FICHA DE AVALIAÇÃO - FISIOTERAPIA neuro

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FICHA DE AVALIAÇÃO NEURO	 
Nome ________________________________________________________________________
Telefone; _____________________________________________________________________
CPF:_____________________________RG:__________________________________________
E-mail ________________________________________________________________________
Data de Nascimento ____________________________________________________________
Estado Civil __________________________________________________________________
Sexo: ( ) Feminino ( ) Masculino
Enderenço ___________________________________________________________________
Bairro ______________________ Cidade ____________________ Estado____CEP_________
Faz uso de algum medicamento: ( )Sim ( ) Não
Quais: _______________________________________________________________________
Convênio _______________________ Tipo de Sangue: ________________________________
Tem diabete ( ) Sim ( )Não Hipertensão: ( ) Sim ( )Não
DESCRIÇÃO DE ATENDIMENTO
 Histórico _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prioridade ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Procedimentos para cada sessão _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
 
 
Obs.: __________________________________________________________________________________________________________________________________________________________
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Obs : 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Orientação para fazer em casa:
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