FICHA KINÉSICA

Fecha __________________

Nombre: _______________________________ Edad: ________ Fecha nac: ___________ Sexo: _____

RUT: ________________ Est. civil: _____________ Previsión: _____________ Ocupación: ___________
Dirección: _____________________________________________ Teléfono: ______________________
Médico tratante: _______________________________________ E-Mail: _________________________
Diagnóstico medico: __________________________________________________________
Diagnóstico kinésico: _________________________________________________________
Cirugía: ____________________________________ Fecha: _________________
Examenes: __________________________________________________________________

Motivo de consulta: __________________________________________________________________

Antecedentes
Patológicos:

HTA Enf. Respiratoria Baja de peso abrupta

Diabetes Cáncer Alergías

DLP Enf. Hormonal Enf. Hepática

Cardiopatías Enf. Renal Enf. Mental

Otros: ______________________________________________________________________
Fármacos: ___________________________________________________________________

No patológicos:

Tabaquismo: ______ /día/_______ años Alcholismo (frec): _______________

Alimentación: ______________________________ Deporte: ________________________

Otros: ______________________________________________

Evaluación:
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S. FECHA PRESTACIONES TRATAMIENTO
Evaluación _____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
1 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
2 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
3 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
4 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
5 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
6 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
7 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
8 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
9 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________

_____________________________________________
⃝ US ⃝ Termoterapia _____________________________________________
10 ⃝ TENS ⃝ Crio. _____________________________________________
⃝ MST ⃝ T.R. _____________________________________________
⃝ E. Erg. ⃝ KTR _____________________________________________