FICHA DE AVALIAÇÃO FISIOTERAPÊUTICA

1. Identificação:
Nome: _______________________________________________________________________
Data de nascimento: ____/____/______ Idade:_____ anos Sexo: ( ) Masc. ( )Femin.
Profissão:______________________________________
Escolaridade:________________________

2. Queixa Principal:
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3. História da Doença Atual – HDA

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4. Doenças Pregressas
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5. História Familiar
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6. Hábitos de Vida
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7. Diagnóstico Clínico
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8. Exame Físico:
- Inspeção e Palpação:
Pele e mucosas:
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Sinais Vitais:
FC:
FR:
PA:
AP:

Avaliação Motora:
ADM:_____________________________________________________________
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Força
Muscular:_________________________________________________________
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Sensibilidade:
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9. Observações:
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10. Diagnóstico cinético Funcional

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