FISIOTERAPIA

FICHA DE AVALIAO- Anamnese

Nome:______________________________________________Sexo:_________
Profisso:_________________________ Hor.de trab:____________________
DN:____/____/____

Idade:______________ Raa:____________________

Naturalidade:________________ Tel:__________________________________
Endereo:
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Encaminhamento:__________________________________________________
Diagnstico Clnico:________ _______________________________________
Diagnstico Fisioteraputico: _______________________________________
Q.P:__ __________________________________________________________
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HPA:____________________________________________________________
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Patologias associadas: ______________________________________________
HPP: ____________________________________________________________
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HSF: ____________________________________________________________
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Medicao atual: _________________________________________________

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Terapia anterior: __________________________________________________
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Exames Complementares:__________________________________________

OBS:_____________________________________________________________
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