AVALIAÇÃO FISIOTERAPÊUTICA

● IDENTIFICAÇÃO PESSOAL

Nome:___________________________________________________________ Idade: ___________

Sexo: ___________________ Telefone: (____) __________________ Profissão: _________________
Endereço: _________________________________________________________________________
Data da avaliação: ______/_______/_________ Responsável: _______________________________

● ANAMNESE E HISTÓRIA CLÍNICA:

Diagnóstico clínico: __________________________________________________________________

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Queixa principal: ____________________________________________________________________
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História da doença atual: _____________________________________________________________
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História patológica pregressa: _________________________________________________________
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Doenças associadas: _________________________________________________________________
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Medicamentos em uso: ______________________________________________________________
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Histórico familiar: ___________________________________________________________________
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Hábitos de vida: ____________________________________________________________________
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● SINAIS VITAIS:

PA: _______________ FC: __________________ SpO2: _______________ FR: _________________

Temperatura: _______________ Dor: _________________________ EVA: _____________________
 ● EXAME FÍSICO:

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● DIAGNÓSTICO FISIOTERAPÊUTICO:

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● OBJETIVOS TERAPÊUTICOS:

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● PLANO TERAPÊUTICO:

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ASSINATURA E CARIMBO