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Resolução 414 Data da avaliação ____/____/_______. Naturalidade: Estado civil: Gênero: ( ) M ( )F Data do nascimento: ____/____/_______. Estado de nascimento: Peso: kg - Altura: Nº Identidade: Endereço: Tel: ( ) Email: Profissão: Diagnóstico Clínico: ANAMNESE: Queixa Principal (QP):________________________________________________________________________________ ___________________________________________________________________________________________________ História da doença atual (HDA): ________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ História patológica pregressa (HPP): ____________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Hábitos de vida: ___________________________________________________________________________________ ___________________________________________________________________________________________________ História familiar: ____________________________________________________________________________________ ___________________________________________________________________________________________________ Exames complementares: _____________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Exame Físico-Funcional (Cinético-funcional): Diagnóstico fisioterapêuticos: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Prognóstico fisioterapêuticos: (compreende a estimativa de evolução do caso) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Quantidade provável de atendimentos: ___________________________________________________________________________________________________ Plano Terapêutico: (descrição dos procedimentos fisioterapêuticos propostos relatando os recursos, métodos e técnicas a serem utilizados e o(s) objetivo(s) terapêutico(s) a ser (em) alcançado(s)) _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _______________________________________________ _________________________________________________ Acadêmico Estagiário Supervisor/ Professor/Profissional
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