FICHA DE AVALIAÇÃO FISIOTERÁPICA EM UROGINECOLOGIA

Prontuário:___________________________ Data: ______________________

Nome:____________________________________________________ Idade: ______________

Data do nascimento: _______/_______/______ Estado civil: ____________________________

Peso: _________________ Altura: _______________ IMC: ____________________________

Profissão: _____________________________________________________________________

Endereço: _____________________________________________________________________

Bairro: _______________________________ Cidade: __________________________________

Estado:______________________________________ CEP: _____________________________

Telefones: _____________________________________________________________________

Diagnóstico Medico: _____________________________________________________________

Médico responsável: _____________________________________________________________

Diagnóstico Fisioterapêutico: ______________________________________________________

Exames complementares:

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Medicamentos em uso:

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Queixa principal:

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HMA/HMP:

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Antecedentes Pessoais:

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Sintomas Urinários:

Perda urinaria:

( ) ao tossir ( ) ao espirrar ( ) erguer peso ( ) agachar

( ) ao caminhar ( ) ao esforço ( ) outras circunstâncias

Quais:_________________________________________________________________________

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Quando iniciou: _________________________________________________________________

Frequência urinária: _____________________________________________________________

Proteção utilizada: ( ) absorvente ( ) fralda ( ) outro

Qual: _________________________________________________________________________

Frequência de troca: _____________________________________________________________

Cirurgias: ______________________________________________________________________

Função intestinal: ( ) Incontinência Anal ( )Hemorroidas ( )Normal ( ) Outro

Qual:__________________________________________________________________________

Cirurgias:______________________________________________________________________

Antecedentes Ginecológicos:

DUM:__________________________ Menarca: ______________________________________

Menopausa:____________________________________________________________________

Tipos de parto: _________________________________________________________________

Cirugia ginecológica:_____________________________________________________________

DST: _________________________________________________________________________

Tipo de contraceptivo: ___________________________________________________________

Tempo: _______________________________________________________________________

INSPEÇÃO FÍSICA

Cicatrizes: _____________________________________________________________________

Trofismo vaginal: ________________________________________________________________

Força muscular: _________________________________________________________________

Sensibilidade: __________________________________________________________________

Testes especiais:

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Outros dados relevantes:

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Fisioterapeuta Responsável