Ficha de Anamnese

-FISIOTERAPIA-

 Data de avaliação: ___/___/____

 Dados pessoais:
___________________________________________________________
 Data de avaliação:
________________________________________________________
 Diagnóstico clínico:
________________________________________________________
 Dominância:
______________________________________________________________
 Q.P:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
____________________________________________________________
 H.D.A: (história da doença)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________________________________
 H.P.P: (história pré doença)

AUTOR;CAMILA CRISTO @ROTINAFISIO_

 ________________________________________________________________
________________________________________________________________
________________________________________________________________
_____________________
 H.FAL: (histórico familiar)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________________________________
 H.S: (histórico social):
________________________________________________________________
________________________________________________________________
________________________________________________________________
______________________________
 Peso atual: ___________
 Altura: _______________
 P.A: ___________
 F.C: ___________
 F.R: ___________

 Medicamentos utilizados:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________
 EXAMES COMPLEMENTARES:
________________________________________________________________
________________________________________________________________
________________________________________________________________

AUTOR;CAMILA CRISTO @ROTINAFISIO_

 ________________________________________________________________
________________________________________
 EXAME FÍSICO:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________________________________
 Sinais e sintomas:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
____________________________________________________________
 Análise da dor:
________________________________________________________________
________________________________________________________________
____________________
 Tipo de dor:
________________________________________________________________
________________________________________________________________
____________________
 Inspeção e palpação: (arco de movimento, flexão, extensão, adução, abdução,
rotação, força, movimentos ativos, goniometria).
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________
 Avaliação óssea e muscular: (testes específicos)
________________________________________________________________
________________________________________________________________
________________________________________________________________
AUTOR;CAMILA CRISTO @ROTINAFISIO_
 ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
______
 Diagnostico cinético funcional: (quais disfunções?)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________________________________
 Prognostico: (curto, médio, longo prazo)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________________________________
 Plano fisioterapêutico:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
______
 Previsão de tratamento:
________________________________________________________________
________________________________________________________________
____________________
 Observações adicionais:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
______

 TERMO DE RESPONSABILIDADE

AUTOR;CAMILA CRISTO @ROTINAFISIO_

 Eu_________________________________, portador(a) do rg, __________________,
Declaro para os devidos fins que as respostas prestadas por mim nesta ficha são
expressamente verdadeiras e estou ciente de todo procedimento a ser realizado.

Local: _____________________________________ Data: ___/___/______.

__________________________ __________________________

Assinatura do paciente Assinatura do

Fisioterapeuta

 Evolução
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
__________________________________________

AUTOR;CAMILA CRISTO @ROTINAFISIO_

IMC= peso x altura²

AUTOR;CAMILA CRISTO @ROTINAFISIO_

 Classificação IMC

Peso normal 18,5 a 24,9 kg/m2

Acima do peso 25 a 29,9 kg/m2

Obesidade Grau I 30 a 34,9 kg/m2

Obesidade Grau II 35 a 40 kg/m2

Pressão arterial

PAD PAS
Classificação
(mmHg) (mmHg)
< 85 < 130 Normal
85-89 130-139 Normal limítrofe
90-99 140-159 Hipertensão leve (estágio 1)
100-109 160-179 Hipertensão moderada (estágio 2)
> 110 > 180 Hipertensão grave (estágio 3)
< 90 > 140 Hipertensão sistólica isolada

Frequência Respiratória (insp+exp por 1 min)

Idade (anos) FR/minuto 0 30 a 40

1-2 25 a 30

2-8 20 a 25

8-12 18 a 20

Adultos 14 a 18

Frequência Cardíaca:

Normal apresenta uma variação entre 60 e 100 batimentos por minuto (bpm).

A aceleração dos batimentos (acima de 100 bpm) indica que a pessoa está com taquicardia. frequência

cardíaca baixa, inferior a 60 bpm, é considerada uma condição de bradicardia.

AUTOR;CAMILA CRISTO @ROTINAFISIO_

AUTOR;CAMILA CRISTO @ROTINAFISIO_