Fundao Presidente Antnio Carlos

Faculdade de Educao e Estudos Sociais de Tefilo

Otoni
Curso de Fisioterapia
- Estgio Supervisionado III

Avaliao Fisioteraputica
Nome: ____________________________________________________ Idade: ____________
Endereo: ___________________________________________Telefone: _______________
Estado civil: ____________________Profisso: _________________
HISTRICO:
Idade gestacional: ___________
Mdico: ______________________________________________________________________
DUM: ____________DPP: __________ G___P___A___
PA: __________ FC: _________ FR: _________
Estado Emocional: _________________________
QP: _______________________________________________________________________
AVALIAO DOS SISTEMAS:
SCV = _______________________________________________________________________
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SD = _________________________________________________________________________
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SME = _______________________________________________________________________
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SR = ________________________________________________________________________
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SU = ________________________________________________________________________
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AVD = _______________________________________________________________________
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EXAME FSICO:
Avaliao Postural: __________________________________________________________
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Encurtamentos
Musculares:
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Diastase do reto abdominal:

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Padro respiratrio:
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Mamas: _________________________________________________________________________
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CONDUTA TERAPUTICA: ________________________________________________________

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OBSERVAES: _______________________________________________________________________
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Data da avaliao: __/__/__

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Assinatura do Acadmico (a)
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Assinatura do Supervisor (a)