FICHA DE AVALIAÇÃO DE FISIOTERAPIA

RESPONSÁVEL: Dra. Lorena

IDENTIFICAÇÃO DO PACIENTE DATA:______/________/__________
NOME:______________________________________________________________________________________________
SEXO: ( ) M ( )F / DATA DE NASCIMENTO:____________________________ / Telefone: ______________________
ENDEREÇO: _________________________________________________________________________________________
PROFISSÃO:____________________________________________CNS:________________________________
_________OBSERVAÇÕES:_____________________________________________________________________________
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ANAMNESE
DIAGNÓSTICO CLÍNICO:_______________________________________________________________________________
QUEIXA PRINCIPAL:______________________________________________________________
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HDA:________________________________________________________________________________________________
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HDP:________________________________________________________________________________________________
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HF:_________________________________________________________________________________________________
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EXAMES COMPLEMENTARES: _________________________________________________________________________
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TABAGISMO: ( ) S __________________ ( ) N/ ETILISMO: ( ) S ( ) N Frequência:_______________________________
ATIVIDADE FÍSICA: ( ) S ( ) N Qual?____________________________________________________________________
MEDICAMENTOS:____________________________________________________________________________
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Acompanhamento médico: ______________________________________________________________________________
ALERGIA: ( ) S_________________ ( ) N / Marca-passo :( ) S ( ) N Cirurgia: ( ) S ( )N SE SIM,QUAL?
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NÍVEL DE ESTRESSE: ( ) Alto ( )Moderado ( ) Baixo / ALTERAÇÃO EMOCIONAL: ( ) S ( ) N Se sim, qual?
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SONO: Horas/dia? Qualidade do sono? ( ) Tranquilo e contínuo ( ) Tranquilo com intervalos ( ) Insônia

EXAME FÍSICO
1. EVA:_________ Local(ais):______________________________________________________________________
2. SENSIBILIDADE
EPÍCRITICA: _________________________________________________________________________________________
PROTOPÁTICA:_______________________________________________________________________________________
3. PACIENTE NEUROLÓGICO
Há quanto tempo:________________________________ Nível da lesão(medular):_________________________________
Reflexos: Patelar____________Aquileu: ___________ Estilorradial ___________ Biciptal:____________ Triciptal:
________________ Cutâneo plantar : __________ Glabelar:_____________________ Cutâneo abdominal:______________
Déficits e potenciais:____________________________________________________________________________________
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________Clônus:P ( )_________________Ausente( ) Marcha: Deambula ( ) Não deambula ( ) Deambula com
dificuldade ( )

PALPAÇÃO
INTEGRIDADE DA PELE: _______________________________________________________________________________
EDEMA/SINAL DE CACIFO:_____________________________________________________________________________
TÔNUS:_____________________________________________________________________________________________
TRIGGER POINTS:____________________________________________________________________________________
TENDER POINTS:_____________________________________________________________________________________
SINAIS VITAIS
FC:__________FR:___________ PA:____________ T:____________ PESO:_______________ALTURA:_________

PERIMETRIA:
SEGMENTO DIREITO ESQUERDO DIFERENÇA

GONIOMETRIA
ARTICULAÇÃO:_______________________________________________________________________________________
MOVIMENTO:________________________________________________________________________________________
MEDIDAS: D__________ E_____________ Parâmetro:___________ Diferença:___________________________________

Goniômetrias (outras articulações):

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TESTE DE FORÇA MUSCULAR

Músculo GRAU 0 GRAU 1 GRAU 2 GRAU 3 GRAU 4 GRAU 5

Observações quanto a mobilidade:

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DIAGNÓSTICO CINETICO FUNCIONAL/OBJETIVOS DE TRATAMENTO E CONDUTAS:

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Prognóstico:__________________________________________________________________________________________

Assinatura/Paciente/Responsável:___________________________________________