DATA: ___/___/___

FICHA DE AVALIAO ORTOPDICA

IDENTIFICAO:
Nome:____________________________________________ Sexo: ( ) M
Idade:_____

Data de Nasc.: ____/____/____

Cor:_______

()F

Estado Civil:______________

Profisso:__________________ Tempo de Servio:_____________ Escolaridade:_________

RG:____________________

Tipo Sanguneo:_________ Peso:_________ Altura:________

Endereo:________________________________________________ Telefone:____________
Mdico que encaminhou:___________________________
Diagnstico Clnico:____________________________________________________________
Diagnstico Cinesiolgico-funcional:_______________________________________________
APRESENTAO DO PACIENTE:
_______________________________________________________________________________
___________________________________________________________________________
ANAMNESE:
Queixa Principal:_______________________________________________________________
HMP:________________________________________________________________________
_____________________________________________________________________________
HMA:__________________________________________________________________________
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AVDs:_________________________________________________________________________
___________________________________________________________________________
Exames Complementares:_________________________________________________________
_____________________________________________________________________________
Patologias Asociadas:____________________________________________________________
Medicamentos:_________________________________________________________________
Snteses Metlicas:______________________________________________________________
INSPEO:
_______________________________________________________________________________
___________________________________________________________________________

Avaliao Postural: ( ) Sim

( ) No

Anlise da Marcha:_____________________________________________________________
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PALPAO:____________________________________________________________________
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Sinais Vitais: P.A.:____________________

F.C.:___________

F.R.:________________

Temperatura:_________ Tnus:__________________________________________________
Perimetria:

MSE:____________________________ MSD:__________________________
MIE:____________________________

MID:__________________________

Mensurao:_____________________________________________________________________
___________________________________________________________________________
Goniometria:

( ) Sim

Testes Especiais:

( ) No

( ) Sim

( ) No

Quais:________________________________________________________________________
Reflexos:______________________________________________________________________
_____________________________________________________________________________
Testes de Sensibilidade: ( ) Sim ( ) No
Quais:________________________________________________________________________
Fora Muscular: ________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_________________________________________________________________________
DIAGNSTICO FISIOTERPICO:___________________________________________________
_______________________________________________________________________________
___________________________________________________________________________
PLANO DE TRATAMENTO:_______________________________________________________
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TRATAMENTO PROPOSTO :_______________________________________________________

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