PROTOCOLO DE DIAGNÓSTICO FISIOTERAPÊUTICO

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PROTOCOLO DE AVALIAÇÃO DE FISIOTERAPIA
Data: ______________ Acadêmico Responsável: ______________________________
1-IDENTIFICAÇÃO:
Nome: _________________________________________________________________
Idade: _______________ Sexo: ( )F ( )M
Estado Civil: _____________________ Número de filhos: ________________________
Profissão: _______________________ Grau de escolaridade: ____________________
Endereço:_______________________________________________________________________________________________________ Telefone: _____________________
2-OUTROS DADOS:
Médico Responsável: ______________________ Especialidade: __________________
Medicamentos em uso: ___________________________________________________
Exercício Físico: ( )Não ( )Sim. Qual? ______________________________________
Exames Radiográficos:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Diagnóstico Clínico: ______________________________________________________
3-HISTÓRIA CLÍNICA:
Q.P.:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
H.D.A:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Período do dia em que a dor é mais intensa: __________________________________
O que melhora ou piora a dor: _____________________________________________
Qualidade do sono: ______________________________________________________
H.P.P
( ) Asma 
( ) Hipertensão
( ) Câncer 
( ) Diabetes
( ) Cardiopatia 
( ) Reumatismo (Qual?) 
( ) Osteoporose
( ) Pneumonia
( ) Trauma (Qual?)
( ) Cirurgia (Qual?)
( ) Infarto
OUTROS:_____________________________________________________________________________________________________________________________________________________________________________________________________________
História Familial:
____________________________________________________________________________________________________________________________________________________________________________________________________________
História Funcional e Profissional (Funções comprometidas-AVD’s/AVP’s)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
História Social:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________