UNIPINHAL

CLÍNICA DE FISIOTERAPIA

AVALIAÇÃO FISIOTERAPÊUTICA

Data:___/___/________ Registro:________

ANAMNESE

Nome:______________________________________________________________________________
Endereço:____________________________________________________________________________
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Tel._________________
Data de nascimento: ___/___/________ Idade:_______ Estado civil:___________________
Profissão atual:__________________________________Anteriores:____________________________
Atividade esportiva:___________________________________________________________________
Encaminhamento: Dr.__________________________________________________________________

Diagnóstico Clínico:___________________________________________________________________

Queixa Principal:______________________________________________________________________
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História da Doença:___________________________________________________________________
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EXAME FÍSICO

1-Sinais Vitais: PA:_______________FC:____________FR:_____________TO ax:______

2-Goniometria:

Passivo Ativo
movimento D E D E
3-Dor:

Tipo:________________________________________________
E.V.A._______________________________________________
Mensuração:___

4- MRC:

DIAGNÓSTICO CINESIOLÓGICO FUNCIONAL:

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PLANO DE TRATAMENTO

Objetivos:___________________ ________________________________________________________
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Conduta:____________________________________________________________________________
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Orientações:__________________________________________________________________________
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Fisioterapeuta