Unidade Básica de Saúde de São José do Divino-MG

Avaliação Fisioterápica

Data da Avaliação: ____/____/______

Nome: __________________________________________________________________ Data de Nasc.: ____/____/_____

Raça: _______ Sexo: ( M ) - ( F ) CNS:______________________________________ ACS:_______________
Endereço:______________________________________________Bairro:__________________Cidade:_________________/MG
Fone:(___)__________________________ Escolaridade: _______________________ Profissão:________________________

Anamnese Clínica:

Diag. Clínico: ____________________________________________________________________CID: ____________________

PA: ______ X ______mmHg Pratica alguma atividade física? NÃO – SIM: ____________________________________________________
Fuma? NÃO – SIM: ______cigarros/dia Bebidas Alcoólicas? NÃO – SIM: _______VEZES POR SEMANA EAV:______

QP:_____________________________________________________________________________________________________
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Impede tarefa ou movimento? NÃO - SIM: __________________________________________________________________________________________

HMA/ HPP:______________________________________________________________________________________________
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HF:_____________________________________________________________________________________________________
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Patologias Associadas:___________________________________________________________________________________
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Medicações:_____________________________________________________________________________________________________________________
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Exames Complementares:_________________________________________________________________________________
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 Unidade Básica de Saúde de São José do Divino-MG

Exame Físico: ADM – FM – ATROFIAS/ENCURTAMENTOS – DESVIOS/ASSIMETRIA – PONTOS DE DOR

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Objetivos:
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Tratamento:
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Evoluções:
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CARIMBO E ASSINATURA DA FISIOTERAPEUTA RESPONSÁVEL: