Dr. Orlando de l.

Ruas Neto
CREFITO: 195279F

Ficha de avaliação inicial

DADOS CADASTRAIS: Data: ____ / ____ / ____

Nome:
Sexo: Data de nascimento: ____ / ____ / ____ Idade:
RG: CPF: Profissão:
Endereço Telefone: ( )
E-mail:

ANAMNESE

Diagnóstico Médico:
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Queixa Principal:
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HMP e HMA:
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INTENSIDADE DA DOR: _________ (De 0 a 10).
OBS:______________________________________________________________________
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Doenças
Associadas:_________________________________________________________________
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Histórico Familiar:
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Medicação:
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Atividade Fisica:_____________________________________________________________

Massa: _________ Altura: _________ Sinais Vitais: P.A. (mmHg): _________

FC.C: _________ F.R: ______

Objetivos:__________________________________________________________________
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Observações:
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Cidade,________/__________/_______

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Orlando de Lucena Ruas Neto
Fisioterapeuta
DATA EVOLUÇÃO