly veganLacto-vegetarianNon vegetarianEggsFishWhat is your main meal (the one with the largest volume of food)?BreakfastLunchDinnerAre you intensely hungry at mealtimes?What time do you feel most hungry?Your digestion is:GoodReasonableWeekBriefly describe your typical daily meals: Briefly describe your typical daily meals:Breakfast?Lunch?Dinner?Which flavor do you like most?SweetSaltyAcidSpicyBitterAstringentDo you often eat:CandyDessertsFried foodChocolatesFast foodYogurtIce creamMilk shakesIs there any type of food that creates some form of discomfort when you ingest it?Do you practice physical exercise?LittleModerateVigorousHow often?RegularlyOccasionallyNeverWhat type of exercise?AerobicsSwimmingYogaTai Chi ChuanDancingOthersWhich?Do you have a tendency to:Gain weightLose weightStay at the same weightI gain weight and lose weight with the same easeDo you smoke?YesNoHow many cigarettes/day?Do you drink alcoholic beveragesYesNoOccasionallyWhat kind and how much?Other habitsWhat is your mental state like?GoodAnxiousIrritadedDepressedOtherDescribeAnd how is it currently?Are you under any medical careYesNoWhat kind of treatment?Have you had any side effects with the treatments received?YesNoDescribe:How is your sleep?DeepInterruptedWhat time do you normally sleep and wake up?Do you sleep during the day?YesNoHave you been feeling some kind of fear for no apparent reason?YesNoHow is your sweating?AbundantScarceNormalOften, with a strong odorWith sweet odorOdorlessYour menstruation is:RegularIrregularVery frequentUncommonAbsentHow many days does your period last?Your menstrual flow is:scarceAbundantNormalDo you have any type of discharge outside of your menstrual period?YesNoSymptoms associated with menstruation:NonePainDepressionAcneStressedFluid retentionHeadachesDescribe below in detail your physical characteristics hair (colour, baldness, etc.), skin (dry, oily, with blemishes, etc.), eyes, physical structure (slim, heavy, medium, muscular, overweight, etc.) Note: If you have changed a lot in the last few years, describe what it was like before and how it is now, and the approximate time of the changes.Submit
