FICHA DE AVALIAO FISIOTERAPUTICA

FISIOTERAPEUTA:_____________________________________________. DATA DA AVALIAO: ___ / ___ / ___.

NOME: _______________________________________________________. IDADE: _______.SEXO: ____________.
DATA DE NASCIMENTO:_________________. ESTADO CIVIL: _____________. CIDADE: ____________________.
ENDEREO: ___________________________________________________________________________________.
MDICO RESPONSVEL: ________________________________________________________________________.

DIAGNSTICO
CLNICO:
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QUEIXA
PRINCIPAL:
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H.M.A.
(PPA,
PTAM,
SAASS):
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H.M.P.
(IHM,
TAQP):
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ANTECEDENTES
FAMILIARES?
MEDICAMENTOS
UTILIZADOS?
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ANTROPOMETRIA: ALTURA: _____ M. PESO:_____ KG. IMC: ____. SITUAO: _____________.
SINAIS VITAIS: FC: _____BPM. PA: ____MMHG. FR:______IPM.
LOCOMOO: _____________________________________________________________________________
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DADOS REFERENTES SADE DO PACIENTE:
H
PATOLOGIAS
ASSOCIADAS,
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CIRURGIAS?_________________
FRATURAS?_________________
PINOS
METLICAS:______________

QUAIS?
E

PLACAS

DADOS RELATIVOS DOR:

SENTE DOR? ( )SIM. ( )NO. CASO SEJA SIM: H QUANTO TEMPO EST COM DOR?
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ONDE SE LOCALIZA?_______________________. A DOR IRRADIADA? PARA ONDE?
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QUAIS
AS
CIRCUNSTNCIAS
DE
INCIO
DA
DOR?
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O
QUE
FAZ
COM
QUE
A
DOR
PIORE
OU
MELHORE?
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J
FEZ
TTO
DE
FISIOTERAPIA?
RESULTADOS:
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EXAME FISICO:
INSPEO:
MEDIDA
REAL:
APARENTE:____________________________.

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MEDIDA

PERIMETRIA (AAE):
SEGMENTO
PONTO DE
REFERNCIA
MEDIDA
5 cm
10 cm
15 cm
20 cm
25 cm
GONIOMETRIA:

FORA MUSCULAR:

TESTES
ESPECIAIS
(RESULTADO):________________________________________________________________
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SENSIBILIDADE:
DERMATOMO: ___________________________________________________________________________
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MIOTOMO:______________________________________________________________________________
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EXAMES
COMPLEMENTARES:
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DIAGNOSTICO
FISIOTERAPUTICO:
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OBJETIVOS
DO
TRATAMENTO
FISIOTERAPUTICO:
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CONDUTAS
FISIOTERAPUTICAS:
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OBSERVAES
(
CAPTAO
____________________________________________

DE

IMAGENS,

INFORMAES):

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