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1

FICHA CLÍNICA TERAPIA FLORAL SESION Nº_____

Fecha ______________

NOMBRE ALUMNO-A ____________________________________________

Nombre consultante _________________________________________________________RUT________________ Edad _________ Dirección______________________________________________________________________________Comuna_______________ Teléfono fijo ________________________ Celular_____________________ Teléfono de recado ___________________________ Mail ________________________________________________________________________________________________________ Ocupación __________________________________________________________________________________________________ Está o ha estado en algún tratamiento

médico□

psicológico □

psiquiátrico□

e. florales

□

ninguno

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Mes(es) y año(s) tratamiento ____________________________________________________________________________________ Diagnostico ___________________________________________________________________________________________________________

MOTIVO DE CONSULTA FLORAL _______________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ VERBALIZACIONES

FLOR

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FLORES QUE RECETÓ

PARA QUE RECETÓ CADA FLOR

FRASCO 1 1 ___________________

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2 ___________________

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3 ___________________

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4 ___________________

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5 ___________________

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6 ___________________

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7 ___________________

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DOSIFICACION Y FRECUENCIA

____ gotas

____ veces al día