FACULDADES METROPOLITANAS UNIDAS

CURSO DE FISIOTERAPIA

FOTO DO PACIENTE
Data : Prontuário:

FICHA DE AVALIAÇÃO
FISIOTERAPIA ESPORTIVA
DADOS

Nome: ___________________________________________________________
Data de Nascimento:__________________________ Idade: _______________
Telefones:______________________________ Recado:__________________
Esporte Praticado:__________________________________________________
Tipo de Atleta: ( ) Profissional ( ) Amador ( ) Recreacional
Diagnóstico Médico:_________________________________________________
Médico:___________________________________________________________
Nome do Acadêmico: ________________________________________________

QUEIXA PRINCIPAL
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HMA / HMP / MECANISMO DE LESÃO

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MEDICAÇÃO
Nome/Princípio Ativo:__________________________________ Efeito:____________________
Nome/Princípio Ativo:__________________________________ Efeito:____________________
Nome/Princípio Ativo:__________________________________ Efeito:____________________
 FACULDADES METROPOLITANAS UNIDAS
CURSO DE FISIOTERAPIA

AVALIAÇÃO DA DOR

COMPORTAMENTO E CARACTERISTICAS:
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FATORES QUE PIORAM E ALIVIAM
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RESPOSTA AO ESPORTE
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Escala Analógica da dor: 0______________________5______________________10

Obs:

CIRURGIA
 DATA:____/____/_____ LOCAL:________________MÉDICO:_________________
 TÉCNICA CIRÚRGICA: _________________________________________________
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 RECOMENDAÇÕES CLÍNICAS: __________________________________________
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ANAMNESE

Inspeção e Movimentação Ativa

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Palpação e Movimentação Passiva

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TESTE ESPECIAIS TESTES FUNCIONAIS/PROPRIOCEPTIVOS

 FACULDADES METROPOLITANAS UNIDAS
CURSO DE FISIOTERAPIA

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EXAMES COMPLEMENTARES
TIPO: _________________________________________________DATA:____________________________________
PARECER/LAUDO:__________________________________________________________________________________
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TIPO: _________________________________________________DATA:____________________________________
PARECER/LAUDO:__________________________________________________________________________________
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FOTOS DO PACIENTE E EXAMES COMPLEMENTARES

DIAGNÓSTICO FISIOTERAPÊUTICO/ LAUDO MORFOFUNCIONAL

 FACULDADES METROPOLITANAS UNIDAS
CURSO DE FISIOTERAPIA

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OBJETIVOS DO TRATAMENTO

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PROGRAMA DE TRATAMENTO

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