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N° DE HISTORIA_________

VALORACIÓN DE FISIOTERAPIA

FECHA: ___________________________

NOMBRE: ________________________________________________________

GENERO: __________________EDAD: ___________ TALLA__________PESO____________IMC: ________________-

OCUPACION: _________________________________

MOTIVO DE CONSULTA: __________________________________________________________________________

ANTECEDENTES FAMILIARES

DIABETES: ______________________________________________________________________________________

HTA: ___________________________________________________________________________________________

CANCER: _________________________________________________________________________________________

ENF. REUMAT: _____________________________________________________________________________________

CARDIOPATÍAS: _____________________________________________________________________________________

CIRUGÍAS: _________________________________________________________________________________________

ALERGIAS: _________________________________________________________________________________________

ACCIDENTES: _______________________________________________________________________________________

FRACTURAS: _______________________________________________________________________________________

SIGNOS VITALES: T/A___________TEMP.__________FC_________FR__________

EXPLORACION NEUROLOGICA

REFLEJOS:
SENSIBILIDAD:
ORIENTACION:
OTRO:

MARCHA
N° DE HISTORIA_________
NORMAL ANTALGICA
ESPASTICA ATAXICA
CON AYUDA OTRAS:

DOLOR

REGIÓN PRINCIPAL Y LA IRRADIACION DEL DOLOR: _________________________________________________________

EVALUACION MUSCULAR
N° DE HISTORIA_________
DIAGNOSTICO FISIOTERAPETICO
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PLAN DE TRATAMIENTO

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EVOLUCION

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