Avaliacao reumatológica

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AVALIAÇÃO FISIOTERAPIA REUMATOLÓGICA 
Data: __/__/____ 
 
Identificação: 
Nome: _______________________________________________________________________________ 
Endereço:_________________________________________________ Telefone ____________________ 
DN: __/__/____ Idade: ______ Gênero: ________ Etnia: ______ Religião:___________________ 
Estado civil: __________ Procedência: _______________________ Naturalidade: ________________ 
Escolaridade: _________________ Profissão: ________________ Jornada de trabalho: ______________ 
( ) Assalariado ( ) Autônomo ( ) Voluntário ( ) Aposentado 
( ) Desempregado (doença) ( ) Desempregado (outros) 
Dominância: _______________ Meio de transporte: ___________________________________________ 
Diagnóstico Clínico ou HD: _______________________________________________________________ 
Médico Responsável: ___________________________________________________________________ 
Outros Profissionais da Saúde: ____________________________________________________________ 
Dados coletados: ( ) Diretamente paciente ( ) Outro informante ( ) Prontuário 
Em caso de emergência, avisar (nome e telefone):_____________________________________________ 
 
H.M.A:_______________________________________________________________________________ 
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Q.P.:_________________________________________________________________________________
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Antecedentes Pessoais: 
Doenças associadas: 
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Medicamentos:_________________________________________________________________________
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Exames Complementares (laudo):__________________________________________________________ 
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ESCALA VISUAL ANALÓGICA (EVA) 
 
 
Hábitos de vida: 
Atividade física: ________________________________________________________________________ 
Lazer: _______________________________________________________________________________ 
Etilismo: ______________________________________________________________________________ 
Tabagismo: ___________________________________________________________________________ 
Alimentação: __________________________________________________________________________ 
Sono: ________________________________________________________________________________ 
 
Antecedentes Cirúrgicos:_________________________________________________________________ 
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Antecedentes Familiares:_________________________________________________________________ 
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EXAME FÍSICO: 
 
DADOS VITAIS: PA: _______X_______ mmHg FC: _____ bpm FR: _____ rpm 
 
INSPEÇÃO: __________________________________________________________________________ 
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PALPAÇÃO (Geral): ___________________________________________________________________ 
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PALPAÇÃO: 
Trofismo Muscular: 
MMSS: ___________________________________________________________________________ 
MMII: _____________________________________________________________________________ 
 
Tônus Muscular: 
MMSS: ___________________________________________________________________________ 
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MMII: _____________________________________________________________________________ 
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ADM DA ÁREA AFETADA: 
MMSS: ___________________________________________________________________________ 
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MMII: _____________________________________________________________________________ 
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Sensibilidade: 
 a) Profunda: ( ) cinético-postural ( ) discriminação de pontos ( ) vibração 
 
b) Superficial: 
 MMSS: ___________________________________________________________________________ 
 __________________________________________________________________________________ 
 Tronco: ___________________________________________________________________________ 
 __________________________________________________________________________________ 
 MMII: _____________________________________________________________________________ 
 __________________________________________________________________________________ 
 
 
MOTRICIDADE VOLUNTÁRIA: 
 
 - DD/DL/DV: _______________________________________________________________________ 
 __________________________________________________________________________________ 
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 - decúbito/sentado: __________________________________________________________________ 
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 - sentado/em pé: ____________________________________________________________________ 
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 - sentado ou decúbito/gato: ___________________________________________________________ 
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 - gato/ajoelhado: ____________________________________________________________________ 
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 - ajoelhado/semi-ajoelhado: ___________________________________________________________ 
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 - semi-ajoelhado/em pé: ______________________________________________________________ 
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Atividades de Vida Diária (AVDs): 
 a) Preensão: _______________________________________________________________________ 
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 b) Higiene pessoal: ____________________________________________________________________________________________________________________________________________________ 
 c) Continência vesical e anal: __________________________________________________________ 
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 d) Vestuário: _______________________________________________________________________ 
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 e) Locomoção: _____________________________________________________________________ 
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Equilíbrio estático: 
 a) sentado: ________________________________________________________________________ 
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 b) em pé (testes cronometrado – marcar o tempo): 
 * Romberg - OA: ____________________________________________________________________ 
 (Pés juntos) OF:_____________________________________________________________________ 
 
 * Romberg Sensibilizado (Tanden) - OA: _________________________________________________ 
 OF:__________________________________________________ 
 * Apoio unipodal: - OA: _______________________________________________________________ 
 OF:________________________________________________________________ 
 
 
Avaliação da Marcha: 
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Diagnóstico Fisioterapêutico: 
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Funcionalidade 
- Estruturas do Corpo 
- Funções do Corpo 
- Atividades e Participação 
- Fatores Ambientais 
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OBJETIVOS: 
 
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Fisioterapeuta responsável: 
 
 
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