Ficha amputações, órteses e próteses

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Curso de Fisioterapia
Disciplina de Amputações Órteses e Próteses 
FICHA DE AVALIAÇÃO
IDENTIFICAÇÃO
Data da Avaliação: ___/____/____
DADOS PESSOAIS
Nome:__________________________________________________________________________________
Data de nascimento: ___/___/___ Idade:________Sexo: F ( )M ( )Fone:_____​​_______________________ 
Email:__________________________________________________________________________________
Endereço:_______________________________________________________________________________
Ocupação:________________________________________________Estado Civil:_____________________
Escolaridade:____________________________________________________________________________
Nome da instituição:______________________________________________________________________ Série:________________Turma:________________ Período: Manhã ( ) Tarde ( ) Noite ( )
Nome do pai:____________________________________________________________________________ Nome da mãe:___________________________________________________________________________ Nome do responsável:_____________________________________________________________________
Meio de transporte: Bicicleta ( ) A pé ( ) Carona ( ) Ônibus ( ) Outros ( )__________________________
Diagnóstico Médico:______________________________________________________________________
Médico:________________________________________________________________________________
Possui convênio médico: Não ( ) Sim ( ) Qual?________________________________________________ 
Em caso de emergência falar com (nome, contato): _____________________________________________
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ANAMNESE
Queixa principal: _________________________________________________________________________
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H.D.A:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
H.D.P:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Deficiência: Física ( ) Motora ( ) Visual ( ) Intelectual ( ) 
Toma alguma medicação? Não ( ) sim ( ) 
Nome do medicamento, horário e dosagem:___________________________________________________
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Usa órtese MMSS: Sim ( ) Não ( ) 
	 MMII: Sim ( ) Não ( ) 
( )Bengala ( )Muleta axilar ( )Muleta canadense ( )Andador ( )Cadeira de rodas
Outros:_________________________________________________________________________________
Possui controle de esfíncter? ( )Sim ( )Não
Higiene: Sozinho Mão D( ) Mão E( ) Com auxilio( )
Alimentação: Sozinho Mão D( ) Mão E( ) Com auxilio( )
Vestuário: Sozinho Mão D( ) Mão E( ) Com auxilio( )
Cirurgias e/ou Tratamentos Prévios:__________________________________________________________
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EXAME FÍSICO:
Pressão Arterial:___________________________		Frequência Cardíaca:_______________________
Peso:_____________________ 	Altura:_________________ 		IMC: ________________________
Avaliação Respiratória:
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Inspeção (geral e especifica): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Amplitude de Movimento:
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Teste de Força Muscular:
 5 - Normal 4 - Bom 3- Regular 2 - Ruim 1 - Traço Zero
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Reflexos de Estiramento e Sensibilidade cutânea: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Palpação:
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Testes Especiais:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Avaliação Postural (vista anterior, posterior e perfil):
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Diagnóstico Fisioterapêutico: 
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Observações importantes: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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	Objetivos
	Condutas terapêuticas
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
Evolução:
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TERMO DE CONSENTIMENTO
 Eu _________________________________________________________, declaro estar ciente e autorizo gratuitamente e expressamente, acadêmicos da Universidade Federal do Pampa, a reproduzir e utilizar áudios e imagens. Do (a) meu (minha) filho (a), através de fotografias e vídeos, para fins de estudos e/ou avaliação fisioterapêutica e por todas as formas de comunicação existentes e sem necessidade de nova autorização.
 Uruguaiana/RS _______/_______/_________
 Nome do participante:__________________________________________________________
Assinatura do responsável:_______________________________________________________