Ficha de avaliação ORTOPEDIA / TRAUMATOLOGIA E REUMATOLOGIA

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PRONTUÁRIO:__________________________Data da avaliação: ____/____/____
FICHA DE AVALIAÇÃO ORTOPEDIA / TRAUMATOLOGIA 
E REUMATOLOGIA
Paciente: ___________________________________________________Idade:____________ 
Estado Civil: _______________________ Data de Nascimento: : ____/____/____
Telefone: ____________________________________________________________________
Profissão: ______________________________________________________________________
Cidade: __________________ Estado: __________________________ Cep: ___________________
Endereço: ________________________________________ Bairro:____________________________
Examinador (a):____________________________________________________________________
APRESENTAÇÃO DO PACIENTE: __________________________________________________________________________________________________________________________________________________________
HISTÓRIA CLÍNICA
Diagnóstico Clínico:___________________________________________________________________________
Exames Subsidiários:__________________________________________________________________________
Medicação:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Antecedentes Cirúrgicos: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
AVALIAÇÃO DA DISFUNÇÃO
Queixa Principal: ______________________________________________________________________________________________________________________________________________________________________________________________
H.M.P/H.M.A:__________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DADOS VITAIS
Pressão arterial sistêmica (p.a.s):___________________________________________________________________
Frequência cardíaca (f.c.): ________________________________________________________________________
Frequência respiratória (f.r.): ______________________________________________________________________
INSPEÇÃO 
Alteração da pele:___________________________________________________________
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Alterações Articulares:___________________________________________________________
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Alterações Musculares: __________________________________________________________
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Marcha: ______________________________________________________________________
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PALPACÃO: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Alterações de sensibilidade: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Alterações de temperatura: _____________________________________________________________________________
EXAME FUNCIONAL:	
Goniometria: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Perimetria: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prova de função muscular:
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Teste Especiais:
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Conclusão: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OBJETIVOS DE TRATAMENTO: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PROGRAMAÇÃO DO TRATAMENTO:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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	Ficha de Avaliação |ORTOPEDIA / TRAUMATOLOGIA E REUMATOLOGIA
@DADOSCLINICOS
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