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com

AVALIAÇÃO NEUROLÓGICA

DATA da AVALIAÇÃO: ___ /___/____

Anamnese
Paciente:_________________________________ Idade: _________ Sexo: ____
RG:_______________CPF: ___.___.___-___ Data de Nascimento: __ / __ / ___
End:_____________________________________________Tel: ( ) ____ - ____
Estado Civil: __________ Profissão: ___________________________________
FC:____________ FR: ___________ PA:____________

HMA:
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QP/Duração:
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HD:______________________________________________________________

Antecedentes Pessoais e Familiares:

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Exames Complementares:
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Medicamentos:
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Rotina pré-morbidade:
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Rotina pós-morbidade (sono / alimentação / funções vesical e intestinal /

atividade física / etc):
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Possui cuidador?___________________________________________________

AVDs:
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Cognição:_________________________________________________________
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EXAME FÍSICO

Inspeção:
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Exame Sensorial

Sensibilidade Superficial:

Tato:
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Dor:
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Temperatura:
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Sensibilidade Profunda:

Pressão:
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Propriocepção (cinestesia / artrestesia):

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Exame Perceptual:
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Obs.:
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Exame motor:

Motricidade Voluntária:
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ADM:
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Tônus:
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Reflexos:
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Coordenação Motora:
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Equilíbrio:
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Força:
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Mudanças de Decúbito:
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Transferências:
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Marcha:
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Obs.:
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Avaliador: _________________________________ Data:____ / ____ / ____