FICHADE AVALIAÇÃO Data: / /

Nome:
Idade:_____________________Profissão__________________________Endereço:______________________
____________________________Telefone:__________________________ CPF: _____________________
Carteira plano: _____________________
ANAMNESE
QP:
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HMAP: ___________________________________________________________________________________
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Doenças Associadas: _________________________________________________________________________
Medicamentos: ______________________________________________________________________________
Atividadefísica/ sociais:

___________________________________________________Cirurgias:__________________________________________
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Sono: ___________________________________________________________________________________________
Condições psicológicas: __________________________________________________________________________________
Diagnóstico clínico: ____________________________________________________________________________________
Diagnóstico Físico-funcional ______________________________________________________________________________
Exames _______________________________________________________________________________________________
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Dornomomento:

Sem dor 0 1 2 3 4 5 6 7 8 9 10 dor máxima

Reavaliação(EVA):
EXAME FÍSICO
DESCRIÇÃO COMPLETA DOS ACHADOS
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TESTE ESPECIAL(MENCIONAR NOME OU FUNÇÃO):
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*Em caso de uso de questionários, anexáloscom respectivos resultados.

Objetivo/PlanodeTratamento:

DATA/ AVALIAÇÃO DIÁRIA/CONDUTAS

CARIMBO
Aval:

Condutas:

Aval:

Condutas:

Aval:

Condutas:

Aval:

Condutas: