DADOS PESSOAIS
Data da Avaliação: ____/____/____
Nome: ______________________________________________________
Idade:_____________Sexo:___________Estado Civil:________________
Endereço:____________________________________________________
Bairro:___________________________ Cidade:_____________________
Fone: _____________________________Cel:_______________________
DIAGNÓSTICO CLÍNICO:
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QP:
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HMA:
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OUTRAS QUEIXAS:
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ANTECEDENTES PATOLÓGICOS:
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MEDICAMENTOS E TRATAMENTOS ANTERIORES:
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HÁBITOS E VÍCIOS:
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ANTECEDENTES FAMILIARES:
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EXAME FÍSICO:
SINAIS VITAIS: PA_____________________FC___________________
PESO:_______________________ALTURA:______________________
INSPEÇÃO:
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PALPAÇÃO:_________________________________________________
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AVALIAÇÃO
POSTURAL:_________________________________________________
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PERIMETRIA:_______________________________________________
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OBJETIVOS E OBSERVAÇÕES:
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