FICHA DE AVALIAÇÃO – FISIOTERAPIA ORTOPÉDICA

DATA ____/____/____ Pront. nº. _______________

1. DADOS PESSOAIS:
Nome:_________________________________________________________________________________________
DataNascimento_____/____/____ Sexo:____________________________ EstadoCivil:____________________
Endereço:________________________________________________________________Fone:_________________
Profissão/Ocupação: _____________________________________________________________________________
DiagnósticoMédico:______________________________________________________________________________

2.QUEIXAPRINCIPAL ___________________________________________________________________________
______________________________________________________________________________________________
Duração: ( ) anos ( ) meses ( ) dias

3.HDA/HMA:________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_______________________________________________________________
Intensidade da dor
0 1 2 3 4 5 6 7 8 9 10

Caracteres da Dor _____________________________________________________________________________

_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
____________________________

4. ANTECEDENTES FAMILIARES
_______________________________________________________________________________________________________________________
_____________________________________________________________________

5.DOENÇAS ASSOCIADAS:
( ) H.A.S ( ) DIABETES ( ) CARDIOPATIAS ( ) VISÃO ( ) OUTROS:
_______________________________________________________________________________________________________________________________
_____________________________________________________________

6.HABITOS E VÍCIOS
( ) Tabagista: quantidade diária: __________ tempo_________________________________________________
( ) Etilista____________________________________________________________________________________
( ) Drogas Tipo:________________________________________________________________________________

7.MEDICAMENTOS EM USO
________________________________________________________________________________________________________

8.EXAMES COMPLEMENTARES
( ) RX data: ___/___/___ Parecer: __________________________________________________
( ) Ressonância data: ___/___/___ Parecer: ___________________________________________________
( ) Tomografia data: ___/___/___ Parecer:___________________________________________________
( ) U.S. data: ___/___/___ Parecer: __________________________________________________
( ) Densitometria data: ___/___/___ Parecer:___________________________________________________
( ) Outros tipos data: ___/___/___ Parecer: __________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_________________________________________________________________________________________

9. CIRURGIAS E TRATAMENTOS:
______________________________________________________________________________________________

EXAME FÍSICO

10.Altura: __________ Peso: _________ PA ______x _______mmHg FC _________ bpm FR _____________ipm

11.INSPEÇÃO:________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
MOVIMENTAÇÃO ATIVA
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___________________

12.PALPAÇÃO:_______________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
MOVIMENTAÇÃO PASSIVA
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_____________________________________________________________________________________________

13.TESTES CLÍNICOS (especiais, sensibilidade, encurtamentos, reflexos, propriocepção,etc.)

___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_______________________________________

14. ADM: ( ) Goniômetro ( ) Flexímetro

Movimento Abd Ad
Flexão Extensão Abdução Adução Rot. Inter Rot. Exter.
Horiz. Horiz.
Articulação D E D E D E D E D E D E D E D E
Ombro
Cotovelo
Punho
Quadril
Joelho
Tornozel
o

15. PROVA DE FORÇA MUSCULAR

Grupo Flexores Extensores Abdutores Adutores Rot. Internos Rot. Externos
Muscular D E D E D E D E D E D D
Ombro
Cotovelo
Punho
Quadril
Joelho
Tornozel
o

16. MENSURAÇÕES:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_________________________________________________________________________________________

17. ALTERAÇÕES POSTURAIS

Pés: ( ) cavo ( ) plano ( ) simétricos ( ) assimétricos > ( ) D ( )E

( ) abduzidos ( ) aduzidos ( ) simétricos ( ) assimétricos > ( ) D ( ) E
Tornozelo: ( ) varo ( ) valgo ( ) simétricos ( ) assimétrico > ( ) D ( ) E ( )
Joelho: ( ) varo ( ) valgo > ( ) D ( ) E ( ) recurvatum
( ) patelas medializadas ( ) patelas lateralizadas
Quadril: ( ) rotação interna ( ) rotação externa > ( ) D ( )E
Pelve: ( ) D + alto ( ) E + alto ( ) retroversão ( ) anteversão ( ) antepulsão ( ) retropulsão
Lombar: ( ) hiperlordose ( ) retificação
Torácica: ( ) hipercifose ( )retificação
Cervical: ( ) hiperlordose ( ) retificação
Plano Escapular: ( ) anteriorizado ( ) posteriorizado ( ) normal
Ângulo de Thales: ( ) > D ( )>E ( ) simétrico
Ombro D: ( ) elevado ( ) protuso ( ) enrolado ( ) rot. interna
Ombro E: ( ) elevado ( ) protuso ( ) enrolado ( ) rot interna
Cabeça: ( ) anteriorizado ( ) inclinado à D ( ) inclinado à E

Escoliose Convexidade: ( ) lombar ( )D ( )E graus: _____________________________________

( ) torácica ( )D ( )E graus: _____________________________________
( ) cervical ( )D ( )E graus: _____________________________________

18. ALTERAÇÕES DA MARCHA

_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
________________________________________________________________________________________

19. DIAGNÓSTICO FISIOTERÁPICO (LAUDO MORFOFUNCIONAL)

_______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___________________________________________________________________________

20. OBJETIVO DE TRATAMENTO:

_______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___________________________________________________________________________

21. TRATAMENTO

_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______

_____________________________ ______________________________
Estagiário Supervisor