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Antecedentes personales

o Nombre:
o Edad:
o Fecha de nacimiento:
o Nacionalidad:
o Rut:
o Telfono:
o Ocupacin u oficio:
o Estado civil:
o Hijos:
o Direccin:
o Lateralidad o dominancia:
o Fecha de ingreso:
o Diagnstico mdico:

Anamnesis remota

o Antecedentes mrbidos :
-HTA:
-DM:
-Problemas reumticos:
-Artritis:
-Artrosis:
-Otra enfermedad crnica:
o Medicamentos:

o Antecedentes familiares:

o Hbitos:
-Consumo de alcohol:
-Fumador (a):
-Deporte o actividad fsica:
-Otro:
o Alrgias:
o Antecedentes mdicos (cirugas/hospitalizaciones):

o Antecedentes de vivienda (opcional):


Anamnesis Prxima

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Exmenes complementarios:

Evaluacin

o General:
-observacin inicial:
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-Postura:
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-equilibrio:
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-Marcha:
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o Especifica o segmentaria:
-Inspeccin:
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-Palpacin:
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-Dolor:
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-ROM:
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-End feel:
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-Fuerza muscular:
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-Sensibilidad (profunda y superficial):
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CIF

Deterioros Alteraciones Limitacin en Restriccin Componentes


estructurales (por funcionales actividades en la ambientales y
sistema) participacin personales

Diagnostico kinsico:
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Objetivos:

General:____________________________________________________________
___________________________________________________________________
Especfico:__________________________________________________________
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Operacionales:_______________________________________________________
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Pronstico:

Plan kinsico:

Reevaluacin: