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FICHA CADASTRAL DO PACIENTE

NOME:___________________________________________________________________________________________________

ENDEREÇO:____________________________________________________CIDADE:___________BAIRRO:_________________

NATURALIDADE:____________________ESTADO CIVIL____________PROFISSÃO____________________________________

GENERO: _______________DATA DE NASCIMENTO: _____________________ RG: _____________- CPF:_________________

NOME DA MÃE: ____________________________________________________________________________________________

COR DO PACIENTE
01 Branca ( ) 03 Preta ( ) 02 Amarela ( ) 04 Parda ( )

FISIOTERAPIA: Ortopédica Cardiologia Neurológica adulta


Pneumofuncional Neurológica infantil Geriatria Pediatria

DATA ____/___/_____

ANAMNESE

DIAGNÓ STICO MEDICO:__________________________________________________________________________________________

QUEIXAPRINCIPAL:_______________________________________________________________________________________________

HDA/HDP ( historia da doença atual e pregressa)

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HÁ BITOS SOCIAIS ( Avds, lazer, etilismo, tabagismo, atividade física, frequência/ quantidade,
antecedentes familiares)

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EXAMES COMPLEMENTARES ( RX,ECG, TC)

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SIANIS VITAIS

PA ____________________ F. cardíaca: _________ FR: ___________________


EXAME FISICO

INSPEÇÃ O

o Observaçã o do paciente( estado geral e emocional)


o Verificarã o (do estado geral da pele, alteraçõ es cutâ neas e articulares detalhadas e localizaçã o)
o Presença de curativos, fixadores, cicatrizes, manchas
o Avaliaçã o da marcha.

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PALPAÇÃ O

Tô nus, trofismo, presença de triggers points, dor a palpaçã o( localizaçã o), edema local, fora muscular e
ADM

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AVALIAÇÂ O SUBJETIVA DA DOR

NENUNHA DOR 0 1 2 3 4 5 6 7 8 9 10 PIOR DOR POSSÍVEL

Testes ortopédicos e neurologia

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Diagnó stico fisioterapêutico:

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Objetivos do tratamento e conduta:

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EVOLUÇÂO DO PACIENTE

DATA ASSINATURA