Ficha de Avaliao Fisioteraputica Mastectomia

Unidade:_______________________________________Data______/______/____
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1-Dados pessoais
Nome:________________________________________________________________
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Data de Nascimento: ___/____/____ Sexo:______
End.:
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Bairro:
____________________________Tel.:_____________Recado_____________
Profisso/
Ocupao
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anterior:

Mdico
Responsvel:_____________________________________________________
Medicamentos:_______________________________________________________
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2.
Diagnstico
clnico:____________________________________________________
3.
Queixa
principal:______________________________________________________
4.HMA/HMP:__________________________________________________________
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5.
Antecedentes
Pessoais:_________________________________________________

6. Antropemetria: Peso_____________
Altura:________________
7. Sinais Vitais:
FC: _______
Temperatura:_______

PA: _________ FR:__________

8. Estado Geral:
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9. Data da cirurgia: ___________________________________________
10. Tipo de cirurgia:
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10.1 Intercorrncia:
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11. Radioterapia (

) Sim

) No

Quimioterapia

) Sim

) No

Hormonioterapia (

) Sim

( ) No

12. Dor:
13. ADM:
14. Fora muscular:
15. Presena de edema: (
Biometria
Cotovelo:
10cm acima do cotovelo
10cm abaixo do cotovelo
Axila
Punho
Metatarso

) Sim

)No
Direito

Esquerdo

16. Objetivos:
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17. Condutas:
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Ass. Acadmico

Ass. Supervisor