FICHA DE AVALIAÇÃO FISIOTERAPIA

Data da Avaliação: ___/ ___/___
DADOS PESSOAIS
Nome: ________________________________________________________________
Idade: ________ Data de Nascimento: ___/___/_____ Sexo: ( ) F ( )M Cor:_________
Estado Civil: ( ) Casado ( ) Solteiro ( ) Viúvo ( )Divorciado ( ) Outros.
Profissão: _______________________________ Tipo de Trabalho: _______________
Aposentado: ( )Sim ( ) Não
Pratica Atividade Física
( )Sim ( ) Não
-Que tipo de atividade: ___________________________________________________
-Quantas vezes por semana: _______________________________________________
-Duração: ______________________________________________________________
QUEIXA PRINCIPAL: __________________________________________________
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________
HDA: __________________________________________________
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________
HPP: __________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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Historia familiar: __________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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SINAIS VITAIS:
P.A : _____________________________
F.R : _____________________________
F.C : ______________________________
A.P : ______________________________

História Social ( ) cigarro _______/dia ou ________semana ( ) Bebida alcoólica ________/dia ou ________semana ( ) Drogas _______/dia ou ________semana Há quanto tempo: ________________________________________________________ Exames Complementares: _________________________________________________________________________ ___________________________________________________________________ ______________________________________________________________________ Data: _______________ Laudo: ____________________________________________ ______________________________________________________________________ Exame físico: ______________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________________________________________ Tratamento: ______________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________ .