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FICHA AVALIAÇÃO FISIO ORTOPEDIA.2018 1 (1)

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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: ________________________________________________________________________
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História da Moléstia Pregressa: _____________________________________________________________
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História da Moléstia Atual: ________________________________________________________________
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História Familiar: ________________________________________________________________________
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Medicamentos em uso: ____________________________________________________________________
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Exames Complementares (Raio-X, TC, RM): __________________________________________________
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Patologias Associadas: ____________________________________________________________________
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Procedimento cirúrgico: ___________________________________________________________________
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	Exame Físico
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