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�� FICHA DE AVALIAÇÃO ORTOPEDIA ADULTO Aula Prática Fisioterapia na Saúde do Adulto I Prof. Supervisor: Identificação: Nome: _________________________________________________________________________________ Sexo: F ( ) M ( ) Cor:_________________ Data de Nascimento: ____/____/____ Idade: ________ (anos) Estado Civil: _________________ Naturalidade: _________________Profissão: _____________________ Endereço: ____________________________________________________________ Nº: ______________ Bairro: __________________________ Cidade: ________________________________ UF: ___________ Telefone Residencial: (___) __________________ Celular: (___) __________________ Cuidador(a): _____________________________________________________ Idade: _________ (anos) Parentesco: _______________________________ Contato: (___) ________________________ Diagnóstico Clínico: _______________________________________ Data da Avaliação: ____/____/_____ Diagnóstico Fisioterapêutico: _______________________________________________________________ Examinador(es)(Acadêmico): ______________________________________________________________ Anamnese: Queixa Principal: ________________________________________________________________________ _______________________________________________________________________________________ História da Moléstia Pregressa: _____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ História da Moléstia Atual: ________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ História Familiar: ________________________________________________________________________ _______________________________________________________________________________________ Medicamentos em uso: ____________________________________________________________________ _______________________________________________________________________________________ Exames Complementares (Raio-X, TC, RM): __________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Patologias Associadas: ____________________________________________________________________ _______________________________________________________________________________________ Procedimento cirúrgico: ___________________________________________________________________ _______________________________________________________________________________________ Exame Físico _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ TESTES ESPECÍFICOS: __________________________________________________________________ _______________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ CONCLUSÃO:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ OBJETIVO DO TRATAMENTO FISIOTERAPÊUTICO: _______________________________________ _______________________________________________________________________________________1:___________________________________________________________________________________ 2:_____________________________________________________________________________________3:_____________________________________________________________________________________4:____________________________________________________________________________________ 5:_____________________________________________________________________________________6:_____________________________________________________________________________________7:_____________________________________________________________________________________8:_____________________________________________________________________________________9:_____________________________________________________________________________________ CONDUTA PROPOSTA: _________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ 1.1____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 2.1_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3.1__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________ Assinatura do(a) Acadêmico(a) Assinatura do(a) Acadêmico(a) _________________________________ DELSON VALERIO NEVES JUNIOR Prof. Estágio
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