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Avaliação Fisioterapêutica

Data da Avaliação:
Identificação do paciente
Nome:
Data de nascimento: Idade:
Endereço: Telefone de contato:

ANAMNESE

Diagnóstico médico:
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Queixa principal do paciente:


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História pregressa:
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História da Doença atual:


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Objetivo e expectativa do paciente:
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Medicamentos em uso:
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Exames complementares:
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AVALIAÇÃO FUNCIONAL

Estrutura e Função (deficiência)


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Atividade (Limitação)
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Participação (Restrição)
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PLANO TERAPÊUTICO

Deficiências/Limitações/Restrições Objetivo Conduta

METAS A CURTO PRAZO:


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METAS A MÉDIO PRAZO:

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METAS A LONGO PRAZO


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ORIENTAÇÕES AO PACIENTE

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Assinatura: ____________________________________________________