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HOJA DE EVALUACION DE FISIOTERAPIA

Datos Personales NOMBRE: ______________________________________________EDAD: ___ SEXO: ___ Diagnostico: _____________OCUPACION: _________ FECHA: ___ HISTORIA CLINICA ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ EVALUACION FISICA: Actitud Postural:

Normal____

Alterada_____

Evaluación de piel: Color: Normal_____ Erimatosa____ Equimosis____ Estado: Normal___

Seca: _____ Brillante: _____

Edema: Ninguno____

Leve: _____ Moderada____

Severo_____

Evaluación de dolor: ________________________________________________________________________ ________________________________________________________________________ Evaluación de la sensibilidad: Superficial_______________ Profunda__________ Evaluación Osteoarticular:___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Evaluación neuromuscular: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Padece una enfermedad: ___________________________________________________ PLAN DE TRATAMIENTO: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________