Nombre: ______________________________________Edad:_____ Fecha de nacimiento: ________

Fecha: _______________ Numero de sesión: ________Sexo: ________ Religión: _______________

Domicilio: __________________________________________________________________________

Teléfono: ________________ Teléfono de emergencia: ____________ Ocupación: _____________

Estado civil: ____________ Motivo de consulta: __________________________________________

Diagnostico medico: _________________________________________________________________

Diagnostico funcional: ______________________________________________________________

Peso: _________ Estatura: _______ Toxicomanías: _______________________________________

Presión arterial: _____________________________________________________________________

Saturación de oxigeno: ________________________ Alergias: _______________________________

Temperatura: ________ Frecuencia respiratoria: ____________ Frecuencia cardiaca: ___________

Antecedentes familiares de enfermedades:

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Enfermedades:________________________________________________________________________
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Medicamentos:________________________________________________________________________
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Cirugias:_____________________________________________________________________________
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Lesiones:____________________________________________________________________________
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Tratamientos:_________________________________________________________________________
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Horas de sueño: ___________ Alimentación: ______________Dolor:________________________

Comportamiento del
dolor:________________________________________________________________________________
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Exploración física:

Pruebas especiales:

Tratamiento fisioterapia:

Objetivos:

Corto plazo Mediano plazo Largo plazo

Pronostico:

Observaciones:_______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Fisioterapeuta: _______________________________________________________________________

Firma: _________________________ Cedula: ________________________ Hora: _________________

Nombre: __________________________________________________________ Edad: _____________

Diagnostico medico: ___________________________________________________________________

Diagnostico funcional: _________________________________________________________________

Presión arterial: _______________________________________Temperatura:____________________

Saturación de oxigeno: ________ Frecuencia cardiaca: ______ Frecuencia respiratoria: __________

Medicamentos:
_____________________________________________________________________________________
_____________________________________________________________________________________

Notas de
evolución:____________________________________________________________________________
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Tratamiento:

Pruebas especiales:

Observaciones:_______________________________________________________________________
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Fecha: _________________________ Hora: ________________________________________________

Fisioterapeuta: _______________________________________________________________________

Cedula: ________________________ Firma: _______________________________________________