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Nome: ____________________________________________________

Sexo: ( )M ( ) F
Data de nascto: __/__/____ Idade: ___ Profisso: ______________ Estado Civil:______________
Peso: ____ Altura: _______ IMC: _______ Fones:______________________________________
E-mail: ______________________________________________ Facebook:__________________

Data:____________

1 Queixa ou Objetivo(s):

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Assinatura do Paciente

Atesto para fins de direito que as informaes que por mim aqui prestadas so
verdicas, pois daro base para intervenes de massoterapia.

Ficha de Avaliao para Massagem Teraputica

2 Histrico de Doenas Atuais


( ) dores na coluna ( ) dores musculares ( ) dores articulares ( ) diabetes
( ) problemas cardacos ( ) problemas vasculares ( ) problemas respiratrios.
( ) hipertenso ( )depresso ( ) ansiedade ( ) cimbras ( ) fibromialgias

( ) outros especifique:

Aspecto Funcional da Dor:


( ) ao caminhar (deambulao)
( ) ao sentar (sedestao)
( ) ao deitar. Decbito?
( ) em qualquer posio

3 Histrico Familiar
( ) Problemas Respiratrios ( ) Cardiovasculares ( ) Hipertenso ( ) Obesidade e Dislipidemias
Especifique:

4 Atualmente realiza alguma espcie de tratamento:


( ) Tratamento Mdico:
_
( ) Tratamento Fisioteraputico:
( ) Outro Tratamento: _______________________________________________________
Observaes:

5 Faz uso de medicao?


( ) no ( ) sim , especifique:

6 Sobre Possvel Gestao?


Vista Anterior

Vista Posterior

7) Avaliao Postural:
Cifose( ) Lordose( ) Escoliose( )
Joelho: Valgo( ) Varo( )
P: Cavo( ) Plano( ) Normal ( )
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TRATAMENTO

1 sesso(___/___/___) Conduta:__________________________________________________________________________________
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Evoluo:____________________________________________________________________________________________________
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2 sesso(___/___/___) Conduta:_________________________________________________________________________________
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Evoluo:____________________________________________________________________________________________________
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3 sesso(___/___/___) Conduta:_________________________________________________________________________________
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Evoluo:____________________________________________________________________________________________________
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4 sesso(___/___/___) Conduta:_________________________________________________________________________________
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Evoluo:____________________________________________________________________________________________________
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5 sesso(___/___/___) Conduta:_________________________________________________________________________________
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Evoluo:____________________________________________________________________________________________________
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Observaes Adicionais: _______________________________________________________________________________________
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Massoterapeuta:____________________________________________________

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