Escolar Documentos
Profissional Documentos
Cultura Documentos
EMPRESA OU DO
PROFISSIONAL
1.0 IDENTIFICAÇÃO:
Nome: ______________________________________________________________________________
Data de Nascimento: ____/___/____ Telefone: ____________________Sexo:___________________
Cidade: ____________________Bairro: __________________________ Profissão: _______________
Endereço Residencial: _________________________________________________________________
Endereço Comercial: _________________________________________________________________
Naturalidade: ___________________________________ Estado Civil: ________________________
Diagnóstico Clínico: __________________________________________________________________
Diagnóstico Fisioterapêutico: __________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2.0 AVALIAÇÃO:
2.1 História Clínica:____________________________________________________________________
2.2 Queixa Principal do Paciente: _________________________________________________________
2.3 Hábitos de Vida: HAS ( ) Etilista ( )DM ( )Tabagista ( ) Outros ______________________________
2.4 AF.: _____________________________________________________________________________
2.5 HMA:____________________________________________________________________________
2.6 HMP:____________________________________________________________________________
2.7 Antecedentes Pessoais: ______________________________________________________________
2.8 Antecedentes Familiares:_____________________________________________________________
2.9 Tratamentos Realizados: _____________________________________________________________
Fisioterapeuta: ________________________
CREFITO-8 n°
Carimbo
LOGOMARCA DA
EMPRESA OU DO
PROFISSIONAL
3.6 INSPEÇÃO/PALPAÇÃO:
( ) Normal ( ) Edema ( ) Cicatrização incompleta ( ) Eritemas ( ) Outros
3.7 SEMIOLOGIA:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Fisioterapeuta: ________________________
CREFITO-8 n°
Carimbo
LOGOMARCA DA
EMPRESA OU DO
PROFISSIONAL
___________________________________________________________________________________
Fisioterapeuta: ________________________
CREFITO-8 n°
Carimbo
LOGOMARCA DA
EMPRESA OU DO
PROFISSIONAL
____________________________________________________________________________________
____________________________________________________________________________________
4.4 EVOLUÇÃO ( descrever na evolução estado de saúde do paciente, conduta aplicada, resultados
obtidos e eventuais intercorrências)
__/__/____:__________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
_
___________________________________________________________________________________
_
__/__/____:__________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
_
__/__/
____:_______________________________________________________________________________
____________________________________________________________________________________
_______________________________________________________________________________
___________________________________________________________________________________
_
Fisioterapeuta: ________________________
CREFITO-8 n°
Carimbo