FICHA PACIENTE:

1. Datos Personales:

Nombre:
Edad:
Direccin:
Fono / Celular:
E- mail:
Talla:
Peso:
Sexo:
Estado Civil:
Actividad / Profesin:

Previsin:
Mdico que lo enva:

Motivo de Consulta:
Dg. Mdico:

- OTRAS ENFERMEDADES: Diabetes / Hipertensin / Endocrino

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ANTECEDENTES QUIRURGICOS (fecha de la intervencin)

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- Medicamentos:
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HISTORIA FAMILIAR (muerte o no de los padres, enfermedades familiares: Diabetes,

HTA, etc)

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2. Dolor: 0 10

Localizacin en el cuerpo: Mapa del dolor

Mapa del dolor

Smbolos
/// Como una pualada
000 Hormigueos

XXX Ardiente
=== Entumecimiento

Caractersticas del dolor:

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3. Inspeccin:
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4. Palpacin:
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5. Rango Activo:
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6. Rango Pasivo:
OSTEOKINEMATICA
GONIOMETRA
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ARTROKINEMATICA
ENDFEEL
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7. Longitud Muscular
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8. Fuerza Muscular
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9. Pruebas Especiales:
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10. Test Neuromuscular y Neurovascular:
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11. Imgenes:
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12. Resumen Hallazgos:
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13. Diagnstico Kinsico:
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14. Pronstico
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15. Tratamiento:
Objetivo General
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Objetivos Especficos
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Plan de tratamiento.
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