FICHA DE AVALIAO SADE DA MULHER I

Acadmico (a): _________________________________________________________________

Data da avaliao: ____/____/____ Professor responsvel: ____________________________

1- Dados Pessoais:
Nome: ____________________________________________Idade:________Raa:__________
Endereo: ________________________________________________________ N:_________
Bairro: _______________________________________________________________________
Cidade: __________________________________ UF:_________________________________
Telefone: ( )_________-_________ /( )_________-__________
Estado Civil: ____________________________________
Profisso: _______________________________________

2- Avaliao Gestacional:
2.1 Gestao Anterior
H histria de Gestao anterior?

( ) Sim ( ) No

Houve intercorrncias durante a gestao?

Quantas:_______________

( ) Sim ( ) No

Quais:
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Houve intercorrncias durante o Parto: ( ) Sim ( ) No
Quais:
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Tipo de Parto:
( ) Natural

( ) Cesrea

Aborto: ( ) Sim ( ) No

2.2 Gestao Atual

Idade Gestacional: ______________________________
Tipo de parto que pretender ter:
( ) Natural

( ) Cesrea

Data da ltima mestruao: ___/___/___

Data provvel para o parto: ___/___/____
Peso Inicial: _______________ Peso Atual: ________________ Altura: _________________
PA antes da Gestao: _____________ PA durante a Gestao: _____________ FC:_________
Curva de Glicemia: ______________________

T: ________________

FR:________ Padro Respiratrio:________________ Ausculta Respiratria: _______________

2.3 Alteraes apresentadas no organismo:
Sistema Digestrio:
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Sistema Cardiovascular:
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Sistema Urinrio:
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3- Exame Fsico:
3.1 Avaliao Postural
Ortostatismo:
Vista Anterior:
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Vista Lateral:
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Vista Posterior:
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Sentada:
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3.2 Apresenta Edema:
( ) Sim ( ) No

Se Sim: ( ) Com Cacifo

( ) Sem Cacifo

Local:________________________________________________________________________
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Cirtometria:
Segmento/MMII

Coxa

Perna

Pontos de referncia
MID
MIE

3.3 Amplitude de Movimento e Fora Muscular

Articulao

GlenoUmeral

mero-Ulnar

UlnaCarpeana

Coxo-femural

Femorotibial

Movimento

FM

D/E

D/E

Observaes

Talocrural

3.4 Realiza Atividade Fsica:

( ) Sim ( ) No
Qual:
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Quantas vezes por semana:
( )1

( )2

( ) mais de 3

3.5 Possui Limitaes nas Atividades de Vida Diria AVDs:

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4- Avaliao das Mamas:

Simetria:
( ) Simtricas ( ) Assimtricas
Condio Mamilar (H formao do mamilo (exteriorizao), Pigmentao, presena de
rachaduras e/ou outras alteraes):
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DIAGNSTICO FISIOTERAPEUTICO
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OBJETIVOS
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ORIENTAES
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PLANO DE TRATAMENTO
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