FICHA DE AVALIAÇÃO FISIOTERAPEUTICA

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FICHA DE AVALIAÇÃO FISIOTERAPEUTICA
DATA DA AVALIAÇÃO: _____/_____/_____
IDENTIFICAÇÃO:
Nome: _____________________________________________________________________
Data de Nascimento:___/___/____   Telefone:_____________________________Sexo:______
Cidade: __________________________________Bairro: ____________________ 
Profissão: ________________________________________________________________
Endereço Residencial: _________________________________________________________
Estado Civil: __________________________
Diagnóstico Clínico: _____________________________________________________________________________
Queixa Principal do Paciente: ___________________________________________________
HMA: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HMP:______________________________________________________________________________________________________________________________________________________
Antecedentes Familiares:
____________________________________________________________________________
Tratamentos Realizados:
_____________________________________________________________________________
AVALIAÇÃO DA INTENSIDADE DOR
Escala Visual Analógica (EVA): _____________________
APRESENTAÇÃO DO PACIENTE:                       
(  ) Deambulando                                                        (  ) Internado  
(  ) Deambulando com apoio/auxílio                            (  ) Orientado                                  
(  ) Cadeira de rodas                                                       
EXAMES COMPLEMENTARES:
(    ) Sim (    ) Não       Se sim, quais?
_____________________________________________________________________________
USA MEDICAMENTOS:
(    ) Sim  (    ) Não      Se sim, quais?
_____________________________________________________________________________
_____________________________________________________________________________ 
REALIZOU CIRURGIA:
(    ) Sim  (   ) Não      Se sim, quais? _____________________________________________________________________________
INSPEÇÃO/PALPAÇÃO: 
(  ) Normal  (  ) Edema  (  ) Cicatrização incompleta  (  ) Eritemas  (  ) Outros
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MOVIMENTOS ATIVOS: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
TESTES ESPECIFICOS:
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FORÇA MUSCULAR
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
GONIOMETRIA
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
PLANO TERAPÊUTICO
OBJETIVOS DE TRATAMENTO
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PLANO DE TRATAMENTO/ CONDUTAS
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ASSINATURA DO PROFISSIONAL