Professional Documents
Culture Documents
Nome:_______________________________________________________________________________
Nascimento:_______________Estado civil:_________________________Profisso:________________
Endereo:____________________________________________________________________________
Data da avaliao:______________Telefone:_____________________Email:______________________
1 - Objetivo Relacionado a atividade fsica:
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2 - Anamese:
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3 - Hbitos de vida e Histria pessoal:
Tabagismo:
( ) Sim ( ) No Quanto tempo:____________ Cigarros por dia: ________________
Etilismo:
( ) Sim ( ) No Tipo:____________ Quanto tempo: ______ Frequencia: _________
Sono
( ) Regular ( ) Irregular Descreva:_________________________________________
Atividade Fsica: ( ) Sim ( ) No Tipo:_________________ Freqncia: _______________________
Ingesto de lquidos:____________________________________________________________________
Alimentao:__________________________________________________________________________
Cirurgias:_____________________________________________________________________________
Gravidez: ( ) No ( ) Sim Quantas?___________ Tipo de parto:_________________ Aborto?________
4 Patologias Associadas: ______________________________________________________________
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5 Medicamentos em uso: ______________________________________________________________
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6 Exames Complementares: ___________________________________________________________
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7 - Histrico Familiar: _________________________________________________________________
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8 - Exame Fsico
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8.1 Vista Anterior
C abe a
Om bros
Tron co
ngul o de Tal es
Ci c at riz um bi li c al
C rist as Il a cas
Joel hos
P s
In cl i nad a
El evado
R odado
S im t ri co
Al i nhada
S im t ri ca
Val go
R ot ao l at er al
P l ano
P ronado
R odada
Dep ri m i do
In cl i nado
Mai or
Desvi o
El evad a
Var o
R ot ao m edi al
C avo
S upi nado
Abduz i da
El evada
Escol i ose
Aduz i da
P rot usa
Ci fose
Si m t ri cas
Rot a o l at e ral
Si m t ri cas
Val go
El evad a
R ot ao m edi al
El evad a
Var o
8.4 - Fl exi bl i d ad e :
Tr c eps S ural :
Isq ui oti bi ai s:
TF L:
Quadr c eps:
Rot ador es ext e rnos:
Rot ador es i nt ernos:
Adut ores de quadri l :
P arave rt ebr ai s:
Quadr ado l om bar:
Fl ex ores de om bro:
Ex t ensores de om bro:
Adut ores de om bro:
Abdut ores de om bro:
Fl ex ores de pescoo:
Ex t ensores de pesco o:
Rot ador es de pescoo:
9 - Testes esp eci ai s:
9.1 - E xame d o Core
Enrol am ent o da col una
Pont e
Pont e esquerd a
Pont e di r ei t a
P rancha
P rancha esque rda
P rancha di rei t a
Bom
Bom
Bom
Bom
Bom
Bom
Bom
R e gul ar
R e gul ar
R e gul ar
R e gul ar
R e gul ar
R e gul ar
R e gul ar
9.2 - Fora
Meio agachamento
3_______________________________
Agachamento completo
3_______________________________
Elevao de calcanhar
3_______________________________
Push up
3_______________________________
Prancha lateral
3_______________________________
Super-homem
3_______________________________
3_______________________________
3_______________________________
Hundred
3_______________________________
9.3 - Flexibilidade
Aranha na parede
3_______________________________
Extenso em prono
3_______________________________
Rui m
Rui m
Rui m
Rui m
Rui m
Rui m
Rui m
3_______________________________
3_______________________________
Sentado em Z
3_______________________________
3_______________________________
INTERMEDIRIO
(1,5 a 2,4)
AVANADO
(2,5 a 3,0)
Al ongar
Evit a r
C ui dado/ At en
o
Evit a r
Observ ao:
C i ent e, ____________________________________________________
Belo Horizonte, ________de_______________ de 20_____.
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Fi si ot erap eut a