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FICHA DE AVALIAÇÃO FISIOTERAPÊUTICA

(RUPTURA DO TENDÃO DE AQUILES)

Dados de identificação:
1. Nome completo_____________________________________________________________
2. Data de nascimento:___/___/___ 3. Idade: _________ 4. Sexo: F( ) M( )
5. Estado civil: _______________
6. Endereço:___________________________________________________________________
7. Contato (celular): _________________

História da lesão atual:


Tendão rompido: D( ) E( ) / Membro dominante: D( ) E( )
Sintomas prévios no tendão rompido:
_____________________________________________________________________________
_____________________________________________________________________________
Realizou algum tratamento? SIM( ) NÃO( )
Mecanismo da lesão:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Como o pé estava posicionado no momento em que ocorreu a lesão?
_____________________________________________________________________________
_____________________________________________________________________________
Sintomas após a lesão:
_____________________________________________________________________________
_____________________________________________________________________________
Data da lesão: __/__/__ Data da cirurgia: __/__/__
Tempo entre a lesão e a cirurgia:________________________________
Diagnóstico(s) clínico(s):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Exames complementares:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Medicamentos em uso:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

História Familiar:
Algum caso na família de ruptura ou lesão tendinosa?
_____________________________________________________________________________
_____________________________________________________________________________

Q.P:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Escala Visual Analógica de Dor (EVA):

Relato do(a) pcnt:______________________________________________________________

Exame físico:
FM:_________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ADM:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
TÔNUS/TROFISMO:___________________________________________________________
FAZ USO DE DISPOSITIVO AUXILIAR? SIM( ) NÃO( ). SE SIM, QUAL?
_____________________________________________________________________________
______________________________________________________________________

Diagnóstico fisioterapêutico:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Plano de tratamento:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Observações: