Universidade Católica de Brasília – UCB

Curso de Fisioterapia
Estágio Supervisionado de Geriatria
Lar Cecília Ferraz de Andrade - Casa do Vovô

Avaliação Fisioterapêutica Geriátrica

Paciente: _______________________________________________________ Ala: ______

Cuidador: _________________________________________________________________
Data da Admissão na Inst.: ________________ Data da Avaliação: _________________
Idade:______________ Data de Nascimento: _____________ Sexo: Fem. ( ) Masc. ( )
Diagnóstico Clínico: ________________________________________________________
Diagnóstico Fisioterapêutico: ________________________________________________
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Patologias/Problemas Associados: ____________________________________________
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Medicamentos: _____________________________________________________________
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Anamnese:
Queixa Principal/HMA:_______________________________________________________
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História Pregressa: _________________________________________________________
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Exame Físico
Sinais Vitais: PA: ____________________ FC: ______________________
FR: ____________________ SpO2 : ____________________
AP: ___________________________________________________________
T°: _________________________

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Inspeção: _________________________________________________________________
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Postura:___________________________________________________________________
Palpação/Dor: ______________________________________________________________
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Trofismo: _________________________________________________________________
Tônus: ____________________________________________________________________
Sensibilidade: ______________________________________________________________
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Amplitude de Movimento:
MMSS: ____________________________________________________________________
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MMII: _____________________________________________________________________
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Axial:_____________________________________________________________________
Força Muscular:
MMSS: ____________________________________________________________________
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MMII: _____________________________________________________________________
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Axial: _____________________________________________________________________
Retrações/Encurtamentos: ___________________________________________________
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Equilíbrio: _________________________________________________________________
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Ortostatismo/Marcha: _______________________________________________________
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Obs.: _____________________________________________________________________
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 Avaliação Funcional:
AVD:
*Banho: ( ) Dependente ( ) Parcialmente Dependente ( ) Independente
*Vestir: ( ) Dependente ( ) Parcialmente Dependente ( ) Independente
*Continência: ( ) Supervisão, Catéter, Incontinente ( ) Acidentes ocasionais ( ) Continente
*Comer: ( ) Dependente ( ) Parcialmente Dependente ( ) Independente
Tipo de alimentação:________________________________________________________________
*Higiene Pessoal: ( ) Dependente ( ) Parcialmente Dependente ( ) Independente
*Transferências: ( ) Dependente ( ) Parcialmente Dependente ( ) Independente
Mudança de decúbito: ( ) Dependente ( ) Parcialmente Dependente ( ) Independente
Locomoção: ( ) Dependente ( ) Parcialmente Dependente ( ) Independente
Tipo de Auxílio: ____________________________________________________________________
*Escala de AVD (Katz, 1969): ________ – Obs: __________________________________________
Mini-Exame do Estado Mental (Folstein, 1975): _____/30 – Obs: ___________________________
Timed Up & Go (Podsiadlo et al, 1991): ____ seg. – Obs: __________________________________
POMA (Tinetti, 1986): ______/28 Equilíbrio: _____/16 Marcha: _____/12 – Obs: ________________
Teste de Alcance Funcional (Duncan et al, 1992): _____ cm. – Obs: ________________________
Escala de Equilíbrio de Berg (Berg et al, 1986): _______/ 56 – Obs: _________________________

Planejamento Fisioterapêutico
Objetivos de Tratamento: ____________________________________________________
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Tratamento: _______________________________________________________________
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Estagiário: ________________________________________________________________
Visto (Supervisor):__________________________________________________________
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Evolução:
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