FISIOVIDA – Clínica de Fisioterapia S/C Ltda

Ficha de Avaliação em Traumato-Ortopedia

ANAMNESE

Nome: _____________________________________________________________ Sexo: F ( ) M ( )

Endereço: __________________________________________________________________________

Data de Nascimento: _____/_____/_____ Idade:______ Tel: ________________ E.C.:_____________

Profissão: ____________________________________________________ Peso:______ Altura: _____

Médico Responsável: ____________________________________ Diagnóstico Clínico : ___________

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Farmacoterapia: ( ) __________________________________________________________________

Q.P.:______________________________________________________________________________

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H.D.A.:____________________________________________________________________________

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H.P.P.:
- Sistema músculo-esquelético: ( ) ______________________________________________________

- Sistema Nervoso: ( ) _______________________________________________________________

- Sistema Cardiovascular: ( ) __________________________________________________________

- Sistema Respiratório: ( ) ____________________________________________________________

- Outros: ___________________________________________________________________________
História Social e Familiar: _____________________________________________________________

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Exames Complementares: _____________________________________________________________

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Tratamentos Anteriores, Atuais e Resultados: ______________________________________________

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EXAME FÍSICO

Sinais Vitais: P.A.:______________________________ F.C.:______________ F.R.:______________

Inspeção: __________________________________________________________________________

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Palpação: __________________________________________________________________________

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Amplitude de Movimento (em graus): ____________________________________________________

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Força Muscular (0 – 5): _______________________________________________________________

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Perimetria: _________________________________________________________________________

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Testes Específicos: ___________________________________________________________________

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Fisiodioagnóstico: ___________________________________________________________________

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Fisioterapeuta Responsável
Objetivos e Tratamento Fisioterapêutico: