Classificao Internacional de Funcionalidade:

Paciente: ________________________________________________________________________________
Avaliador: _______________________________________________________________ Data:__________________

Condio de Sade

Incapacidades
Deficincias Limitaes Restries
Estrutura e funo acometidas Atividade - situaes de dor, de falha Participao restrio do
(muscular, sseo, neural). (contexto da limitao) envolvimento em situaes sociais

Fatores pessoais: Fatores ambientais

Diagnstico fisioteraputico: _____________________________________________________________

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Objetivos: _______________________________________________________________________________
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Consideraes: _______________________________________________________________________
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