Dra.

Nome do Fisioterapeuta
CREFITO:

Ficha de avaliação
Fisioterapia em Ortopedia e Traumatologia

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Nome:___________________________________________________

Nascimento:___/___/___ Idade: _______ Sexo: ( ) M ( ) F Estado Civil:

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SINAIS VITAIS

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HISTÓRIA CLÍNICA

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EXPECTATIVA:
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HF:
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EXAME FÍSICO

INSPEÇÃO:
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PALPAÇÃO:
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AVALIAÇÃO POSTURAL (ANTERIOR / POSTERIOR / LATERAL)

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EXAME DE MOVIMENTO:

Ativo geral:
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Passivo:
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MOVIMENTOS ACESSÓRIOS:
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TESTES FUNCIONAIS:
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TESTES ESPECIAS:
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EXAMES COMPLEMENTARES:
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DIAGNÓSTICO CINÉTICO FUNCIONAL:

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OBJETIVOS DO TRATAMENTO FISIOTERAPÊUTICO:

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CONDUTAS FISIOTERAPÊUTICAS:
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ACADÊMICAS:
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SUPERVISOR:
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Cidade,________/__________/_______

Assinatura e carimbo do profissional

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Nome do profissional

CREFITO-4/ 00.000F