FICHA DE AVALIAÇÃO EM PEDIATRIA

Nome: ____________________________________________________________ Data: _________

Data de nascimento: ____________________________ Idade: ______________ Sexo: _________

Endereço: ___________________________________________________________________

Fone: ( ) ________________Cidade: ____________________________________ Estado: ______

Filiação: Pai: ________________________________________________________ Idade: _______

Mãe: _______________________________________________________ Idade: _______

Encaminhamento médico: __________________________________________________________

Diagnóstico clínico: _______________________________________________________________

Diagnóstico fisioterapêutico: ________________________________________________________

Patologias concomitantes: __________________________________________________________

Medicação atual: __________________________________________________________________

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Antecedentes familiares: ___________________________________________________________

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Queixa principal: _________________________________________________________________

Informante: ______________________________________________________________________

Antecedentes Pessoais
Criança desejada: ( ) sim ( ) não. Ordem gestacional: ______________ Abortos: __________

Gestação (condições emocionais da mãe) ______________________________________________

Complicações: ___________________________________________________________________

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Medicamentos: ___________________________________________________________________

Pré-natal: ( ) sim ( ) não

História do Nascimento

Local: _______________________________________ Idade Gestacional____________________

Peso: _________ Estatura: _________Apgar: 1º min____ 5º min____ Tipo de parto: ____________

Intercorrências: ___________________________________________________________________

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Impressões Gerais
Relacionamento mãe-criança: _______________________________________________________-
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Grau de independência: ____________________________________________________________
Estado emocional: ________________________________________________________________
Desenvolvimento
HMA: __________________________________________________________________________
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Hábitos da criança

Alimentação: posição: _____________________________________________________________

Independência: ___________________________________________________________________

Tipo: ___________________________________________________________________________

Sono: Local: _____________________________________________________________________

Horário: _________________________________________________________________________

Tipos de brinquedo de interesse: _____________________________________________________

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Com quem brinca: ________________________________________________________________

Com quem passa a maior parte do tempo: ______________________________________________

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Controle esfincteriano: ( ) sim ( ) não

Freqüenta a escola: ( ) sim ( ) não Qual:

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Comunicação: ____________________________________________________________________

Órteses: ( ) sim ( ) não quais?

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 Órgãos Sensoriais

Visão: __________________________________________________________________________

Audição: ________________________________________________________________________

Mental: _________________________________________________________________________

Posturas: alinhamento global, controle de cabeça, distribuição de peso, dissociação de cinturas

● Supino: ______________________________________________________________________
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● Prono: ______________________________________________________________________
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● Tracionado para sentar: ____________________________________________________________
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● Sedestação_______________________________________________________________________
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Gatas:
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● Ajoelhado:___________________________________________________________________
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● Semi-ajoelhado ________________________________________________________________
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● Em pé: _______________________________________________________________________
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● Marcha: ______________________________________________________________________
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*Corrida: ________________________________________________________________________
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● Subir e Descer escada: ____________________________________________________
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Perímetros
PC: ______________ PT: _____________ PA-P: ________________ PBiauricular: ____________

Avaliação pulmonar: ______________________________________________________________

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Para crianças deambuladoras:

Marcha na ponta dos pés: ___________________________________________________________

Marcha sobre os calcanhares: ________________________________________________________

Tandem: ________________________________________________________________________

Salto em distância: ________________________________________________________________

Salto em altura: ___________________________________________________________________

Apoio unipodal (D/E): _____________________________________________________________

 Articulações Ativo (ADM ativa e Passivo (ADM passiva e Conclusões
força muscular) tônus muscular)
Cervical

Tronco

Ombro/escapulas/
cotovelo

Punho/dedos

Quadril/pélvis

Joelho/tornozelo
Coordenações Sensório-Motoras: _____________________________________________________
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Conclusão: ______________________________________________________________________
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Objetivos do tratamento: (funcional – atividade e participação; específico - estrutura e função do

corpo) __________________________________________________________________________

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Conduta: ________________________________________________________________________

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Exames complementares: ___________________________________________________________

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Observações: _____________________________________________________________________

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Data da 1a entrega:

Data da 2a entrega:

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Estagiário: . Supervisor: .
Reflexo Resposta
Glabelar + presente-
Sucção - ausente
Busca -+ aparecendo
Deglutição +- desaparecendo
Cócleo-palpebral
Reação dos olhos de boneca
Preensão palmar
Preensão plantar
RTCA
RTCS
Moro
Magnético
Extensão cruzada
Cutâneo plantar em extensão
Galant
Propulsão
R. marcha
R. positiva de suporte
R. de colocação dos pés
R. de colocação das mãos
R. retificação cervical
R. retificação corporal
R. de retificação labiríntica
R. ótica de retificação
Reação de landau
R. paraquedas
Reação de anfíbio
Reação de proteção
● frente
● lado
● trás
Reação de equilíbrio
● supino
● prono
● sentado
● gato
● em pé