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EVALUACIN NEURO-REHABILITACIN INFANTIL

ANTECEDENTES PERSONALES:
Nombre:_____________________________ Fecha Nacimiento:
____________________________
Edad Cronolgica: ______________________ Edad Corregida:
_____________________________
Direccin:
________________________________________________________________________
Telfono: _________________________________
Diagnstico Mdico:
________________________________________________________________________________
________________________________________________________________________________
ANTECEDENTES PERINATALES:
Parto: Normal ___ Cesrea ___ Uso Forcep ___Pre trmino ____ Trmino ____ Pos
trmino ____
Alimentacin: _________________________________________________________________
Fecha Evaluacin: __________________________ Evaluador:
_____________________________
Antecedentes Mrbidos:
____________________________________________________________
________________________________________________________________________________
Control de Esfnteres: Anal_____________ Vesical ____________ Uso de Sonda
_______________
Tratamiento Farmacolgico:
_________________________________________________________
________________________________________________________________________________
ANAMNESIS
Anamnesis Remota:
_______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________________________
Anamnesis Prxima:
_______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________________________

IMPRESIN GENERAL DEL PACIENTE:


Uso de ayuda tcnica:
Silla de ruedas: _____ Andador:_____ Bastn: _____ No usa: _____ Otra:
__________________
Elementos de ortopedia:
________________________________________________________
Estado del paciente:
Vigil: ________ Obnubilado: ________ Somnolencia: ________ Sopor: ________
Coma: ________
EVALUACIN ESTADO CONCIENCIA
Conexin:
________________________________________________________________________
________________________________________________________________________________
Respuesta a estmulos visuales:
______________________________________________________
________________________________________________________________________________
Respuesta a estmulos auditivos:
_____________________________________________________
________________________________________________________________________________
Respuesta a rdenes simples y complejas:
______________________________________________
________________________________________________________________________________
ENTORNO SOCIAL
(Vivienda, accesibilidad, barreras arquitectnicas de su domicilio, locomocin
colectiva, etc)
________________________________________________________________________________
________________________________________________________________________________
ANTECEDENTES FAMILIARES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
GENOGRAMA:

EVALUACIN INICIAL
Estado de Salud General del Paciente:
_________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Objetivo del Paciente:
______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN PSICOMOTORA
SUPINO
Cabeza (Gira, eleva contra la gravedad, logra lnea media, inclinada, Girada):
_________________
________________________________________________________________________________
________________________________________________________________________________
Extremidades Superiores (Logra lnea media, eleva, coje objetos, manipula,
traspasa, cruza lnea media):
_________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Tronco (Alineacin, transferencia de peso):
_____________________________________________
________________________________________________________________________________
________________________________________________________________________________
Pelvis (Anteversin, Retroversin):
___________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Extremidades Inferiores (Caderas, Rodillas, Pies, Movimientos espontneos,
disociados/bloques): _
________________________________________________________________________________
________________________________________________________________________________
GIRO
Secuencia (Bloque, Disociado, Caractersticas):
__________________________________________
________________________________________________________________________________
________________________________________________________________________________
PRONO
Cabeza (Gira, eleva contra la gravedad, logra lnea media, inclinada, Girada):
_________________
________________________________________________________________________________
________________________________________________________________________________

Apoyo de Extremidades Superiores (Caractersticas,


Simetra)______________________________
________________________________________________________________________________
________________________________________________________________________________
Tronco (Alineacin, transferencia de peso, centro de gravedad, superficie de
apoyo, base de sustentacin, carga de peso):
________________________________________________________
________________________________________________________________________________
Pelvis (Anteversin, Retroversin):
___________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Extremidades Inferiores (Caderas, Rodillas, Pies, Movimientos espontneos,
disociados/bloques): _
________________________________________________________________________________
________________________________________________________________________________
SEDENTE
(Logra por si slo, mantiene posicin, control de cabeza, tronco, carga de peso,
posicin EESS, EEII, Reacciones de proteccin, traccin a sedente; incluir
sedente piernas extendidas y/o sobre banco)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
CUATRO APOYOS
(Logra por s solo, caracterstica de la posicin)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
GATEO
(Maduro, inmaduro, coordinado, simetra)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
TRASPASO A BPEDO
(Logra por si slo, uso de EESS, EEII, Transferencia de peso, etc)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
BPEDO

(Logra por s solo, mantiene, reacciones equilibrio, enderezamiento, proteccin)


________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
MARCHA
(Independiente, dependiente, Caractersticas de patrn segn fases)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN DEL TONO:
(Incluir pruebas de Holding /Placing, Presencia de reacciones asociadas,
descripcin de patrn, Hipotona/ Hipertona, escala de Asworth)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN ARTICULAR
(Limitaciones articulares, rango de movilidad pasiva, articulaciones inestables,
riesgo de deformidades, etc.)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN DE LA SENSIBILIDAD SENSORIALIDAD PERCEPCIN
Sensibilidad Superficial:
____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Sensibilidad Profunda:
_____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Visin:
__________________________________________________________________________
________________________________________________________________________________
Audicin:
________________________________________________________________________
________________________________________________________________________________
Gnosias:
_________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Praxias:
_________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN DEL DOLOR:
Zona del Dolor:
___________________________________________________________________
Dolor reposo (EV) 0___ 1___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 7 ___ 8 ___ 9 ___ 10 ___
Dolor Movimiento (EV) 0___ 1___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 7 ___ 8 ___ 9 ___ 10
___
Caractersticas:
___________________________________________________________________
________________________________________________________________________________
REFLEJOS PERSISTENTES
Moro:
___________________________________________________________________________
Prehensin Palmar:
________________________________________________________________
Prehensin
Plantar_________________________________________________________________
Galant:_________________________________________________________________________
_
HALLAZGOS CLNICOS
Impedimentos Primarios:
___________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Impedimentos Secundarios:
_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
RAZONAMIENTO CLNICO (DIAGNSTICO KINSICO)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Clasificacin Internacional de Funcionalidad CIF
DETERIORO
ESTRUCTURAL:

LIMITACIN
ACTIVIDAD

RESTRICCIN
PARTICIPACIN

FUNCIONAL:

OBJETIVO GENERAL
________________________________________________________________________________
________________________________________________________________________________
OBJETIVOS ESPECFICOS
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
OBJETIVOS OPERACIONALES
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PRONOSTICO FUNCIONAL
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVOLUCIN
________________________________________________________________________________
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