Ficha de Avaliação em Fisioterapia - REF RES COFFITO 414

Prévia do material em texto

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