Ficha de Avaliação

Nome:_________________________________________________________________
Idade:_________________ Telefone:________________________________________
Data da Avaliação________________________________________________________
Data do início do Tratamento:______________________________________________
Diagnóstico Clínico:______________________________________________________
Diagnóstico Funcional:____________________________________________________
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Queixa Principal:
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História da Doença Actual

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História Social e Familiar:

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História da Doença Pregressa
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Exame Físico:

Inspeção_______________________________________________________________
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Relato da DOR: _________________________________________________________

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EVA _______

Marcha________________________________________________________________
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Equilíbrio______________________________________________________________
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Força__________________________________________________________________
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Tônus_________________________________________________________________
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Coordenação____________________________________________________________
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Reflexos_______________________________________________________________
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Sinais Meníngeos________________________________________________________
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Nervos Cranianos________________________________________________________
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Exame Cognitivo _______________________________________________________

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Testes especiais realizados_________________________________________________

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Observações ___________________________________________________________
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Escalas Abordadas_______________________________________________________
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Avaliador/Data