FICHA DE AVALIAÇÃO FISIOTERAPEUTICA GERIÁTRICA

DATA DA AVALIAÇÃO: ___/___/___

1.0 IDENTIFICAÇÃO:

Nome: ______________________________________________________________________________
Data de Nascimento: ____/___/____ Telefone: ____________________Sexo: ( ) Masc ( ) Fem
Cidade:____________Bairro: ___________________Profissão:____________ Religião:___________
Endereço Residencial: _________________________________________________________________
Endereço Comercial: _________________________________________________________________
Naturalidade: ___________________________________ Estado Civil: ________________________
Diagnóstico Clínico: __________________________________________________________________
2.0 Diagnóstico Clínico:
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3.0 Medicamentos em uso:

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4.0 Queixas Principais:

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Mini-Mental Test: ____________ Clock Task: _____________ Barthel: _____________ PPT:

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NÍVEL DE CONSCIÊNCIA:
( ) lúcido-orientado ( ) lúcido com momentos de desorientação
( ) desorientado ( ) inconsciente

ESTADO EMOCIONAL:
( ) calmo ( ) agitado ( ) depressivo ( ) ansioso ( ) agressivo

SISTEMA RESPIRATÓRIO:
( ) ventilação espontânea
( ) ventilação espontânea com suporte de O2 _________________________ _____________ _________

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Ritmo: ( ) regular ( ) taquipnéia ( ) bradipnéia ( ) dispnéia
Padrão Muscular Ventilatório:
( ) diafragmático ( ) costo-diafragmático ( ) intercostal ( ) intercostal
( ) acessório ( ) paradoxal

Expansibilidade Torácica:
( ) normal ( ) diminuída ( ) assimétrica ________________________________

Ausculta:
( ) mvbd s/ra ( )mv diminuído ______________________ ( ) mv abolido _____________________

Ruídos Adventícios:
( ) crepitações ( ) roncos ( ) sibilos

Tosse:
( ) ausente ( ) seca ( ) úmida ( ) produtiva
Aspecto da secreção:
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SISTEMA OSTEOMIOARTICULAR:
( ) mov. Voluntário ( ) mov. Involuntário ( ) plegia ( ) paresia
Força Muscular:
( ) normal ( ) diminuída ___________________________________________________________
Tônus:
( ) normal ( ) hipotônico ( ) hipertônico ( ) clônus
Amplitude Articular:
( ) normal ( ) diminuída __________________________________________________________
( ) luxação ___________________ ( ) rigidez ___________________( ) fratura
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( ) desvios posturais
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DEAMBULAÇÃO:
( ) livre ( ) bengala ( ) andador ( ) cadeira de rodas

MARCHA:
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EQUILÍBRIO/COORDENAÇÃO
( ) normal ( ) anormal ____________________________________________________________

PELE:
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EDEMA: Local: ________________________________ Tipo: __________________ Grau:

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SEQUELAS
de:_____________________________________________________________________________
APARELHO DIGESTÓRIO:
( ) continência ( ) incontinência fecal ( ) obstipação
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Abdomen:
( ) normal ( ) rígido ( ) flácido
( ) distendido ( ) doloroso ____________________________________________________________

APARELHO GENITOURINARIO
( ) continência ( ) função sexual ________________________________________________________
( ) incontinência
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OBSERVAÇÕES:
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5 - DIAGNÓSTICO FISIOTERAPÊUTICO:
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CONDUTAS:
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