Ficha de Avaliação

Nome: _______________________________________________________________________

Endereço: _____________________________________________ Número: ______________

Bairro: __________________________ CEP: _________________ UF: __________________

Telefone: ____________________________ Celular: ________________________________

Data de Nascimento: ______________________ Idade: ______________ Sexo: ___________

Peso: ______________________________ Altura: ___________________________________

1. História Patológica Pregressa

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2. História Familiar

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3. História Social (tabaco/álcool/drogas/sono/dentista)

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5. História da Doença Atual

Queixa Principal ________________________________________________________________

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Duração da Sintomatologia _______________________________________________________

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Modo do início _________________________________________________________________

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Localização ___________________________________________________________________

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Caráter/ natureza/ qualidade _______________________________________________________

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Intensidade/quantidade/gravidade __________________________________________________

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Duração do sintoma/episódios _____________________________________________________

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Periodicidade (contínua/periódica-intermitente, remitente, recorrente) _____________________

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Frequência (número de vezes/ período de tempo) ______________________________________

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Predomínio (matinal/diurno/vespertina/noturna) _______________________________________

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Fatores Desencadeantes__________________________________________________________

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Fatores Agravantes______________________________________________________________

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Fatores Aliviantes_______________________________________________________________

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Evolução do Quadro Clínico (progressão/regressão/estacionário) _________________________

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Manifestações Clínicas Associadas _________________________________________________

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6. Inspeção

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7. Mobilidade dos Segmentos

Movimentos Passivos: ___________________________________________________________

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Movimentos Ativos: _____________________________________________________________

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8. Movimentos do Jogo Articular

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9. Teste Muscular Manual

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10. Avaliação Funcional

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11. Testes Clínicos Especiais

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12. Diagnóstico Fisioterapêutico

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