FICHA DE AVALIAÇÃO TRAUMATO-ORTOPÉDICA

Nome: _____________________________________________________ Idade: _____

Sexo: __________ Data Nasc.: ____/____/____ Estado Civil: ____________________
Peso: _________ Altura: __________ Profissão: _______________________________
Endereço: ____________________________________________________________

Data de Avaliação___/___/___ Fone/Cel: ____________________________________

Médico Responsável: _____________________________________________________

Diagnóstico Clínico: ______________________________________________________
Q.P.: ___________________________________________________________________
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H.D.A: _________________________________________________________________
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H.P.P.:
Aparelho Locomotor ( ) ________________________________________
Cardiorrespiratório ( ) ________________________________________
Cardiovascular ( ) ________________________________________
Ginecológico ( ) ________________________________________
Outros ( ) ________________________________________
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H.F.: __________________________________________________________________
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Usa algum medicamento? _________________________________________________
Exames Complementares: _________________________________________________
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SINAIS VITAIS: P.A.: _______ x _______ mmHg FC: _______ bpm FR: _______ rpm

EXAME FÍSICO:
Inspeção: ______________________________________________________________
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Palpação: ______________________________________________________________
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Mobilidade: __________________________________________________________________
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Tônus: ( ) Normal ( ) Hipertônico ( ) Hipotônico
Testes especifico: ______________________________________________________________
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Tipo de Marcha: _________________________________________________________________

GONIOMETRIA
MOVIMENTO GRAU

DIAGNOSTICO CINETICO FUNCIONAL: ___________________________________

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OBJETIVO DO TRATAMENTO: ____________________________________________

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TRATAMENTO PROPOSTO: _______________________________________________

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Paciente Fisioterapeuta