Terapia Czaszkowo- Krzyżowa
Imię i nazwisko:---------------------------------------Data urodzenia/wiek--------------------------
Adres ---------------------------------------------------------------Telefon-----------------------------
Data pierwszej wizyty-------------------------------------- Data ostatniej wizyty--------------------
Zawód /rodzaj wykonywanej pracy-------------------------------------------------------------------
Wzrost---------------------------- Waga-----------------------------------------------------------------
Dolegliwości: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dotychczasowe leczenie --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Zażywane leki ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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Witaminy i suplementy -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Ciśnienie krwi:-------------------------------------------------------------------------------------------
Wygląd skóry , włosów i paznokcie----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Wygląd języka--------------------------------------------------------------------------------------------
Wzrok, słuch, węch i smak-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Trawienie--------------------------------------------------------------------------------------------------
Stosowana dieta--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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Wypróżnienia---------------------------------------------------------------------------------------------
Układ hormonalny ---------------------------------------------------------------------------------------
Alergie i nadwrażliwości pokarmowe ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
- 2 -
Układ Hormonalny---------------------------------------------------------------------------------------
Alergie-----------------------------------------------------------------------------------------------------
Stresy i życie emocjonalne -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Poziom energii-------------------------------------------------------------------------------------------
Aktywność fizyczna---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Przebyte choroby ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Genetyczne skłonności/ choroby w rodzinie ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Przebyte operacje ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Wypadki w życiu dorosłym i dzieciństwie ----------------------------------------------------------
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Badanie układu kranialnego
Czaszka kształt, asymetrie, poszczególne kości czaszki sprawdzenie rytmu -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Kręgosłup szyjny ---------------------------------------------------------------------------------------------------------------------------------------------------
Kończyny górne ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Klatka piersiowa ( żebra)-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
- 3 -
Jama brzuszna ------------------------------------------------------------------------------------------------------------------------------------------------------
Kręgosłup lędźwiowy----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Kość krzyżowa-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Miednica-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Kończyna dolna-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
badanie:
- 4 -
Zastosowane leczenie: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Data: _____/_____/___ podpis: ______________________________________
Nazwisko terapeuty : ______________________________
Adres zamieszkania, nr telefonu---------------------------------------
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Daty ukończenia kursów------------------------------------------------
Maggia