FICHA DE AVALIAÇÃO

Nome:_________________________________________________________________

Idade:_____ | Sexo:_____ | Peso:_____ | Altura:_____ | Estado

Civil:_____________

Profissão:______________________________________________________________

Endereço:______________________________________________________________

Data: ___/___/_____

ACADÊMICOS RESPONSÁVEIS:

Cecílio Pereira Neto

Gustavo de Oliveira Rocha

ANAMNESE:
QUEIXA PRINCIPAL:
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HMP:
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HMA:
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HISTÓRICO FAMILIAR:
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DOENÇAS ASSOCIADAS:
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ANTECEDENTES PESSOAIS (PATOLÓGICOS E CIRÚRGICOS):

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MEDICAMENTOS:
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PRATÍCA ALGUMA ATIVIDADE FÍSICA?
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CADEIRANTE? ( ) não ( ) sim | USO DE OUTRO DISPOSITIVO? ( ) não ( ) sim
HABITOS DE VIDA:
TABAGISMO: ( ) não ( ) sim | CONSUMO DE ALCOOL: ( ) não ( ) sim
ESTRESSE: ( ) não ( ) sim
QUALIDADE DO SONO: ( ) Ruim( ) Boa | HORAS DE SONO: _______________
ALIMENTAÇÃO:
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AVD’S QUE POSSUI DIFICULDADE:
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É TÍMIDO (a)? GOSTA DE REALIZAR ATIVIDADES EM GRUPO?
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POSSUI TOLERÂNCIA PARA ALGUMA ATIVIDADE ESPECÍFICA?
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ALTERAÇÕES CARDIOVASCULARES: ( ) TVP ( ) edema de extremidades ( )
hipertensão
ALTERAÇÕES RESPIRATÓRIAS: _______________________________________
HORA DO DIA/NOITE: _________________________________________________
PRESENÇA DE DOR: __________________________________________________
HORA DO DIA/NOITE: ________________________________________________
LOCALIZAÇÃO E FATORES PRECIPITANTES:
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EVA – ESCALA VISUAL ANALÓGICA

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SINAIS VITAIS:

P.A: ___________ | F.C: _________ | Saturação: ___________ | Temperatura: ____

EXAME FÍSICO:
PALPAÇÃO:
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ALTERAÇÕES DA PELE:
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FORÇA MUSCULAR:
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PERIMETRIA:

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GONIOMETRIA:

D E

TESTES ESPECIAIS:

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OBSERVAÇÕES DA MARCHA:
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AVALIAÇÃO POSTURAL:

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OBJETIVOS DO TRATAMENTO:

À CURTO PRAZO:
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À MÉDIO PRAZO:

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À LONGO PRAZO:

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CONDUTAS FISIOTERAPÊUTICAS:

CONDUTAS A CURTO PRAZO:

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CONDUTAS A MÉDIO PRAZO:

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CONDUTAS A LONGO PRAZO:

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PROFESSOR RESPONSÁVEL:

Altair Argentino Pereira Junior

Cristiano Coelho de Souza
Mayane dos Santos Amorim