FICHA DE AVALIAO NEUROLGICA

I. IDENTIFICAO
Nome:__________________________________________Idade:__________________
Data de nascimento:____/____/____ Sexo:_____________Cor:___________________
Endereo:_______________________________________Telefone:_______________
Profisso:_____________________Encaminhado por:__________________________
Diagnstico clnico:__________________________Data de avaliao:____/____/_____
II. HISTRIA CLNICA
Anamnese
a) Q.P.:________________________________________________________________
b) HMA/HMP:___________________________________________________________
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c) AP e HS_____________________________________________________________
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d) AF:_________________________________________________________________
Medicamentos em uso:__________________________________________________
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Exames complementares:________________________________________________
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Diagnstico fisioteraputico:_____________________________________________
III.EXAME FSICO
a) Nvel de conscincia: __________________________________________________
b) Sinais vitais: FC:___________PA:___________FR:____________TEMP:_________
c) Regulao autonmica e endcrina:
Perfuso perifrica:____________________Trofismo de pele:____________________
Sudorese:___________________________Anexos:____________________________
Edema:_____________________________Temperatura de extremidades:__________
d) Sistema sensorial
Ttil:___________________________ Algsico:_______________________________
Cintico postural:_________________ Especial:_______________________________
e) Sistema motor
Integridade ssea:_______________________________________________________
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ADM:_________________________________________________________________
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f) Reflexos
Miotticos:
Aquiliano:_______________________ Patelar:________________________________
Estilo-radial:_____________________ Biciptal:________________________________
Triciptal:________________________
Superficial:
Babinski:_______________________________________________________________
Posturais:
Ajustes posturais tnicos:__________________________________________________
Ajustes posturais fsicos:__________________________________________________
g) Tnus muscular: ______________________________________________________
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h) Trofismo muscular:_____________________________________________________
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i) Motricidade voluntria:__________________________________________________
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j) Motricidade involuntria e reaes associadas:_______________________________
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k) AVDs: ______________________________________________________________
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l) Esquema corporal/imagem corporal:_______________________________________
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m) Relaes espaciais: ___________________________________________________
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n) Marcha:_____________________________________________________________
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o) Avaliao respiratria:__________________________________________________
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IV. PLANO DE TRATAMENTO
Objetivos: _____________________________________________________________
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Goinia, ___/___/___.
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Fisioterapeuta