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Stephane Bispo @vidadefisio_study Nome: _______________________________________________________________________________ Idade : __________ Estado Civil: ___________________________________ Sexo: ________________ Raça : ___________________ Ocupação :___________________________________________________ Estrutura Familiar: ____________________ Endereço:_________________________________________ _____________________________________________________________________________________ Te l: _________________ Data da Avaliação : _______________________________________________ Medica mentos em uso: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Queixas Principais : _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Sinais Vitais: FC: _____________ FR : _____________ T : __________ P A : ______________ Medidas Corporais: Peso: ________ Altura: __________ História da Doença Atual – HDA: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Doenças Associadas: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Doenças Pregressas: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ História Familiar: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Anamnese Stephane Bispo @vidadefisio_study Antecedentes pessoais: ( ) doença cardiorrespiratória ( ) constipação intestinal ( ) doença renal ( ) hemorróidas ( ) neoplasias ( ) infecção urinária ( ) diabetes ( ) obesidade ( ) alergias ( ) tabagismo/etilismo ( ) outros: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ História Familiar: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Hábitos de Vida: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Atividade física: ( ) sim ( ) não Frequência/tempo? ________________________ Tratamentos anteriores: Fisioterapia: ( ) sim ( ) não Cirurgias: ( ) sim ( ) não Qual(is)? _______________________________________________________________________________________________ Diagnóstico Clínico: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Avaliação Postural: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
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