Modelo Ficha de Avaliação Fisioterapeutica Residencial

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FICHA DE AVALIAÇÃO Nº_______
	NOME: 
	DATA DE NASC. SEXO: IDADE: 
	PROFISSÃO: ESTADO CIVIL:
	ENDEREÇO:
	CIDADE: 
	DATA DA AVALIAÇÃO: FONE:
	DIAGNÓSTICO CLÍNICO: 
	ALUNOS:
	PRECEPTOR DE ESTÁGIO:
	EXAME FÍSICO GERAL:
	PESO : ALTURA : P.A : FC :
	FR: TEMPERATURA:
	AUSCULTA:
ANAMNESE:
QUEIXA PRINCIPAL: ____________________________________________________________________________________________________________________________________________________________________________________
EXPECTATIVA DO PACIENTE:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
HISTÓRIA DA MOLÉSTIA ATUAL:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HISTÓRIA PREGRESSA:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HISTÓRIA FAMILIAR:
____________________________________________________________________________________________________________________________________________________________________________________
HISTÓRIA SOCIAL: 
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Uso de Marca-passo: ______
Osteossíntese: 
__________________________________________________________________________________________
Órtese:
____________________________________________________________________________________________________________________________________________________________________________________
Cirurgias:
____________________________________________________________________________________________________________________________________________________________________________________
Medicamentos:
________________________________________________________________________________________________________________________________________________________________________________
Exames Complementares: ________________________________________________________________________________________________________________________________________________________________________________
EXAME FÍSICO
INSPEÇÃO E PALPAÇÃOTrofismo:
______________________________________________________________________________________________________________________________________________________________________________________________
 Tônus:
_______________________________________________________________________________________________________________________________________________________________________________________________
Pele/Cicatriz:
_______________________________________________________________________________________________________________________________________________________________________________________________
Edema:
_______________________________________________________________________________________________________________________________________________________________________________________
Alterações corporais / Deformidades:
_______________________________________________________________________________________
_______________________________________________________________________________________
Marcha: 
_______________________________________________________________________________________________________________________________________________________________________________________
Contratura muscular: ______________________________________________________________________________________________________________________________________________________________________________
ANÁLISE DA ATIVIDADE:
Escala de Lawton (AVD): ______________________________________________________________________________________________________________________________________________________________________________________
Escala de Katz (AVD Básicas): ______________________________________________________________________________________________________________________________________________________________________________________
Escala de Borg Adaptada (percepção de esforço):
______________________________________________________________________________________________________________________________________________________________________________________
MOVIMENTOS: ATIVOS / PASSIVOS / INVOLUNTÁRIOS 
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
AVALIAÇÃO DA FORÇA MUSCULAR
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AVALIAÇÃO DA ADM/GONIOMETRIA
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PERIMETRIA: ( ) 3 em 3 cm ( ) 5 em 5 cm
Local de Referência:__________________________________________________________________________
	MMSS
	MMII
	Direito
	Esquerdo
	Direito
	Esquerdo
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
CONSIDERAÇÕES SOBRE AS DORES
Dor:_______________________________________________________________________________________
Localização e intensidade: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 
Irradiação: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 
Horário: ( ) Matutino ( ) Vespertino ( ) Noturna ( ) Sem horário fixo 
É o primeiro episódio? ( ) Sim ( ) Não 
Estágio: ( ) Aguda (duração de 1 – 4 semanas) ( ) Subaguda (5 – 12 semanas) ( ) Crônica (mais de 12 semanas) ( ) Crônica com exacerbação aguda
Fatores de piora: ( ) Esforço físico ( ) Repouso prolongado ( ) Posição em pé
( ) Posição sentada ( ) Deambulação ( ) Tensão Emocional ( ) Esporte ( ) Movimento
( ) Outros: __________________________________________________________________________________
EXAME NEUROLÓGICO
Sensibilidade:
	
	Normal
	Aumentada 
	Diminuída 
	Ausente
	
	MS
	MI
	MS
	MI
	MS
	MI
	MS
	MI
	
	D
	E
	D
	E
	D
	E
	D
	E
	D
	E
	D
	E
	D
	E
	D
	E
	TátilTérmica Quente 
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	Térmica Fria
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	Dolorosa
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
REFLEXOS
	
Direito
	
Esquerdo
	Bicipital
	
	
	Tricipital
	
	
	Estilorradial
	
	
	Patelar
	
	
	Aquileu
	
	
TESTES ESPECIAIS: 
	Nome do Teste
	Resposta
	Romberg
	( )Positivo ( ) Negativo
	TUG
	( )Positivo ( ) Negativo
	TC6
	( )Positivo ( ) Negativo
	
	( )Positivo ( ) Negativo
	
	( )Positivo ( ) Negativo
DEFICIENCIAS GLOBAIS (OUTROS SISTEMAS)
______________________________________________________________________________________________________________________________________________________________________________________
DIAGNÓSTICO CINÉTICO-FUNCIONAL
______________________________________________________________________________________________________________________________________________________________________________________
OBJETIVOS DO TRATAMENTO (curto, médio e longo prazo):
Mobilizar e alongar MMII e MMSS
Fortalecer musculatura intrínseca (postural) 
Reeducar transferências de forma independente (sentar e levantar)
Promover educação ergonômica
TRATAMENTO FISIOTERAPÊUTICO (curto, médio e longo prazo):
Cinesioterapia com elásticos
Mobilização articular passiva em MMII
Mobilização ativa/assistida em MMSS 
PNF com descarga de peso para MMSS e MMII
Preceptora Responsável 				 Estagiário (a) Responsável
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EVOLUÇÃO:
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