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AVALIAÇÃO FI SIOTERAPÊUTICA – PARALISIA FACIAL

IDENTIFICAÇÃO DO PACIENTE :
Data da avaliação: ______/______/________

Nome:__________________________________________________________
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Data Nasc.: _____/_____/________
Endereço:_______________________________________________________
______________________________________ nº: _________________
Bairro:__________________________________________________________
Cidade:_________________________________________________________
Telefone: (___)________________ Telefone Celular: (___)______________
Grau de Instrução:______ ___________ Sexo: ( ) Masculino ( ) Feminino
Massa:__________Kg. Altura:________ ____cm .
Estado Civil: ( ) Solteiro ( ) Casado ( ) Divorciado ( ) Viúvo ( ) Outros.
Profissão anterior:________________________________________________
Profissão atual: __________________________________________________
Acompanhante ou Responsável: _____________________________________
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Encaminhamento Médico: __________________________________________

Diagnostico clínico:
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ANAMNESE

QUEIXA PR INCIPAL:
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QUEIXA FUNCIONAL:
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TRATAMENTOS ANTERIORES:
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MEDICAMENTOS:
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EXAMES COMPLEMENTARES:
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EXAME FÍSICO DA FACE:

INSPEÇÃO:
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COMO REALIZA AVDS:


(1) Totalmente dependente (2) Parcialmente dependente (3) Independente

( ) Alimentação
( ) Escovar os dentes
( ) OUTROS

PELE E CIRCULAÇÃO:
( ) Manchas ( ) Ressecada ( ) Processo alérgico ( ) Descolorações
( ) Edema ( ) Descamações ( ) Cianose ( ) Lustrosa

Observações:____________________________________________________________
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REFLEXOS:
( ) Epífora
( ) Sinal de Bell
( ) Lagoftalmo
( ) Reflexo viso -palpebral
( ) Sinal negro
( ) Reflexo trigêmio-facial
( ) Reflexo naso-palpebral
( ) Sinal de Hin gazzini
( ) Reflexo córneo-palpebral
( ) Reflexo oro-orbicular

FUNÇÃO MUSCULAR:
SENSIBILIDADE:
SUPERFICIAL:

EXAME SENSORIAL

Sensibilidade gustativa:
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Sensibilidade olfativa:
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Sensibilidade auditiva:
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Deglutição:
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Mastigação:
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Fala:
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OBJETIVOS DO TRATAME NTO


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PLANO DE TRATAMENTO
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OBSERVAÇÕE S
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Fisioterapeuta: _________________________________________________________

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