FICHA DE AVALIAÇÃO FISIOTERAPIA

Data da Avaliação: ___/ ___/___

DADOS PESSOAIS

Nome: ________________________________________________________________

Idade: ________ Data de Nascimento: ___/___/_____ Sexo: ( ) F ( )M Cor:_________

Estado Civil: ( ) Casado ( ) Solteiro ( ) Viúvo ( )Divorciado ( ) Outros.

Profissão: _______________________________ Tipo de Trabalho: _______________

Aposentado: ( )Sim ( ) Não

Pratica Atividade Física ( )Sim ( ) Não

-Que tipo de atividade: ___________________________________________________
-Quantas vezes por semana: _______________________________________________
-Duração: ______________________________________________________________

QUEIXA PRINCIPAL: __________________________________________________

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HDA: __________________________________________________
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HPP: __________________________________________________
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Historia familiar: __________________________________________________

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SINAIS VITAIS:
P.A : _____________________________
F.R : _____________________________
F.C : ______________________________
A.P : ______________________________
História Social
( ) cigarro _______/dia ou ________semana
( ) Bebida alcoólica ________/dia ou ________semana
( ) Drogas _______/dia ou ________semana
Há quanto tempo: ________________________________________________________

Exames Complementares:
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Data: _______________ Laudo: ____________________________________________
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Exame físico: ______________________________________________________________

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Tratamento: ______________________________________________________________
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