ficha de avaliacao-EN

Prévia do material em texto

ANAMNESIS FORM
NAME
GENDER
DATE OF BIRTH 
PROFESSION (JOB)
HOW I HAVE COME TO YOU
PAIN BACKGROUND
PAIN IN RESTING POSITION? YES NO
INITIAL SYMPTOMS
HEAD
NECK
CERVICAL SPINE
SHOULDER BLADE/ SCAPULA
ELBOW
GLUTEUSLUMBAR SPINE
POSTERIOR THIGH
CALF
BALL OF THE FOOT
PLANTAR FASCIA
SHOULDER
ARM
FOREARM
HAND
FINGERS
CHEST
ABDOMEN
PUBIS
WAIST
HIP
THIGH
KNEE
LEG
FOOT/FEET
TMJ
 (TEMPOROMANDIBULAR JOINT DISORDER)
SE SD
RD
E
RE
F
HEAD HEADACHE NECK ARM ELBOW FOREARMSHOULDER
HAND BACK LUMBAR BACK
(LOW BACK)
THIGH LEGKNEE FOOT (FEET)
HEAD HEADACHE NECK ARM ELBOW FOREARMSHOULDER
HAND BACK LUMBAR BACK
(LOW BACK)
THIGH LEGKNEE FOOT (FEET)
SPECIFIC DIFFUSE
YES NO HOW LONG EVERY NIGHT?
YES NO PLACE
YES NO WHICH
RADIATING TINGLING
BACK SIDE STOMACHFETAL POSITION
OTHER COMPLAINTS
FREQUENT SYMPTOMS
KIND OF PAIN
SLEEP WELL PREVIOUS TREATMENTS
SURGERIES/ ACCIDENTS/ DELIVERIES:
FAVORITE SLEEPING POSITION
SCARS
IT IS WORSE
WORST PERIOD
IT IS BETTER
STANGINDING STILL BENDING SITTING DOWN LYING DOWN STANDING UPTURNING WALKING RUNNING JUMPING
MORNING DURING THE DAY AT MIDDAY AT THE END OF THE DAY IN THE SMALL HOURS ALL THE TIME
BEST PERIOD
YES
HEALTHY
FLEXION EXTENSION RIGHT AND LEFT ROTATION RIGHT AND LEFT BENDING
UNHEALTHY
NO
YES NO HOW MANY LITERS
WHICHWORKOUT
FOOD HABITS
PAIN MAP
WATER INTAKE
HOW OFTEN
A
B
C
D
E
I
J
L
K
S
T
V
U
W
X
Y
Z
M
N
O
Q
P
F
G
H
ANKLE
MORNING DURING THE DAY AT MIDDAY AT THE END OF THE DAY IN THE SMALL HOURS ALL THE TIME
R
Mayara Oshiro do Carmo - carmomay335@gmail.com - CPF: 026.524.211-82