Avaliação Fisioterapia Geral

Unidade Básica de Saúde de São José do Divino-MG

Avaliação Fisioterápica Data da Avaliação: ____/____/______

Nome: ______ ___________ ___________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ___________ _______ __ Raça: ______ _______ _

Sexo: ( M )

- (F)

Data de Nasc.: ____/ ____/____/_ ____/_____ ____

CNS:______________________________________

ACS:_______________

Endereço:______________________________________________Bairro:__________________Cidade:_________________/MG Fone:(___)__________________________ Escolaridade: _______________________ Profissão:________________________

Anamnese Clínica: Diag. Clínico: ____________________________________________________________________CID: ____________________

PA: ______ X ______mmHg

Pratica alguma atividade física? NÃO – SIM:

____________________________________________________ Fuma? NÃO – SIM: ______cigarros/dia

Bebidas Alcoólicas? NÃO – SIM: _______VEZES POR SEMANA

EAV:______

_____________________________________________________________________________________________________ QP: _____________________________________________________________________________________________________ ________________________________________________________________________________________________________ _______________________________________________________________________________________________________ Impede tarefa ou movimento? NÃO - SIM:

__________________________________________________________________________________________ HMA/ HPP:______________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ _____________________________________________________________________________________________________ HF: _____________________________________________________________________________________________________ ________________________________________________________________________________________________________

Patologias Associadas:___________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Medicações:_____________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ Exames Complementares:____________________ Complementares:_________________________________________________________________________________ _____________________________________________________________ ___________________________________________________________________________________ _____________________


________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Exame Físico: ADM – FM – ATROFIAS/ENCURTAMENTOS – DESVIOS/ASSIMETRIA – PONTOS DE DOR ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Objetivos: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Tratamento: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Evoluções: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

CARIMBO E ASSINATURA DA FISIOTERAPEUTA RESPONSÁVEL:


Avaliação Fisioterapia Geral

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