NOMBRES: _______________________________________________________________________

APELLIDOS: ______________________________________________________________________

DOC IDENTIDAD: _________________________

EDAD: ____________ SEXO: _____________

ESTADO CIVIL: ___________________________ PROCEDENCIA: ___________________________

OCUPACION: ___________________________

DIAGNOSTICO: ____________________________________________________________________

MEDICAMENTOS:__________________________________________________________________
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CIRUGIAS:________________________________________________________________________
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TIEMPO DE LA MOLESTIA: ___________________________________________________________

PRACTICA ALGUN DEPORTE: _________________________________________________________

INICIO DE LA TERAPIA FISICA: ________________

FINALIZACION DE LA TERAPIA FISICA: ______________

OBJETIVOS DE TRATAMIENTO:
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PLAN DE TRATAMIENTO:

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