UNIDADE DE ATENO

ESPECIALIZADA
FICHA DE AVALIAO ORTOPDICA

AVALIAO
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Nome:_____________________________________________________________________________ Sexo: F( ) M
( )
Profisso:___________________________ Natural:_____________________________________
DN:_____/____/______
RG:__________________________ Fone:______________________ N
CNS_____________________________________
Endereo: ______________________________________ Distrito:____________________
Cidade____________________
Diagnostico Mdico:_____________________________________________________________
CID___________________
DM ( ) HAS ( ) Cardaco( ) Etilismo( )
Outros:_____________________________________________________________
Acidente: Moto ( ) Carro ( ) Queda ( ) Atropelo ( )
Outros:_________________________________________________
Medicamento em
uso:_________________________________________________________________________________
Diagnostico
Fisioteraputico:____________________________________________________________________________
QP:
________________________________________________________________________________________________
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_
HDA:
_______________________________________________________________________________________________
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___________________________________________________________________________________________________
___________________________________________________________________________________________________
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Exames complementares:
______________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
____
Exame Fsico: ________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
____
Goniometria:_________________________________________________________________________________________

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Condutas:_________________________________________________________________________________________
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___________________________________________________________________________________________________
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Relatrio:
1 ___/___/_____
2 ___/___/_____
3 ___/___/_____
4 ___/___/_____

Ass: _____________________
Ass: _____________________
Ass: _____________________
Ass: _____________________

1
2
3
4

Ass:
Ass:
Ass:
Ass:

___/___/_____
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Ass:________________________________________

Avaliao