ESTÁGIO SUPERVISIONADO CURRICULAR

FICHA DE AVALIAÇÃO - FISIOTERAPIA

TRAUMATO ORTOPÉDICA

Identificação Data da avaliação: ____/____/______

Nome:_________________________________________________________________________

Nome social: ___________________________________________________________________

Data de nascimento:____/____/______ Idade:______
Gênero: Feminino ( ) Masculino ( ) Não Binário ( ) Outro:_____________________________
Nacionalidade:__________________________________________________________________
Cidade:________________________ Estado:__________________________________________
Endereço:______________________________________________________________________
Escolaridade: Ens. Fundamental ( ) Ens. Médio ( ) Ens. Superior ( )
Profissão:______________________________________________________________________
Contatos: ( )_____________________ ( )____________________ ( )____________________

Diagnóstico clínico:________________________________________________________________

Anamnese

Q.P:___________________________________________________________________________
H.D.A.:________________________________________________________________________
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H.D.P.:_________________________________________________________________________
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H.Familiar:______________________________________________________________________
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H.Social:________________________________________________________________________
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H.Médico:______________________________________________________________________
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Exame físico

Sinais vitais

F.C.:__________.b.p.m. F.R.:__________i.r.p.m. P.A.:______/______mmHg

Inspeção:_______________________________________________________________________
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Palpação:_______________________________________________________________________
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Testes de movimentos articulares:

Articulação Ativo Passivo Acessório

 Articulação Ativo Passivo Acessório

Discrepância:

Membros Superiores
Medida Real
MMSS E: cm MMSS D: cm

Membros Inferiores
Medida Real Medida Aparente
MMII E.: cm MMII E.: cm
MMII D: cm MMII D: cm

Perimetria:

1. Região:___________________________________________________________________

Membros Superiores
Terço proximal Terço medial Terço distal
E.: cm E.: cm E.: cm
D.: cm D.: cm E.: cm
Membros Inferiores
Terço proximal Terço medial Terço distal
E.: cm E.: cm E.: cm
D.: cm D.: cm D.: cm

2. Região:___________________________________________________________________

Membros Superiores
Terço proximal Terço medial Terço distal
E.: cm E.: cm E.: cm
D.: cm D.: cm E.: cm

Membros Inferiores
Terço proximal Terço medial Terço distal
E.: cm E.: cm E.: cm
D.: cm D.: cm D.: cm

3. Região:___________________________________________________________________

Membros Superiores
Terço proximal Terço medial Terço distal
E.: cm E.: cm E.: cm
D.: cm D.: cm E.: cm

Membros Inferiores
Terço proximal Terço medial Terço distal
E.: cm E.: cm E.: cm
D.: cm D.: cm D.: cm
Goniometria:

Articulação/Segmento Movimento Esquerdo Direito

Observação:______________________________________________________________________

Trofismo muscular:

Segmentos e regiões:_____________________________________________________________

Normotrófico ( ) Hipertrófico ( ) Hipotrófico ( ) Atrófico( )

Observação:______________________________________________________________
Força Muscular – Escala de Oxford:

Grupo Muscular Esquerdo Direito Grau

Testes específcos:

Articulação e/ou segmento:__________________________________________________________

Teste:_________________________________________________ Laudo: presente ( ) ausente ( )

Articulação e/ou segmento:__________________________________________________________

Teste:_________________________________________________ Laudo: presente ( ) ausente ( )

Articulação e/ou segmento:__________________________________________________________

Teste:_________________________________________________ Laudo: presente ( ) ausente ( )

Articulação e/ou segmento:__________________________________________________________

Teste:_________________________________________________ Laudo: presente ( ) ausente ( )

Articulação e/ou segmento:__________________________________________________________

Teste:_________________________________________________ Laudo: presente ( ) ausente ( )
Avaliação postural:_______________________________________________________________
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Exames Complementares:_________________________________________________________
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Observação:______________________________________________________________________
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Diagnóstico cinesiológico funcional:_________________________________________________
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Objetivos:_______________________________________________________________________
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Condutas fisioterapêuticas:________________________________________________________
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Preceptor (a):__________________________ Aluno (a):_________________________