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FICHA DE AVALIAO FISIOTERAPUTICA
FISIOTERAPEUTA:_____________________________________________. DATA DA AVALIAO: ___ / ___ / ___.NOME: _______________________________________________________. IDADE: _______.SEXO: ____________.DATA DE NASCIMENTO:_________________. ESTADO CIVIL: _____________. CIDADE: ____________________.ENDEREO: ___________________________________________________________________________________.MDICO RESPONSVEL: ________________________________________________________________________.
DIAGNSTICO CLNICO:__________________________________________________________________________.
QUEIXA PRINCIPAL:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
H.M.A. (PPA, PTAM, SAASS):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
H.M.P. (IHM, TAQP):___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ANTECEDENTES FAMILIARES? MEDICAMENTOS UTILIZADOS?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ANTROPOMETRIA: ALTURA: _____ M. PESO:_____ KG. IMC: ____. SITUAO: _____________.SINAIS VITAIS: FC: _____BPM. PA: ____MMHG. FR:______IPM.LOCOMO!O: ____________________________________________________________________________________________________________________________________________________________________________
DADOS REFERENTES " SA#DE DO PACIENTE:
H$ PATOLOGIAS ASSOCIADAS, QUAIS?___________________________________________________________CIRURGIAS?_________________ FRATURAS?_________________ PINOS E PLACASMET$LICAS:______________
DADOS RELATIVOS " DOR:
SENTE DOR? ( )SIM. ( )N!O. CASO SE%A &SIM': H$ QUANTO TEMPO EST$ COM DOR?________________________ONDE SE LOCALIZA?_______________________. A DOR IRRADIADA? PARA ONDE?________________________QUAIS AS CIRCUNSTNCIAS DE INCIO DA DOR?____________________________________________________O QUE FAZ COM QUE A DOR PIORE OU MELHORE?__________________________________________________%$ FEZ TTO DE FISIOTERAPIA? RESULTADOS:_______________________________________________________
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EXAME FISICO:
INSPE!O:
MEDIDA REAL: _____________________________. MEDIDAAPARENTE:____________________________.
PERIMETRIA (AAE):
SEGMENTOPONTO DE
REFER*NCIAMEDIDA D E D E D E D E D E
+ -/ -+ -0/ -0+ -
GONIOMETRIA:
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FORA MUSCULAR:
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TESTES ESPECIAIS(RESULTADO):_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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SENSI1ILIDADE:
DERMATOMO: ___________________________________________________________________________
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MIOTOMO:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EXAMES COMPLEMENTARES:_________________________________________________________________________________________________________________________________________________________________
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