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AVALIAÇÃO FISIOTERAPEUTICA Nome: ____________________________________________________________________ Sexo: ______ Idade: ____________ Data de Nascimento: ____________ Cor: ____________ Estado Civil: ___________ Naturalidade: _____________________________________ Nacionalidade: _________________________ Procedência: _____________________________________ Religião: ______________________________ Escolaridade: _____________________________________ Profissão: _____________________________ Endereço: _____________________________________________________________________________ Telefone: ___________________________________ Celular: ____________________________________ Diagnóstico Clínico: ______________________________________________________________________ Médico Responsável: ____________________________________________________________________ Queixa Principal: ________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ História da Moléstia Atual (HMA): ___________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ História Funcional: ____________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ História da Moléstia Pregressa (HMP): _______________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ História Familiar: _____________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ História Social: _______________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Tratamentos/Medicamentos anteriores: ______________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Exames Complementares anteriores: _______________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Apresentação do Paciente: _____________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Diagnóstico Fisioterapêutico: ____________________________________________________________ Fisioterapeuta: _______________________________________________________________________
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