ficha de avaliação uroginecologia

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FICHA DE AVALIAÇÃO FISIOTERÁPICA EM UROGINECOLOGIA
Prontuário:___________________________ Data: ______________________
Nome:____________________________________________________ Idade: ______________ 
Data do nascimento: _______/_______/______ Estado civil: ____________________________ 
Peso: _________________ Altura: _______________ IMC: ____________________________ 
Profissão: _____________________________________________________________________ 
Endereço: _____________________________________________________________________ 
Bairro: _______________________________ Cidade: __________________________________ 
Estado:______________________________________ CEP: _____________________________ 
Telefones: _____________________________________________________________________ 
Diagnóstico Medico: _____________________________________________________________ 
Médico responsável: _____________________________________________________________ 
Diagnóstico Fisioterapêutico: ______________________________________________________ 
Exames complementares: 
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Medicamentos em uso: 
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Queixa principal: 
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HMA/HMP: 
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Antecedentes Pessoais: 
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Sintomas Urinários:
Perda urinaria: 
( ) ao tossir ( ) ao espirrar ( ) erguer peso ( ) agachar
( ) ao caminhar ( ) ao esforço ( ) outras circunstâncias
Quais:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Quando iniciou: _________________________________________________________________ 
Frequência urinária: _____________________________________________________________ 
Proteção utilizada: ( ) absorvente ( ) fralda ( ) outro 
Qual: _________________________________________________________________________ 
Frequência de troca: _____________________________________________________________ 
Cirurgias: ______________________________________________________________________
Função intestinal: ( ) Incontinência Anal ( )Hemorroidas ( )Normal ( ) Outro 
Qual:__________________________________________________________________________
Cirurgias:______________________________________________________________________
Antecedentes Ginecológicos: 
DUM:__________________________ Menarca: ______________________________________ 
Menopausa:____________________________________________________________________
Tipos de parto: _________________________________________________________________ 
Cirugia ginecológica:_____________________________________________________________ 
DST: _________________________________________________________________________ 
Tipo de contraceptivo: ___________________________________________________________ 
Tempo: _______________________________________________________________________
INSPEÇÃO FÍSICA
Cicatrizes: _____________________________________________________________________ 
Trofismo vaginal: ________________________________________________________________ 
Força muscular: _________________________________________________________________ 
Sensibilidade: __________________________________________________________________ 
Testes especiais: 
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Outros dados relevantes: 
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Fisioterapeuta Responsável