AVALIAO FISIOTERAPUTICA

Data da Avaliao: ____/____/_______

Convenio: ______________________
Nome: __________________________________________________________
Tel: ____________________________ Cel: ____________________________
Endereo: _______________________________________________________
Estado Civil: _______________ Sexo: ______ Ocupao:
_______________ Medico Solicitante:
_______________________________________________ Diagnstico
Clnico: ______________________________________________
Medicamentos em uso:
___________________________________________
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Queixas Principais: _______________________________________________
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Sinais Vitais: FC: ________ FR:________ T: _________ PA: _____________

Expansibilidade Torcica:
( ) normal
________________

( ) diminuda

) assimtrica

( ) mv diminudo ________

( ) mv abolido

Ausculta:
( ) mv normal
_________________
Rudos adventcios:
( ) crepitaes

( ) roncos

( ) sibilos

Tosse:
( ) ausente
produtiva

) seca

( ) mida

Aspecto da secreo: _____________________________________________________

SISTEMA OSTEOMIOARTICULAR:
( ) mudanas de postura de decbito sozinho
( ) mov. Involuntrio

( ) mov. Voluntrio

) plegia

( ) paresia

Fora muscular:
(

) normal

( ) diminuda _____________________________________________

Tnus:
( ) normal
hipotnico

( ) hipertnico

Anlise articular:
( ) normal

( ) diminuda _______________________________________

( ) luxao ______________

( ) rigidez______________

( ) fratura _____________

( ) desvios posturais _____________________________________________________

DEAMBULAO:
( ) livre
rodas

( ) bengala

( ) andador

( ) leito

( ) auxlio de 3s

( ) abasia

( ) cadeira de
( ) disbasia

MARCHA: ____________________________________________________________
EQUILBRIO:
( ) normal

( ) anormal

) esttico

( ) dinmico

Segmentos: _____________________________________________________________
OBSERVAES:
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