MODELO PRONTUÁRIO FISIOTERAPIA GERIÁTRICA

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FICHA DE AVALIAÇÃO DE FISIOTERAPIA GERIÁTRICA
DATA DA AVALIAÇÃO: ___/___/___
1.0 IDENTIFICAÇÃO:
Nome: ______________________________________________________________________________
Data de Nascimento: ____/___/____ Celular: (___)______________ Sexo: ( ) F ( ) M Idade:_____
Cidade: ____________________Bairro: __________________________ Profissão: _______________
Endereço: ___________________________________________________________________________
Naturalidade: ___________________________________ Estado Civil: ________________________
Diagnóstico Clínico: __________________________________________________________________
Diagnóstico Fisioterapêutico:
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2.0 Sinais Vitais: PA: FC: FR:
3.0 AVALIAÇÃO:
3.1 História da Doença Atual (HDA):______________________________________________________
3.2 Queixa Principal do Paciente (QP): ____________________________________________________
3.3 Hábitos de Vida:____________________________________________________________________
3.4 História Patológica Pregressa (HPP):___________________________________________________
3.5 Histórico Familiar (HF):_____________________________________________________________
3.8 Tratamentos Realizados:_____________________________________________________________
4.0 EXAME CLÍNICO/FÍSICO:
4.1 APRESENTAÇÃO DO PACIENTE:
( ) Deambulando ( ) Internado
( ) Deambulando com apoio/auxílio ( ) Orientado
( ) Cadeira de rodas
4.2 EXAMES COMPLEMENTARES:
( ) Sim ( ) Não Se sim, quais?______________________________________________________
4.3 USA MEDICAMENTOS:
( ) Sim ( ) Não Se sim, quais? ______________________________________________________
4.4 REALIZOU CIRURGIA:
( ) Sim ( ) Não Se sim, quais? ______________________________________________________
4.5 INSPEÇÃO/PALPAÇÃO:
( ) Normal ( ) Edema ( ) Cicatrização incompleta ( ) Eritemas ( ) Outros ______________________
4.6 REALIZA AVDs: ( ) Sim ( ) Não
Obs.:________________________________________________________________________________
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FICHA DE AVALIAÇÃO DE FISIOTERAPIA GERIÁTRICA
4.8 TESTES ESPECÍFICOS:
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4.8 AVALIAÇÃO DA INTENSIDADE DOR:
Escala Visual Analógica (EVA)
5.0 AVALIAÇÃO DAMARCHA:
5.1 Uso de auxílio para marcha: ( ) sim ( ) não
Cadeira de rodas ( ) Andador ( ) Bengala ( ) Muletas ( )
5.2 Avaliação do padrão da marcha:_____________________________________________________
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6.0 PLANO TERAPÊUTICO
6.1 OBJETIVOS DE TRATAMENTO
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6.2 RECURSOS TERAPÊUTICOS
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6.3 PLANO DE TRATAMENTO
FICHA DE AVALIAÇÃO DE FISIOTERAPIA GERIÁTRICA
PERÍODO RECURSOS OBJETIVOS
CURTO __________________________
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FICHA DE AVALIAÇÃO DE FISIOTERAPIA GERIÁTRICA
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6.4 EVOLUÇÃO ( descrever na evolução estado de saúde do paciente, conduta aplicada, resultados
obtidos e eventuais intercorrências)
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