CDIGO DO PACIENTE:_______________

TURNO DO ATENDIMENTO:____________
HORRIO DE ATENDIMENTO: __________
CURSO DE FISIOTERAPIA
FICHA DE AVALIAO EM TRAUMATO-ORTOPEDIA
Data da avaliao: ____ / ____ / ____
IDENTIFICAO
Paciente:_______________________________________________________________________________________________________________
Endereo: __________________________________________________________________________ Bairro: ____________________________
Cidade: ______________________ Estado: __________________ Telefone: ______________________________________________________
Sexo: (

) Masculino

) Feminino

Data de Nascimento:_____ / _____ / _____

Dominncia:____________________________

Profisso / Ocupao:__________________________________________________ Religio: ________________________________________

Estado civil: (

) Casado (

) Solteiro

) Outros

Grau de instruo: (

) 10 Grau

) 20 Grau

) Superior

Mdico Responsvel: ___________________________________________ Telefone:_________________________ ______________________

Diagnstico Mdico: _____________________________________________________________________________________________________
ANAMNESE
QP: ___________________________________________________________________________________________________________________
HDA: __________________________________________________________________________________________________________________
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AP: ___________________________________________________________________________________________________________________
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AF: ___________________________________________________________________________________________________________________
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Hbitos de vida: ________________________________________________________________________________________________________
Medicao em uso: _____________________________________________________________________________________________________
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EXAME FSICO
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Exames complementares:
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Diagnstico Fisioteraputico:
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Objetivos da Fisioterapia:
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Plano de tratamento:
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Acd. Responsvel: ________________________________________

Prof. Responsvel: ________________________________________