Ficha Ortopedia

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CÓDIGO DO PACIENTE:_______________ 
 
TURNO DO ATENDIMENTO:____________ 
 
HORÁRIO DE ATENDIMENTO: __________ 
CURSO DE FISIOTERAPIA 
FICHA DE AVALIAÇÃO EM TRAUMATO-ORTOPEDIA 
Data da avaliação: ____ / ____ / ____ 
 
IDENTIFICAÇÃO 
Paciente:_______________________________________________________________________________________________________________ 
Endereço: __________________________________________________________________________ Bairro: ____________________________ 
Cidade: ______________________ Estado: __________________ Telefone: ______________________________________________________ 
Sexo: ( ) Masculino ( ) Feminino Data de Nascimento:_____ / _____ / _____ Dominância:____________________________ 
Profissão / Ocupação:__________________________________________________ Religião: ________________________________________ 
Estado civil: ( ) Casado ( ) Solteiro ( ) Outros Grau de instrução: ( ) 10 Grau ( ) 20 Grau ( ) Superior 
Médico Responsável: ___________________________________________ Telefone:_________________________ ______________________ 
Diagnóstico Médico: _____________________________________________________________________________________________________ 
 
ANAMNESE 
 
QP: ___________________________________________________________________________________________________________________ 
HDA: __________________________________________________________________________________________________________________ 
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AP: ___________________________________________________________________________________________________________________ 
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AF: ___________________________________________________________________________________________________________________ 
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Hábitos de vida: ________________________________________________________________________________________________________ 
Medicação em uso: _____________________________________________________________________________________________________ 
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EXAME FÍSICO 
 
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Exames complementares: 
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Diagnóstico Fisioterapêutico: 
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Objetivos da Fisioterapia: 
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Plano de tratamento: 
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Acd. Responsável: ________________________________________ Prof. Responsável: ________________________________________