modelo de Ficha de Avaliação-Traumatologia e Reumato

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 UNIC – UNIVERSIDADE DE CUIABÁ 
DEPARTAMENTO DE FISIOTERAPIA 
SETOR DE ORTOPEDIA/TRAUMATOLOGIA E REUMATOLOGIA 
 
 
ANAMNESE 
 
 
1 - IDENTIFICAÇÃO DO PACIENTE 
 
 
NOME: __________________________IDADE:______ SEXO:____RAÇA:_____ 
ESTADO CIVIL:___________________PROFISSÃO:_______________________ 
PROCEDÊNCIA:___________________ENDEREÇO:_______________________ 
INÍCIO DO TRATAMENTO:______________TÉRMINO:____________________ 
 
2 - DADOS CLÍNICOS: 
 
DIAGNÓSTICO CLÍNICO:___________________________________________________ 
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OUTRAS PATOLOGIAS:_____________________________________________________ 
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EXAMES SUBSIDIÁRIOS:___________________________________________________ 
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MEDICAMENTOS:_________________________________________________________ 
 
ANTECEDENTES CIRÚRGICOS:_____________________________________________ 
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3 - AVALIAÇÃO DA DISFUNÇÃO: 
 
Q.P.:______________________________________________________________________ 
 
H.M.P. e H.M.A:____________________________________________________________ 
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ALTERAÇÃO QUE ESTA PATOLOGIA CAUSOU NAS A.V.Ds.:___________________ 
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4 - EXAMES FISIOTERAPÊUTICOS 
 
 
INSPEÇÃO 
 
 
ALTERAÇÃO DE PELE:_____________________________________________________ 
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ALTERAÇÕES ARTICULARES:______________________________________________ 
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ALTERAÇÕES MUSCULARES:_______________________________________________ 
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 EXAME POSTURAL:________________________________________________________ 
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MARCHA:_________________________________________________________________ 
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PALPAÇÃO 
 
 
ALTERAÇÕES DE SENSIBILIDADE:__________________________________________ 
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ALTERAÇÕES DE TEMPERATURA:__________________________________________ 
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PALPAÇÃO ARTICULAR:___________________________________________________ 
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PALPAÇÃO MUSCULAR:___________________________________________________ 
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EXAME FUNCIONAL: 
 
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GONIOMETRIA:____________________________________________________________ 
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 PERIMETRIA: 
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 PROVA DE FUNÇÃO MUSCULAR: 
 
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TESTES ESPECIAIS:________________________________________________________ 
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CONCLUSÃO:_____________________________________________________________
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OBJETIVO DE TRATAMENTO:_______________________________________________ 
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PROGRAMAÇÃO DE TRATAMENTO:_________________________________________ 
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ORIENTAÇÃO DE TRATAMENTO:___________________________________________ 
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FISIOTERAPEUTA RESPONSÁVEL: 
 
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ESTAGIÁRIO RESPONSÁVEL:_______________________________________________ 
 
MÉDICO RESPONSÁVEL:___________________________________________________ 
 
RELATÓRIO DIÁRIO:_______________________________________________________ 
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	SETOR DE ORTOPEDIA/TRAUMATOLOGIA E REUMATOLOGIA
	INSPEÇÃO