Ficha de Avaliação Fisioterapia

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Ficha de Avaliação Fisioterapêutica
Identificação:
Nome: _____________________________________________________________
Data de Nascimento: ____/____/____ Idade: _____________________
Estado Civil: _____________________ Sexo: ______________________
Endereço: __________________________________________________________
Cidade: ____________________________ Telefone: (___) _______-______
Profissão: __________________________________________________________
Anamnese:
Data de Avaliação: ___________________________________________________
Diagnóstico Médico: _________________________________________________
Diagnóstico Fisioterapêutico: __________________________________________
Início do Tratamento: ________________________________________________
Sinais Vitais:
PA: ___________________ FR: _____________________
FC: ___________________ T°: _____________________
Queixa Principal:
______________________________________________________________________________________________________________________________________________
HDA:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HDP:
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HDF:
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H.Social:
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Medicamentos:
______________________________________________________________________________________________________________________________________________
Exame Físico:
Inspeção Estática:
______________________________________________________________________________________________________________________________________________
Inspeção Dinâmica:
______________________________________________________________________________________________________________________________________________
Palpação:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
Sensibilidade:
Tátil: __________________________________________________________________
Térmica: _______________________________________________________________
Dolorosa: ______________________________________________________________
Barestesica: ____________________________________________________________
Goniometria: ___________________________________________________________
_______________________________________________________________________
Perimetria: _____________________________________________________________
_______________________________________________________________________
Grau de Força Muscular:
MMII: _________________________________________________________________
_______________________________________________________________________
MMSS: ________________________________________________________________
_______________________________________________________________________
OBS: __________________________________________________________________
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Alterações da Marcha:
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Alterações Posturais:
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Testes Especiais:
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Exames Complementares:
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Observações:
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Tratamento
Objetivos:
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Condutas:
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Assinatura do Acadêmico
Evolução:
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