Biblioteca 864631.pdf FICHA DE AVALIAÇAO

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CURSO DE FISIOTERAPIA 
FICHA DE AVALIAÇÃO RESPIRATÓRIA 
N
0 
PRONTUÁRIO: _____________ 
Data da avaliação: ____ / ____ / ____ 
Horário de atendimento: _______________ 
 
IDENTIFICAÇÃO 
 
Paciente: ______________________________________________________________________________ Sexo: ( ) M ( ) F Idade: _______ 
Endereço: __________________________________________________________________________ Bairro: ____________________________ 
Cidade: ______________________ Estado: ________________ Telefone: ________________________Data de nascimento:______________ 
Ocupação: ___________________________________________ Moradia: ________________________________________________________ 
Data da avaliação: ____ / ____ / ____ Médico Responsável: _________________________________ Telefone: ______________________ 
Diagnóstico Médico: _____________________________________________________________________________________________________ 
 
ANAMNESE 
 
QP: ___________________________________________________________________________________________________________________ 
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HDA: __________________________________________________________________________________________________________________ 
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Antecedentes patológicos: _______________________________________________________________________________________________ 
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Antecedentes familiares: _________________________________________________________________________________________________ 
Hábitos de vida: ________________________________________________________________________________________________________ 
Sintomatologia: _________________________________________________________________________________________________________ 
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Medicação em uso: _____________________________________________________________________________________________________ 
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EXAME FÍSICO 
 
Peso: _________ Altura: __________ IMC: __________ PA: _______________ f: __________ to: ________ FC: _______ SpO2: ________ 
Inspeção: ______________________________________________________________________________________________________________ 
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Palpação: _____________________________________________________________________________________________________________ 
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AP: ___________________________________________________________________________________________________________________ 
AC: ______________________________________________________________________________________________________ 
Manuvacuometria: PImax:___________________ PEmax: ________________________ 
Ventilometria: VC: _______________ Fr: _________________ VM: __________________CVL:______________________ 
Cirtometria: ( ) Decúbito dorsal ( ) Ortostatismo 
 Inspiração máxima Expiração máxima Mobilidade tóraco-abdominal 
Axilar 
Mamária 
Xifóide 
Abdominal 
 
Prova de função pulmonar: _______________________________________________________________________________________________ 
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 Pré - BD Pós-BD 
CVF 
VEF1 
VEF1 / CVF 
FEF 25% / 75% 
 
Teste de caminhada de 6 minutos: 
 Início Interrupção Final 
FC 
FR 
SpO2 
PA 
Escala de Borg modificada 
Distância 
 
Exames complementares: _______________________________________________________________________________________________ 
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Diagnóstico Fisioterapêutico: 
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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)