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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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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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CIRURGIA
DATA:____/____/_____ LOCAL:________________MÉDICO:_________________
TÉCNICA CIRÚRGICA: _________________________________________________
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RECOMENDAÇÕES CLÍNICAS: __________________________________________
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ANAMNESE
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EXAMES COMPLEMENTARES
TIPO: _________________________________________________DATA:____________________________________
PARECER/LAUDO:__________________________________________________________________________________
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TIPO: _________________________________________________DATA:____________________________________
PARECER/LAUDO:__________________________________________________________________________________
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OBJETIVOS DO TRATAMENTO
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PROGRAMA DE TRATAMENTO
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