Avaliacao fisioterapia

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FICHA DE AVALIAÇÃO FISIOTERAPIA 
Data da Avaliação: ___/ ___/___ 
 
DADOS PESSOAIS 
 
Nome: ________________________________________________________________ 
 
Idade: ________ Data de Nascimento: ___/___/_____ Sexo: ( ) F ( )M Cor:_________ 
 
Estado Civil: ( ) Casado ( ) Solteiro ( ) Viúvo ( )Divorciado ( ) Outros. 
 
Profissão: _______________________________ Tipo de Trabalho: _______________ 
 
Aposentado: ( )Sim ( ) Não 
 
Pratica Atividade Física ( )Sim ( ) Não 
-Que tipo de atividade: ___________________________________________________ 
-Quantas vezes por semana: _______________________________________________ 
-Duração: ______________________________________________________________ 
 
QUEIXA PRINCIPAL: __________________________________________________ 
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HDA: __________________________________________________ 
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HPP: __________________________________________________ 
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Historia familiar: __________________________________________________ 
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SINAIS VITAIS: 
P.A : _____________________________ 
F.R : _____________________________ 
F.C : ______________________________ 
A.P : ______________________________ 
 
História Social 
( ) cigarro _______/dia ou ________semana 
( ) Bebida alcoólica ________/dia ou ________semana 
( ) Drogas _______/dia ou ________semana 
Há quanto tempo: ________________________________________________________ 
 
Exames Complementares: 
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Data: _______________ Laudo: ____________________________________________ 
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Exame físico: ______________________________________________________________ 
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Tratamento: ______________________________________________________________ 
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