D ra.

N om e do Fisioterapeuta
CREFITO :

Ficha de avaliação inicial

DADOS CADASTRAIS: Data: ____________

Nome:_____________________________
Sexo:______________________________
Data de nascimento: ____ / ____ / ____
Idade: ___________
Profissão:__________________________
RG: ____________
CPF:______________________
Endereço:__________________________
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Telefone: ( ) ______________________
E-mail:
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ANAMNESE

Diagnóstico Médico:
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Queixa Principal:
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INTENSIDADE DA DOR: _________ (De 0 a 10).

OBS:______________________________________________________________________
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HMP e HMA:
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Doenças Associadas:
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Histórico Familiar:
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Medicação:
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Fumante: _______________

Dieta:______________________________________________________________________
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Atividade Fisica:_____________________________________________________________

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

FC.C: _________ F.R: ___

Observações:
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Cidade,________/__________/_______

Assinatura e carimbo do profissional

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Nome do profissional
CREFITO-4/ 00.000F
DATA EVOLUÇÃO