AVALIAÇÃO ORTOPEDIA

Data da avaliação__/__/__

Identificação:

Nome:________________________________________________________________
Idade:_________ Nascimento _____/_____/_____ Sexo: ( ) M ( ) F
Naturalidade: ___________________________Estado Civil:_____________________
End.___________________________________________________________________________
Bairro:____________________________Cidade:______________________________
CEP ________________________________ E-mail:___________________________
Profissão:_____________________________________________________________
Telefone:______________________________________________________________

Diagnóstico Clínico:_____________________________________________________

Médico Responsável:_________________________________Telefone:___________

Exames Complementares:

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Queixa Principal:
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HMA:
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HMP:
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H. FAMILIAR E SOCIOECONÔMICA:
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SINAIS VITAIS

HORÁRIO ___:___

Pulso:________________________________________________________________

Respiração: ___________________________________________________________

Pressão Arterial: _______________________________________________________

Temperatura: __________________________________________________________

EXAME FÍSICO:

Inspeção:

Cabeça: ( ) Alinhada ( )Rodada ( ) Inclinada

Ombro: ( ) Alinhado ( ) Elevado D/E ( ) ( ) Deprimido D/E ( )

Clavícula: ( ) Alinhada ( )Elevada D/E ( ) ( )Saliente D/E ( )

Cotovelo: ( ) Alinhado ( ) Valgo D/E ( )

Antebraço: ( ) Neutros ( ) Pronados D/E ( )

EIAS: ( ) Alinhada ( )Mais baixa D/E ( )

Joelhos: ( )Alinhados ( ) Valgos ( ) Varos ( )R. Medial ( ) R. Lateral

Patela: ( ) Alinhadas ( ) Lateralizadas D/E ( ) ( )Medializadas D/E ( ) ( ) Elevada

D/E( )
Pé:( )Alinhados ( )Valgo D/E ( ) ( ) Varos D/E ( ) ( ) Plano ( ) Cavo

Tornozelo: ( )Alinhado ( ) Valgo D/E ( ) ( ) Varo D/E ( )

EIAS: ( )Alinhadas ( )Mais baixas D/E ( ) EIAS: ( )Alinhadas ( )Mais

baixas D/E ( )

Coluna Cervical: ( )Retificada ( ) Normal ( ) Hiperlordose

Coluna Torácica: ( ) Retificada ( ) Normal ( ) Hipercifose

Coluna Lombar: ( )Retificada ( ) Normal ( ) Hiperlordose

Tipo de Marcha:
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Palpação:
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Amplitude Articular:
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Goniometria:
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Perimetria:
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Teste de retração muscular:

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Teste de força muscular:

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Testes especiais:

( )Muscular:___________________________________________________________
( ) Ombro:____________________________________________________________
( )Cotovelo:___________________________________________________________
( )Quadril:_____________________________________________________________
( )ColunaVertebral:_____________________________________________________
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DIAGNÓSTICO FISIOTERÁTICO:

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OBJETIVOS DO TRATAMENTO:
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TRATAMENTO FISIOTERÁPICO
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Estagiário (a) Supervisor (a)