Data: / /

AVALIAÇÃO RPG
Nome:
Idade: anos Data de Nascimento: / / Sexo:
Atividade Profissional:
Estado Civil:
Fone: ( ) -

Questionário de Saúde
Está sob tratamento médico:
Faz uso de medicamentos?
Já teve alguma doença importante ou cirurgia?
Qual? Data?
Problema cardíaco?
Tem pressão alta?
Alguma doença respiratório?
Alergias?
Diabético?
Alterações hormonais?
TPM ?
Ciclo Menstrual?
Faz uso de algum Medicamento?
Problema renal?
Problema gástrico?
Disfunção Intestinal?
Cefaléia?
Tonturas?
Apresenta alguma lesão ou problema ortopédico?
Pratica atividade Física?
Qual? Frequência:
Qualidade do sono?
Horas de sono? Acorda quantas vezes?
ATM: ( ) Tto dentário ( ) Bruxismo ( ) Hábitos parafuncionais
Estresse: (trabalho) (casa)

Avaliação

QP:_____________________________________________________________________________________

HDA:____________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

HPP:____________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Exames Complementares:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Avaliação Postural:

FG INT ELR REEQ PISTAS

OBSERVAÇÕES:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

OBJETIVOS TERAPÊUTICOS:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
EVOLUÇÃO:
( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

( / / )_____________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________