Ficha de Avaliao para Massagem Teraputica

www.sogab.com.br (51) 30 668930 Esta ficha deve ser preenchida pelo profissional massoteraputa.

Data:____________

Nome:__________________________________________________________________
Idade: ________Peso:____ Altura:____ IMC:____kg/m2 Gnero:__________________
Fone:______________________Fone de Familiar ou Responsvel:__________________

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Assinatura do Paciente

Atesto para fins de direito que as informaes que por mim aqui prestadas so
verdicas, pois daro base para intervenes de massoterapia.

Data:________

1 Queixa ou Objetivo(s):
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Aspecto Funcional da Dor:
2 Histrico de Doenas Atuais
( ) ao caminhar (deambulao)
( ) dor na coluna ( ) dores musculares ( ) dores articulares
( ) ao sentar (sedestao)
( ) problemas cardacos ( ) problemas vasculares ( ) problemas respiratrios.
( ) ao deitar. Decbito?________
( ) hipertenso ( )depresso ( ) Perfil Lipdico ( ) Dislipidemias ( ) outros
( ) em qualquer posio
Especifique:
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3 Histrico Familiar
( ) Problemas Respiratrios ( ) Cardiovasculares ( ) Hipertenso ( ) Obesidade e Dislipidemias
Especifique:
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4 Atualmente realiza alguma espcie de tratamento:
( ) Tratamento Mdico: Dr.(a) _________________ Fone: ________________________
( ) Tratamento Fisioteraputico: Dr. (a) _________________ Fone: __________________
( ) Outro Tratamento
Observaes:
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5 Faz uso de medicao?
( ) no ( ) sim , especifique:
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6 Sobre Possvel Gestao?_________________________________________________

Observaes:_______________________________________
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Resumo de Exames Complementares Diagnsticos e
Informaes Clnicas:
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* Formulrio de Avaliao Elaborado por Prof. Pablo Fabrcio
Flores Dias da Escola SOGAB - www.sogab.com.br

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Tratamento Massoterpico:
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