FICHA DE EVALUACION FISIOTERAPEUTICA

INTERNO: FECHA:
HORA:
1. DATOS DEL PACIENTE

NOMBRES

FECHA DE
EDAD SEXO
NACIMIENTO
DNI CELULAR DIRECCION

N.º de HIJOS Ocupación Estado civil

Peso Talla Nº de vacunas

2. ANTECEDENTES PERSONALES
Consume Alcohol: _______ Tabaquismo: _______ Drogas: _______

Actividad física: _______

Enfermedades SI NO OBSERVACIONES

Diabetes

HTA

Alergias

Artritis

Artrosis

Fracturas

Quirúrgicas

Otras enfermedades

EVALUACION
Motivo de la consulta
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¿Hace cuánto tiempo empezó la molestia?

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¿Cómo empezó las molestias?

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¿Con que intensidad describiría el dolor?

1. TIPO DE DOLOR:
Localizado: _______________________________Irradia: _______________________________________________

Frecuencia______________________________________________________________________________________

Uso de analgésico____________________________________________________________________

Cuando aparece el dolor ________________________________________________________________

Afectivo - Emocional______________________________________________________________________________

2. EVALUACIONES FISIOTERAPEUTICAS
_NEURAL_______________________________________________________________________________________

_FASCIAL_______________________________________________________________________________________

_MUSCULAR____________________________________________________________________________________

_ARTICULAR_____________________________________________________________________________________
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_EVALUACIÓN DE MARCHA_______________________________________ ______
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_OTROS________________________________________________________________________________________

3. DIAGNOSTICO FISIOTERAPEUTICO

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4. OBJETIVOS A CORTO Y LARGO PLAZO

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5. PLAN DE TRATAMIENTO

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EVOLUCIONES:

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Sesión: # Fecha:
EVALUACIÓN FINAL FISIOTERAPÉUTICA

Intensidad de dolor:

Comentario

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Interno: