FICHA DE AVALIAÇÃO FISIOTERAPÊUTICA CLÍNICA MÉDICA E CIRÚRGICA

Data da Avaliação: ______/______/______ Prontuário: __________

Data Internação: _________________ Leito: ___________ D. nasc.: ______________
Nome: _______________________________________________________________________
Sexo ( ) M ( )F Idade: _________

Diagnóstico Funcional :
( ) Disfunção ( ) Limitação ( ) Incapacidade
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Diagnóstico de internação:
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QP:__________________________________________________________________________
HDA:________________________________________________________________________
HPP:_________________________________________________________________________
Sinais Vitais: FR: ________ FC:_________ PA:__________________ SaO²______________
AP:__________________________________________________________________________
Nível de Consciência: ____________________________
Condições de vias aéreas/Ventilação:
( ) A.A. ( ) MNBZ _____ L/min ( ) VNI ( ) TQT ____ ( ) Cateter de O²_____L/min.

MOBILIDADE
Marcha: ( ) Independente ( ) Com dispositivo de auxílio ( ) não realiza
Sedestação: ( ) Independente ( ) Com auxílio ( ) Pouco auxílio ( ) não realiza
Posição Ortostática: ( ) Independente ( ) Com auxílio ( ) Pouco auxílio ( ) não
realiza
 Escala Medical ResearchCouncil – Avaliação de Força Muscular Manual

Abd. Ombro Flex. Cotovelo Ext. Punho Flex. Quadril Ext. Joelho Dorsiflexão

E
Observações:
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Plano Fisioterapêutico: (Objetivos/condutas propostas/previsão de tempo de tratamento)

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Prognóstico:
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Avaliador:______________________________________________________________

Reavaliar em: _________________________________