FICHA DE AVALIAO FISIOTERAPIA

Data da Avaliao: ___/ ___/___

DADOS PESSOAIS
Nome: ________________________________________________________________
Idade: ________ Data de Nascimento: ___/___/_____ Sexo: ( ) F ( )M Cor:_________
Estado Civil: ( ) Casado ( ) Solteiro ( ) Vivo ( )Divorciado ( ) Outros.
Profisso: _______________________________ Tipo de Trabalho: _______________
Aposentado: ( )Sim ( ) No
Pratica Atividade Fsica
( )Sim ( ) No
-Que tipo de atividade: ___________________________________________________
-Quantas vezes por semana: _______________________________________________
-Durao: ______________________________________________________________
QUEIXA PRINCIPAL: __________________________________________________
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HDA: __________________________________________________
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HPP: __________________________________________________
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Historia familiar: __________________________________________________
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SINAIS VITAIS:
P.A : _____________________________
F.R : _____________________________
F.C : ______________________________
A.P : ______________________________

Histria Social
( ) cigarro
_______/dia ou ________semana
( ) Bebida alcolica ________/dia ou ________semana
( ) Drogas
_______/dia ou ________semana
H quanto tempo: ________________________________________________________
Exames Complementares:
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Data: _______________ Laudo: ____________________________________________
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Exame fsico: ______________________________________________________________
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Tratamento: ______________________________________________________________
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