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: ____________________________________________________________
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 Research Council – 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: _________________________________