Data __________________________ COGNOME _______________________________________ NOME ____________________________________ ETÀ _____ NATO A _________________________________________ IL __________________ CONIUGATO __________ FIGLI ____ PROFESSIONE ___________________________________ ABITANTE A _________________________________________ VIA ________________________________________________________________________________________ N ________ TEL. _________________________________________________________________________________________________ PESO ___________________________________________ ALTEZZA ____________________________________________

MALATTIE DEI FAMILIARI

: Aborti, Tubercolosi, Sifilide, Malattie nervose, Tumori, Eczemi, Allergie, Diabete, Gotta, Ipertensione.

1) Ramo Paterno ________________________________________________________________________________ 2) Ramo Materno ________________________________________________________________________________ 3) Fratelli-Sorelle ________________________________________________________________________________

MALATTIE INFANTILI

___________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

VACCINAZIONI E SIERI

: (indicare quali, quante volte, eventuali reazioni) __________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

TRAUMI

: (incidenti, operazioni) ____________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

ALTRI RICOVERI

: (date e motivi) __________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

MALATTIE DEL PASSATO

: (date, decorso, cure praticate, anche se non gravi) ______________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

MALATTIE ATTUALI

: ___________________________________________________________________________________ _____________________________________________________________________________________________________

_____________________________________________________________________________________________________ TERAPIE RECENTI

: (medicinali o altro) _____________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

ESAMI E RADIOGRAFIE

: ________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

FUMO

: _______________________________________________________________________________________________

ALCOLICI

: ____________________________________________________________________________________________

CAFFÈ

: ______________________________________________________________________________________________

ATTIVITÀ FISICA

: ______________________________________________________________________________________

STANCHEZZA

: solo al mattino ___________________________________________________________________________ solo alla sera ____________________________________________________________________________ dopo i pasti _____________________________________________________________________________ sempre _________________________________________________________________________________

SI STANCA FACILMENTE?

______________________________________________________________________________

SOLO DOPO SFORZI

___________________________________________________________________________________

MEMORIA

: BUONA __________________________________ DISCRETA ___________________________________ SCARSA _______________________________________________________________________________ PER LE COSE RECENTI __________________________________________________________________

CONCENTRAZIONE ED ATTENZIONE

_____________________________________________________________________

CARATTERE

: CALMO E RIFLESSIVO ___________________________________________________________________ NERVOSO IRRITABILE ___________________________________________________________________ COLLERICO ____________________________________________________________________________ APATICO DEMORALIZZATO _______________________________________________________________ PIANTO ________________________________________________________________________________ APERTO ESTROVERSO __________________________________________________________________

UMORE

: EQUILIBRATO ___________________________________________________________________________ ENERGICO _____________________________________________________________________________ SENZA ENERGIA ________________________________________________________________________ OTTIMISTA _____________________________________________________________________________ PESSIMISTA ____________________________________________________________________________ MOLTO VARIABILE _______________________________________________________________________

PAUROSO O CORAGGIOSO

: ____________________________________________________________________________ _____________________________________________________________________________________________________

PAURE PIÙ FREQUENTI

: ________________________________________________________________________________ _____________________________________________________________________________________________________

SONNO

: ______________________________________________________________________________________________ _____________________________________________________________________________________________________

PRENDE SONNO FACILMENTE?

_________________________________________________________________________ _____________________________________________________________________________________________________

SI RISVEGLIA SPESSO?

________________________________________________________________________________ _____________________________________________________________________________________________________

POSIZIONE PREFERITA E SOGNI

: ________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

TESTA

: EMICRANIA _____________________________________________________________________________ CON NAUSEA ___________________________________________________________________________ CON VOMITO ___________________________________________________________________________ OCCHI _________________________________________________________________________________ ORECCHIE _____________________________________________________________________________ VERTIGINI ______________________________________________________________________________ SVENIMENTI ____________________________________________________________________________

RESPIRATORIO

:MAL DI GOLA ___________________________________________________________________________ RAFFREDDORI __________________________________________________________________________ RAFFREDDORI DA FIENO _________________________________________________________________ SINUSITI _______________________________________________________________________________ BRONCHITI _____________________________________________________________________________ ASMA __________________________________________________________________________________ CATARRRO _____________________________________________________________________________ FEBBRE _______________________________________________________________________________

CIRCOLAZIONE

:PRESSIONE ____________________________________________________________________________ PALPITAZIONI ___________________________________________________________________________ VARICI _________________________________________________________________________________ EMORROIDI ____________________________________________________________________________ GAMBE GONFIE _________________________________________________________________________ GAMBE PESANTI ________________________________________________________________________ CRAMPI ________________________________________________________________________________ FORMICOLIO ___________________________________________________________________________

DIRIGENTE

:

INTESTINO

: APPETITO ______________________________________________________________________________ SETE __________________________________________________________________________________ BOCCA E LINGUA ________________________________________________________________________ _______________________________________________________________________________________ NAUSEA ___________________________ VOMITO ____________________________________________ DIGESTIONE ____________________________________________________________________________ GOLOSITÀ _____________________________________________________________________________ INTOLLERANZE ALIMENTARI ______________________________________________________________ VERMI _________________________________________________________________________________

URINARIO

: QUANTE VOLTE AL GIORNO _______________________________________________________________ COLICHE _______________________________________________________________________________ CALCOLI _______________________________________________________________________________ CISTITI ________________________________________________________________________________

GENITALI PELLE

: : IMPOTENZA ________________________ EIACULAZIONE PRECOCE _____________________________ FRIGIDITÀ _________________________ RAPPORTI DOLOROSI ________________________________ ABORTI ________________________________________________________________________________ CICLO MESTRUALE OGNI QUANTI GIORNI ___________________ RITARDI _______________________ DISTURBI PRIMA DEL CICLO ______________________________________________________________ FLUSSO _______________________________________________________________________________ PERDITE BIANCHE ______________________________________________________________________ MAMMELLE ____________________________________________________________________________ MENOPAUSA ___________________________________________________________________________ PILLOLA __________________________________ SPIRALE _____________________________________

ARTICOLAZIONI

:FRATTURE _______________________________________RIGIDITÀ _____________________________ DOLORI MUSCOLARI _____________________________________________________________________ DOLORI OSSEI __________________________________________________________________________ DOLORI ARTICOLARI _____________________________________________________________________ NEVRALGIE (denti, trigemino, sciatica) _______________________________________________________ _______________________________________________________________________________________ GRASSA __________________________________ SECCA ______________________________________ CAPELLI GRASSI ___________________________SECCHI _____________________________________ ECZEMA _______________________________________________________________________________ ACNE __________________________________________________________________________________ ORTICARIA _____________________________________________________________________________ FUNGHI ________________________________________________________________________________ VERRUCHE _____________________________________________________________________________ UNGHIE ________________________________________________________________________________ PRURITO _______________________________________________________________________________

FREDDOLOSO

: ________________________________________________________________________________________

CALOROSO

: __________________________________________________________________________________________

MANI E PIEDI DI GIORNO

: _______________________________________________________________________________

MANI E PIEDI DI NOTTE

: ________________________________________________________________________________

SUDA POCO / MOLTO

: __________________________________________________________________________________

DOVE SUDA DI PIÙ

: ____________________________________________________________________________________

SOLO DOPO SFORZI O PER ALTRI MOTIVI

: ________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________