FICHA DE AVALIAÇÃO PROTOCOLO DE ALTA 2019

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FICHA DE AVALIAÇÃO FISIOTERAPÊUTICA 
PROTOCOLO DE ALTA 
Fisioterapeuta Responsável: Ingrid Mendes 
Data da avaliação:___/___/_____ Acadêmico Responsável:_____________________________ 
Nome:________________________________________________________________________ 
Data de nascimento:____/____/________ Idade:_______________ Sexo: ( ) M ( ) F 
Estado Civil:_____________________ Ocupação:_____________________________________ 
Endereço:_____________________________________________________________________
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Mora Sozinho(a): ( ) Sim ( ) Não Com quem:__________________________________________ 
Alimentação:__________________________________________________________________ 
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Qualidade do sono:_____________________________________________________________ 
Hábitos de vida:________________________________________________________________ 
Diagnóstico Clínico:_____________________________________________________________ 
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QP:__________________________________________________________________________
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HDA:_________________________________________________________________________ 
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HDP:_________________________________________________________________________ 
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Medicamentos:________________________________________________________________
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Sinais Vitais PA: _________________ FC: ___________FR: ____________ 
Análise da Dor 
Característica:_________________________________________________________________ 
Fatores Agravantes:____________________________________________________________ 
Fatores Atenuantes:____________________________________________________________ 
Escala visual analógica da dor: ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 8 ( ) 9 ( ) 10 
Exame Físico 
Qualidade do Tônus Muscular: ( ) Normotônico ( ) Hipertônico ( ) Hipotônico 
FM: 
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ADM: 
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Sensibilidade: 
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TESTES ESPECÍFICOS: 
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A quanto tempo vem sendo acompanhada na Instituição? ______________________________ 
Porque a Fisioterapia é importante? 
( ) Melhora minha qualidade de vida ( ) Alivia as dores 
( ) A companhia do grupo me faz bem, me sinto melhor na presença de todos. 
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