FICHA DE AVALIAÇÃO EM FISIOTERAPIA

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: __________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________________________________________ Historia familiar: __________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ________________________________________________________________ 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: ______________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________