CÓDIGO DO PACIENTE:_______________
TURNO DO ATENDIMENTO:____________
HORÁRIO DE ATENDIMENTO: __________
CURSO DE FISIOTERAPIA
FICHA DE AVALIAÇÃO EM TRAUMATO-ORTOPEDIA
Data da avaliação: ____ / ____ / ____
IDENTIFICAÇÃO
Paciente:_______________________________________________________________________________________________________________
Endereço: __________________________________________________________________________ Bairro: ____________________________
Cidade: ______________________ Estado: __________________ Telefone: ______________________________________________________
Sexo: ( ) Masculino ( ) Feminino Data de Nascimento:_____ / _____ / _____ Dominância:____________________________
Profissão / Ocupação:__________________________________________________ Religião: ________________________________________
Estado civil: ( ) Casado ( ) Solteiro ( ) Outros Grau de instrução: ( ) 10 Grau ( ) 20 Grau ( ) Superior
Médico Responsável: ___________________________________________ Telefone:_________________________ ______________________
Diagnóstico Médico: _____________________________________________________________________________________________________
ANAMNESE
QP: ___________________________________________________________________________________________________________________
HDA: __________________________________________________________________________________________________________________
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AP: ___________________________________________________________________________________________________________________
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AF: ___________________________________________________________________________________________________________________
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Hábitos de vida: ________________________________________________________________________________________________________
Medicação em uso: _____________________________________________________________________________________________________
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