UNIVERSIDAD UNIVER MILENIUM

PLANTEL SALUD
TERAPEUTA: ______________________________________________________
FECHA: ____________________
___________________

CEDULA PROFESIONAL:

DATOS DEL PACIENTE

NOMBRE: _________________________________________________________________
EDAD: ______________

SEXO: ______________

TALLA: ______________

PESO: ______________

IMC: ______________

DOMICILIO:
______________________________________________________________________
________________________________________________________________________________
NACIONALIDAD: ____________________________
_________________________

TELEFONO:

OCUPACIN: ___________________________________________________________
ANTECEDENTES FAMILIARES
ENFERMEDADES

NEURODEGENERATIVAS
METABOLICAS
CARDIACAS
PULMONARES
PIEL
CNCER

PADRE

MADRE

ABUELOS
PATERNO
S

ABUELOS
MATERNO
S

HERMAN
OS

NEUROLGICAS

ANTECEDENTES PERSONALES
HABITOS
FUMA SI_____ NO: ______

USA DROGAS

SI _____ NO: _____

ENFERMEDADES QUE PADECE:

________________________________________________________________________________
________________________________________________________________________________
CIRUJIAS: SI_____ NO: _______
_____________________________
LESIONES PREVIAS
FRACTURAS SI: ______
______ NO: ______

ESPECIFIQUE CUALES:

NO: ______

ESGUINCES SI:

CICATRICES: ___________________________________________________
ALERGIAS: ____________________________________________________
ADMINISTRACIN DE MEDICAMENTOS
SI: ______ NO: ______
CUALES:
_________________________________________________________________________
ALIMENTACIN

BUENA: ______

REGULAR: _______

MALA: _______

ANTEDECENTES GINECOLOGICOS (MUJERES)

EMBARAZOS

#1:______

#2: ______

#3: ______

4 O MS: ______

ENFERMEDADES DE TRANSMICIN SEXUAL: ________________________

PARTOS

NORMALES: ________________

FECHA DE ULTIMO PARTO:

CIRUJIA: _______________

____ /__________________ / _______

No. DE GESTACIONES: ______________________

ESTA EN CONTACTO CON SUSTANCIAS PELIGROSAS: ____________________
HORAS DE DESCANSO: ___________________________________________
REALIZA ACTIVIDAD FISICA
____________________

SI: ______

NO: ______

SIGNOS
FRECUENCIA CARDIACA: ____________________________

CAL:

FRECUENCIA RESPIRATORIA: _________________________

TENSIN ARTERIAL: ________________________________
GLUCOMETRA: ___________________________________
ESPIROMETRA: ___________________________________

SINTOMAS
DIAGNOSTICO MEDICO PREVIO:
________________________________________________________________________________
ACUDIO A OTRO SERVICIO MEDICO
CAL: __________________________

SI: _______

NO: ________

ESTUDIOS DE LABORATORIO PREVIOS:

_________________________________________________
RX: ___________________________
TOC: __________________________

TAC: _________________________

QUE TIEMPO TIENE LA LESIN: _____________________________________

TIPO DE LESIN: ________________________________________________
MECANISMO DE LESIN:
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN POSTURAL
ESTTICA
CABEZA: _______________________________
CEJAS: _________________________________
OJOS: _________________________________
OREJAS: _______________________________
BOCA: _________________________________
CUELLO: _______________________________
HOMBROS: _____________________________

TETILLAS (HOMBRES): ________________________________

CRESTAS ILIACAS: _________________________________
RODILLAS: __________________________
PIES: _______________________________
ESCPULAS: ____________________________
PLIEGUES GLUTEOS: ______________________________
HUECOS POPLITEOS: _________________________________
DINMICA
MARCHA:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN PALPATORIA

(FORMA/COMPOSICIN FIBRA MUSCULAR)

MUSCULATURA
MIEMBROS SUPERIORES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
MIEMBROS INFERIORES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
TRONCO:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

TENDONES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
ARTICULACIONES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EXAMEN MANUAL MUSCULAR
TONO MUSCULAR:
________________________________________________________________________________
________________________________________________________________________________
FUERZA MUSCULAR:
________________________________________________________________________________
________________________________________________________________________________
SENSIBILIDAD:
________________________________________________________________________________
________________________________________________________________________________
INERVACIN:
________________________________________________________________________________
________________________________________________________________________________
TONO DE PIEL:
____________________________________________________________________
TEMPERATURA DE PIEL:
____________________________________________________________
COLORACIN DE PIEL:
______________________________________________________________
EDEMA:
_________________________________________________________________________
INFLAMACIN:
___________________________________________________________________
HEMATOMAS:
____________________________________________________________________
GRADOS DE MOVILIDAD:
___________________________________________________________

GONIOMETRA:
___________________________________________________________________
EVALUACIN DE LIGAMENTOS:
________________________________________________________________________________
________________________________________________________________________________
PRUEBAS DE DIAGNOSTICO ESPECIFICAS
PRUEBAS DE MANGUITO ROTADOR:
________________________________________________________________________________
________________________________________________________________________________
PRUEBAS DE RODILLA:
________________________________________________________________________________
________________________________________________________________________________
PRUEBAS DE PIRAMIDAL:
________________________________________________________________________________
________________________________________________________________________________
PRUEBAS DE LESIN EN NERVIO CITICO:
________________________________________________________________________________
________________________________________________________________________________
TRATAMIENTO FISIOTERAPEUTICO

(BASANDOSE EN CIF)

DE ACUERDO AL DIAGNOSTICO TERAPEUTICO:

________________________________________________________________________________
________________________________________________________________________________
PROGRAMA TERAPEUTICO
No. DE SESIONES (PROBABLES, DE ACUERDO A EVOLUCIN):
______________________________
FRECUENCIA DE SESIONES:
__________________________________________________________
TIEMPO DE CADA SESIN:
__________________________________________________________
TIPO DE TRATAMIENTO:
____________________________________________________________
INTENSIDAD DE TRATAMIENTO:
______________________________________________________

FRECUENCIA DE EJERCICIOS (REPETICIONES):

________________________________________________________________________________

NOTA CLNICA

(POR SESIN)

PSOAP (SE ANEXA, CONFORME AL AVANCE DE SESIONES)

DIA DE INGRESO: ______ / ____________________ / _________
ALTA FISIOTERAPUETICA:

______ / ____________________ /__________