Dr. Orlando de l.

Ruas Neto
CREFITO: 195279F

Ficha de avaliação de Fisioterapia

DATA DA AVALIAÇÃO: ___/___/___

1.0 IDENTIFICAÇÃO:

Nome:
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Data de Nascimento: ____/___/____
Telefone: ____________________Sexo:___________________
Cidade: ____________________Bairro: __________________________
Profissão: _______________
Endereço Residencial:
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Endereço Comercial:
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Naturalidade: ___________________________________
Estado Civil: ________________________
Diagnóstico Clínico:
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Diagnóstico Fisioterapêutico:
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2.0 AVALIAÇÃO:
2.1 HistóriaClínica:
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2.2 Queixa Principal do Paciente:
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2.3 Hábitos de Vida:
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2.4 HMA:
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2.5 HMP:
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2.6 Antecedentes Pessoais:
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2.7 Antecedentes Familiares:
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2.8 Tratamentos Realizados:
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3.0 EXAME CLÍNICO/FÍSICO:

3.1 APRESENTAÇÃO DO PACIENTE:
( ) Deambulando ( ) Internado
( ) Deambulando com apoio/auxílio ( ) Orientado
( ) Cadeira de rodas

3.2 EXAMES COMPLEMENTARES:

( ) Sim ( ) Não Se sim, quais?
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3.3 USA MEDICAMENTOS:

( ) Sim ( ) Não Se sim, quais?
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3.4 REALIZOU CIRURGIA:

( ) Sim ( ) Não Se sim, quais?
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3.5 INSPEÇÃO/PALPAÇÃO:
( ) Normal ( ) Edema ( ) Cicatrização incompleta ( ) Eritemas ( ) Outros

3.6 SEMIOLOGIA:

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3.7 TESTES ESPECIFICOS:

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3.8 AVALIAÇÃO DA INTENSIDADE DOR:
Escala Visual Analógica (EVA)

4.0 PLANO TERAPÊUTICO

4.1 OBJETIVOS DE TRATAMENTO

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4.2 RECURSOS TERAPÊUTICOS

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4.3 PLANO DE TRATAMENTO

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4.4 EVOLUÇÃO
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Assinatura e carimbo do profissional
Nome do profissional
CREFITO-4/ 00.000F