FICHA DE AVALIAÇÃO E EVOLUÇÃO DE NEURO

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CURSO DE FISIOTERAPIA 
FICHA DE AVALIAÇÃO EM NEUROLOGIA ADULTO E PEDIÁTRICA 
 
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PRONTUÁRIO: _____________ 
Data da avaliação: ____ / ____ / ____ 
Horário de atendimento: _______________ 
IDENTIFICAÇÃO 
 
Paciente:___________________________________________________________________________________________________ 
Endereço:__________________________________________________________________________ 
Bairro:____________________________Cidade:______________________Estado:__________________Telefone:____________ 
Naturalidade: ______________________________ 
Reside com: ( ) cônjuge ( ) filhos ( ) pais ( ) avós ( ) sozinho ( ) só com o cuidador 
Sexo: ( ) Masculino ( ) Feminino Data de Nascimento:_____ / _____ / _____ 
Dominância:____________________________ 
Profissão / Ocupação / Esporte:_____________________________________ Religião:____________________________ 
Estado civil: ( ) Casado ( ) Solteiro ( ) Viúvo ( ) Divorciado ( ) Outros 
Grau de instrução: ( ) Sem instrução ( ) 1
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 Grau ( ) 2
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 Grau ( ) Superior 
Médico Responsável: ___________________________________________ Telefone:__________________________________ 
Diagnóstico Médico: ___________________________________________________________________________________ _____ 
Tratamentos associados: ( ) Fonoaudiologia ( ) Terapia Ocupacional ( ) Hidroterapia ( ) Equoterapia ( ) Outros: 
DIAGNÓSTICO CINÉTICO-FUNCIONAL: _________________________________________________________________________ 
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ANAMNESE 
QP: 
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HDA: 
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AP: ( )Osteoporose ( )HAS ( )Diabetes ( )Artrite ( )Artrose ( )Tabagismo ( )Sedentarismo ( )Alcoolismo 
 ( )Cardiopatia ( ) síndromes ( ) Outros: ________________________ 
AF: _____________________________________________________________________________________________________ 
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Hábitos de vida: ___________________________________________________________________________________________ 
Medicação em uso: ________________________________________________________________________________________ 
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EXAME FÍSICO 
 
Exame Físico : 
F.C.: (bpm) F.R.: (irpm) P.A.: x (mmHg) TEMP.: ºC 
Ausculta Pulmonar: 
Padrão Respiratório: 
- Inspeção Geral (atitude, estado emocional, alterações mentais): 
 
- Inspeção Local: 
 
Face: 
Palpação: 
 
 
 
Movimento Passivo (tônus/ADM): 
 
 
 
 
 
 
Movimento Voluntário: 
 
 Membro Superior: 
 
 Membro Inferior: 
 
 Manobra de Mingazinni (membros inferiores e superiores): 
 
 Manobra de Barrè: 
 
 
Reflexos Superficiais ou Proprioceptivos (patológicos): 
Cutâneo abdominal: Sinal de Babinski: 
Clônus em mão: Clônus na patela: Clônus em pé: 
 
Reflexos Profundos ou Exteroceptivos: 
Bicipital: Estilorradial: Tricipital: 
Patelar: Aquileu: 
 
Reflexos e Reações Infantis 
Reação cervical de retificação: Reação Positiva de Apoio: Reflexo de retirada ou tríplice flexão: 
Reação de Galant: Reflexo de marcha automática: RTL: 
RTCA: RTCS: Reflexo de Moro: 
 
Equilíbrio: 
( 0) Não consegue realizar (1) Realiza com ajuda (2) Realiza sozinho com dificuldade (3) Realiza sozinho sem dificuldade/ normal 
Ortostatismo, pés unidos: 
Romberg Simples: 
Romberg Sensibilizado: 
Ortostatismo, com um pé diante do outro: 
Ortostatismo, sobre um dos pés: 
Ortostatismo, fazendo flexão de tronco: 
Ortostatismo, fazendo flexão lateral de tronco: 
Andar com um pé a frente do outro: 
Andar ao longo de uma linha reta: 
Andar para o lado: 
Andar para trás: 
 
 
Reflexos Posturais e Mudanças de Decúbito: 
( I ) Independente ( IP ) Independente parcial ( D ) Dependente 
Ponte: ( ) I ( ) IP ( ) D Obs.: 
Semirrolar (DD para DLD): ( ) I ( ) IP ( ) D 
Semirrolar (DD para DLE): ( ) I ( ) IP ( ) D 
Rolar completo (DD para DV): ( ) I ( ) IP ( ) D 
Arrastar: ( ) I ( ) IP ( ) D 
DV para apoio em antebraços (puppy): ( ) I ( ) IP ( ) D 
Apoio em antebraços para 4 apoios: ( ) I ( ) IP ( ) D 
4 Apoios para ajoelhado: ( ) I ( ) IP ( ) D 
Ajoelhado para semiajoelhado D: ( ) I ( ) IP ( ) D 
Ajoelhado para semiajoelhado E: ( ) I ( ) IP ( ) D 
Semiajoelhado D para ostostatismo: ( ) I ( ) IP ( ) D 
Semiajoelhado E para ostostatismo: ( ) I ( ) IP ( ) D 
 
Coordenação: 
(R) Realiza (D) Realiza com dificuldade (N) Não realiza 
Índex-índex: Índex-nariz: 
Índex-nariz-índex: Índex-índex terapeuta: 
Diadococinesia: Calcanhar-joelho: 
Grafia (figura): Teste do rebote de Holmes: 
Outros: 
 
 
Sensibilidades: 
Superficial: 
 Tátil: 
 Térmica: 
 Dolorosa: 
 
Profunda: 
 Sentido de posição: 
 Sentido de movimento: 
Sensações combinadas: 
 Palestesia: 
 Barestesia: 
 Barognosia: 
 Grafestesia: 
 
 
Marcha: 
Descrição da Marcha: 
 
 
 
 
Outras alterações: 
Nervos Cranianos: 
 
Sincinesias: 
Linguagem: 
 
AVALIAÇÃO FUNCIONAL: 
Autocuidados: 
Controle esfincteriano: 
Transferências: 
Locomoção: 
 
 
 
Observações adicionais: __________________________________________________________________________________ 
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Exames complementares: ___________________________________________________ ______________________________ 
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Objetivos da Fisioterapia: 
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Plano de tratamento: 
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Reavaliação: _____/_____/_____Acd. Responsável:_______________________________ _____________ 
 
Prof. Responsável: ___________________________________________ 
 (ASSINAR E CARIMBAR) 
 
 
 
 
 
 
 
 
 
 
 
CURSO DE FISIOTERAPIA 
FICHA DE EVOLUÇÃO DIÁRIA 
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