ficha-de-avaliacão fisioterapia geriatrica

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Centro Educacional Leonardo Da Vinci-Uniasselvi 
 Fisioterapia na saúde do Idoso 
 Ficha de Avaliação 
 Data da avaliação:_____/_____/_____. 
Dados pessoais: 
Nome:______________________________________________________________________ 
Gênero ( ) M ( ) FDN: ____/____/____ Idade: _____Estado civil: __________ 
Endereço:________________________________________Telefone:_________ 
Profissão: ___________________________________________________ 
Hipótese diagnóstica, se houver: 
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Anamnese: 
Queixa (s) principal (is) / funcional (is): 
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HDA:________________________________________________________________________
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HDP:________________________________________________________________________
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Cirurgias/internações:_________________________________________________________
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HF:_________________________________________________________________________
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Doenças associadas: 
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Medicamentos: 
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Exames de imagens e laboratoriais: 
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Hábitos de vida: 
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Escalas e/ou testes funcionais:_________________________________________________ 
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Quedas no último ano: Não: _____ Sim: ____: ___________________________________ 
 
Exame físico 
Peso: _______ Estatura _______ 
Sinais Vitais: PA: ____________ FC: _____________ FR: ___________ SatO2:_________ 
 
Inspeção:____________________________________________________________________
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Palpação:___________________________________________________ 
Intensidade da dor (0 -10): ______ Irradia? ( ) Sim ( ) Não 
Tipo de dor: ________________________________________ 
O que piora a dor:_______________________________________________________ 
Sensibilidade(tipo/local):_______________________________________________________
Propriocepção_____________________________ Cordenação motora: _______________ 
Equilíbrio:_______________________________Postura:_____________________________
Marcha: _____________________________________________________________________ 
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Testes especiai(ortopédicos): 
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DIAGNÓSTICO FISIOTERAPÊUTICO: 
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PROGNÓSTICO:______________________________________________________________
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OBJETIVOS:_________________________________________________________________
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PLANO DE TRATAMENTO: 
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