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Profisso (Ocupao):______________________________________
Estado Civil:______________________________________________
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CEP:____________________________________________________
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Presso
Arterial
Alergia
Prtese
Dor na Coluna
Corao
Vascular
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Osteoporose
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Outros:_________________________________________________________________
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Antecedentes Familiares:__________________________________________________
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Observao:_____________________________________________________________
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Data:______/______/______
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Assinatura
Avaliao Subjetiva
Nome:____________________________________________Data:_____/_____/_______
Sexo:___________________Idade:___________Profisso:_______________________
HMP/HMA:
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Queixa Principal
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Patologias Associadas:_________________________________________
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Medicamentos Atuais:__________________________________________
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Exames Complementares
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Comportamento da Dor
Tipo de Dor:___________________________________________________
Agravante da Dor:______________________________________________
Alvio da Dor:__________________________________________________
Posio de Dormir:_____________________________________________
Freqncia da Dor:_____________________________________________
Perodo o qual a dor pior: Manha( ) Tarde( ) Noite( ) Madrugada( )
Avaliao Objetiva
Inspeo/ Palpao/ ADM
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Testes Especficos
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Testes de Movimentos
Fle
Rot
Incl
Rot
Incl
Cabea
Cervical
Ombro
Torcica
Lombar
Plvis
Joelho
Retro-p
Ante-p
Total
Nome:________________________________________________Data:____/____/_____
Objetivos de Tratamento:________________________________
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Conduta de Tratamento:______________________________
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Orientaes:
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Prevenes:
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Periodicidade
Periodicidade 1 semana
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5 ms
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7 ms
8 ms
9 ms
10 ms
11 ms
12 ms
2 semana
3 semana
4 semana
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