Unidade Bsica de Sade de So Jos do Divino-MG

Avaliao Fisioterpica
Data da Avaliao: ____/____/______

Nome: __________________________________________________________________
Raa: _______

Sexo: ( M )

- (F)

Data de Nasc.: ____/____/_____

CNS:______________________________________

ACS:_______________

Endereo:______________________________________________Bairro:__________________Cidade:_________________/MG
Fone:(___)__________________________ Escolaridade: _______________________ Profisso:________________________

Anamnese Clnica:
Diag. Clnico: ____________________________________________________________________CID: ____________________
PA: ______ X ______mmHg

Pratica alguma atividade fsica? NO SIM:

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Fuma? NO SIM: ______cigarros/dia

Bebidas Alcolicas? NO SIM: _______VEZES POR SEMANA

EAV:______

QP:_____________________________________________________________________________________________________
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Impede tarefa ou movimento? NO - SIM:
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HMA/ HPP:______________________________________________________________________________________________
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HF:_____________________________________________________________________________________________________
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Patologias Associadas:___________________________________________________________________________________
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Medicaes:_____________________________________________________________________________________________________________________
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Exames Complementares:_________________________________________________________________________________
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Unidade Bsica de Sade de So Jos do Divino-MG

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Exame Fsico: ADM FM ATROFIAS/ENCURTAMENTOS DESVIOS/ASSIMETRIA PONTOS DE DOR
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Objetivos:
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Tratamento:
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Evolues:
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CARIMBO E ASSINATURA DA FISIOTERAPEUTA RESPONSVEL:

Unidade Bsica de Sade de So Jos do Divino-MG