ANAMNESE-^MFICHA^MDE^MAVALIAO^MINICIAL

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Dra. Nome do Fisioterapeuta 
 CREFITO: 
 
 
 
Ficha de avaliação inicial 
 
DADOS CADASTRAIS: Data: ____________ 
Nome:_____________________________ 
Sexo:______________________________ 
Data de nascimento: ____ / ____ / ____ 
Idade: ___________ 
Profissão:__________________________ 
RG: ____________ 
CPF:______________________ 
Endereço:__________________________
______ 
Telefone: ( ) ______________________ 
E-mail: 
__________________________________ 
 
ANAMNESE 
 
Diagnóstico Médico: 
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Queixa Principal: 
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INTENSIDADE DA DOR: _________ (De 0 a 10). 
OBS:______________________________________________________________________
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HMP e HMA: 
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Doenças Associadas: 
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Histórico Familiar: 
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Medicação: 
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Fumante: _______________ 
Dieta:______________________________________________________________________ 
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Atividade Fisica:_____________________________________________________________ 
Objetivos:__________________________________________________________________
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Massa: _________ Altura: _________ Sinais Vitais: P.A. (mmHg): _________ 
FC.C: _________ F.R: ___ 
Observações: 
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Cidade,________/__________/_______ 
 
Assinatura e carimbo do profissional 
_______________________ 
Nome do profissional 
CREFITO-4/ 00.000F
 
DATA EVOLUÇÃO