Ficha Avaliação

Nome: ________________________________________________________________
Gênero: _________________ DN:_______________ Idade:_______
Endereço: ______________________________________________________________
Telefone:________________ Cidade:_________________________
Estado:_________
Estado Civil: ( ) Casado(a) ( ) Solteiro(a) ( ) Viúvo(a) ( ) União Consensual
Atividade Física: ________________________________________________________
Antecedentes Pessoais: ___________________________________________________
Medicação:_____________________________________________________________
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História Doença Atual:

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História Doença Pregressa:

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Altura: ___________ Peso: ___________IMC: _____________

FC: _____________ PA: ______________ FR: _____________

Goniometria:

Flexão Cervical
Extensão Cervical
Direita Esquerda
Rotação Cervical
 Flexão Lateral Cervical

Força Muscular:

Flexão de Quadril
Extensão de Quadril
Direita Esquerda
Flexão Joelho
Extensão de Joelho
Tríceps Surral

Avaliação Postural:
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Observações:
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 EVOLUÇÃO

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