Ficha de Avaliao

Nome : _______________________________________________________________
Idade:_________
Data Nac: __/__/____
Sexo:__
Cor/Raa :______
Estado Civil:___________

Prof.: _________________

Local de

Trab.:__________
Naturalidade: ______________________

Tel

:_____________________________
End.:
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1. Queixa Principal
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2. HDA
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3. Interrogatrio Sintomatolgico
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4. Antecedentes pessoais e familiares
Pessoais:
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Familiares:
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5. Hbitos de Vida

ExameFsico:
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Fora Muscular Manual
MMSS
Msculos

Graus de fora

Flexores do ombro
Extensores do ombro
Abdutores
Adutores
Rotadores Internos
Rotadores externos
Flexores do cotovelo
Extensores do cotovelo
Flexores de Punho
Extensores de punho
MMII
Msculos
Dorselfexores
Plante flexores
Flexores do joelho
Extensores do joelho

Graus de fora

Abdutores
Adutores
Flexores do quadril
Extensores do quadril

Exames Complementares
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Objetivos
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FISIOTERAPEUTA