Ficha de Avaliação Fisioterapêutica

8/11/2019 Ficha de Avaliao Fisioteraputica

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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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Ficha de Avaliação Fisioterapêutica

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