Avaliação Fisioterapêutica

Académico de fisioterapia responsável: ___________________________________________

Fisioterapeuta responsável: ____________________________________________________

Data: / /
Horário_____________
1. Identificação:

Nome:______________________________________________________________________
Endereço:_________________________________N°:_________Bairro:_________________
Cidade:________________Estado:_______________Celular:( )_______________________
E-mail:_____________________________________________________________________
Sexo: ( ) Masculino ( ) Feminino Data de Nascimento: ____/___/_____ Tipo
Sanguíneo:______Profissão/Ocupação:__________________Responsavel:______________
Parentesco:_________________Estado civil: ( ) Casado ( ) Solteiro ( ) Outros
Grau de Formação: ( )1° Grau ( )2° Grau ( )Superior
Informações Adicionais:________________________________________________________

2. Diagnóstico Clínico:

3. Diagnóstico Cinético Funcional:

4. Queixa Principal

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5. História da Doença Atual - HDA

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6. História social
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7. História Familiar

8. Hábitos de Vida

9. Diagnóstico Clínico

10. Doenças Associadas:

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Pratica alguma atividade física? ( ) NÃO ( ) SIM
Fuma? () NÃO ( ) SIM ______ cigarros/dia
Bebidas Alcoólicas? ( ) NÃO ( ) SIM ______ vezes por semana
Impede tarefa ou movimento? ( ) NÃO ( ) SIM

11. Exame Físico:

ADM

Palpação

Teste de Força D E

Testes
Específicos

Atrofias
Encurtamentos

Desvios
Assimetria

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 Pontos De Dor

12. Sinais Vitais

PA (mmHg): Altura (cm):
Frequência cardíaca: Peso (Kg):
Frequência respiratória:
Temperatura (°C):
Saturação de Oxigênio:

Avaliação Motora:
Tônus:
Reações e Reflexos:
ADM:
Força Muscular:
Sensibilidade:
Controle Motor:

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 13. Objetivo geral:

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12.1 Objetivo geral:

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13.1 Diagnóstico Cinético-funcional:

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14.1 Conduta(s):

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 Assinatura do Paciente Fisioterapeuta Responsável

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