Nome:___________________________________________________

Data da Avaliao:_____/_____/_____
Nmero do Pronturio:_____________________________________
Sexo: (Feminino) (Masculino)________________________________
Data de Nascimento:____/____/_____ Idade:___________________
Profisso (Ocupao):______________________________________
Estado Civil:______________________________________________
Endereo:________________________________________________
Cidade:__________________________________________________
Bairro:___________________________________________________
EST:_____________________________________________________
CEP:____________________________________________________
Tel/Res:_______________Tel/Com:______________Cel:__________
E-mail:___________________________________________________
Mdico Responsvel:______________________________________
Fisioterapeuta responsvel:_________________________________
Diagnstico Mdico:_______________________________________
Indicado por:_____________________________________________
Responsvel:_____________________________________________

Nome:_______________________________________________sexo: (Fem) (Masc).

Idade:________Data deNasc:____/____/_____.Profisso:________________________
Tel/Res:_______________Tel/Com:______________Cel:_________________________
E-mail:_______________________________Indicado por:_______________________
________________________________________________________________________
Quem o seu Mdico responsvel?
________________________________________________________________________
Toma algum tipo de medicamento? Sim ( ) No ( ) Para qu?
________________________________________________________________________
J realizou tratamento Fisioteraputico? Para que?
________________________________________________________________________
Qual a sua ocupao no momento?
________________________________________________________________________
Quantas horas por dia voc trabalha?
________________________________________________________________________
Qual a posio em que voc permanece a maior parte do tempo?
________________________________________________________________________
Alimenta-se adequadamente?
________________________________________________________________________
Apresenta alguma patologia? Sim ( ) No ( ) Quais?
________________________________________________________________________

J se tratou com Quiropraxia antes?

________________________________________________________________________

J realizou outros tratamentos antes desse? Sim ( ) No ( ) Quais?

________________________________________________________________________

Fraturas ? Sim ( ) No ( ) Onde e Quando?

________________________________________________________________________

Cirurgias j realizou? Sim ( ) No ( ) Onde e Quando?

________________________________________________________________________

Voc fumante? Sim ( ) No ( ) A quanto tempo?

________________________________________________________________________

Qual atualmente o seu nvel de estresse de 0 10? Motivo?

________________________________________________________________________


Voc pratica algum tipo de atividade fsica ? Qual? Freqncia?
________________________________________________________________________

Voc dorme bem? Sim ( ) No ( ) Quantas horas?

________________________________________________________________________
Altura:________________Peso:________________Presso Arterial:_______________
Problemas Apresentados:
Dor de Cabea

Presso
Arterial

Alergia

Prtese

Dor na Coluna

Corao

Vascular

Pinos

Osteoporose

Pulmo

Diabetes

Placas

Artrite

Estomago

Colesterol

Marca passo

Artrose

Intestino

Gravidez

Aparelho Auditivo

Outros:_________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Antecedentes Familiares:__________________________________________________
________________________________________________________________________
________________________________________________________________________
Observao:_____________________________________________________________
________________________________________________________________________
________________________________________________________________________

de minha extrema responsabilidade a veracidade dos dados

contidos acima e tambm a no omisso de nenhuma informao
que possa prejudicar a boa evoluo do tratamento.

Data:______/______/______

______________________________
Assinatura

Avaliao Subjetiva

Nome:____________________________________________Data:_____/_____/_______
Sexo:___________________Idade:___________Profisso:_______________________

HMP/HMA:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Queixa Principal
________________________________________________________________________
________________________________________________________________________

Atividades de Vida Diria AVD

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Patologias Associadas:_________________________________________
_____________________________________________________________
Medicamentos Atuais:__________________________________________
_____________________________________________________________
Exames Complementares
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Comportamento da Dor
Tipo de Dor:___________________________________________________
Agravante da Dor:______________________________________________
Alvio da Dor:__________________________________________________
Posio de Dormir:_____________________________________________
Freqncia da Dor:_____________________________________________
Perodo o qual a dor pior: Manha( ) Tarde( ) Noite( ) Madrugada( )

Avaliao Objetiva
Inspeo/ Palpao/ ADM
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Testes Especficos
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Testes de Movimentos

rea e comportamento da Dor

Fle
Rot

Incl

Rot
Incl

Observaes Conservadora e Especfica

________________________________________________
________________________________________________
________________________________________________
Ext
________________________________________________
________________________________________________
Data: ____/____/_____ Data:________________________________________________
____/____/____
Data: ____/____/____
________________________________________________
T1____T2____T3____
T1____T2____T3____
T1____T2____T3____
________________________________________________
________________________________________________
Avaliao Postural
________________________________________________
________________________________________________
Estrutura Fech Abert
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________

Cabea
Cervical
Ombro
Torcica
Lombar
Plvis
Joelho
Retro-p
Ante-p
Total

Nome:________________________________________________Data:____/____/_____

Objetivos de Tratamento:________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Conduta de Tratamento:______________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Orientaes:
______________________________________________________
______________________________________________________

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Prevenes:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Periodicidade
Periodicidade 1 semana
1 ms
2 ms
3 ms
4 ms
5 ms
6 ms
7 ms
8 ms
9 ms
10 ms
11 ms
12 ms

2 semana

3 semana

4 semana

Data:_____/_____/_____EVD:_____________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

_______________________
Terapeuta Responsvel