Ficha de avaliação e evolução FISIO

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FICHA DE AVALIAÇÃO FISIOTERAPÊUTICA
FISIOTERAPEUTA ISADORA FERNANDA – CREFITTO 285314-F
Atendimento Domiciliar
Telefone: (31) 99399-9050 – E-mail: isadora.fernandap@gmail.com
DATA: ____/____/____
	DADOS PESSOAIS
	NOME:
	IDADE:
	SEXO: [ ] M [ ] F
	ESTADO CIVIL:
	PROFISSÃO:
	ENDEREÇO:
	TELEFONE:
	DIAGNÓSTICO CLÍNICO:
	MÉDICO RESPONSÁVEL:
	ANAMNESE
	QUEIXA PRINCIPAL:
	HMA:
	HPP:
	
	EXAMES:
	DADOS CLÍNICOS
	TEM ALGUM PROBLEMA DE SAÚDE:
MEDICAMENTOS:
CIRURGIA: _______ QUAL: _____________________________________ TEMPO: ___________
FRATURA: ____________________________________ QUAL: __________________________
ETILISTA: ____________ TABAGISTA: __________ ANOS/MAÇO EX-TABAGISTA ____________
ATIVIDADE FÍSICA: ____________ FREQUÊNCIA: ______________
	EXAME FÍSICO
	PA:	 MMHG
	FC: BPM
	SAPO2: %
	AP:
	PERIMETRIA
BRAÇO E: __________ COXA E: _________ PANTURRILHA E: ________
BRAÇO D: __________ COXA D: _________ PANTURRILHA D: ________
ANTEBRAÇO E: _______ JOELHO E: _______ TORNOZELO E: __________
ANTEBRADO D: ________ JOELHO D: ________ TORNOZELO D: __________
	AMPLITUDE DE MOVIMENTO
CERVICAL 
OMBRO 
MÃO 
COTOVELO 
LOMBAR
QUADRIL
JOELHOS
TORNOZELO
	GRAU DE FORÇA
	DIREITA
	ESQUERDA
	ABDOMINAIS
	
	
	PARAVERTEBRAIS
	
	
	GLÚTEO MÁXIMO
	
	
	GLÚTEO MÉDIO
	
	
	QUADRÍCEPS
	
	
	ISQUIOTIBIAIS
	
	
	PIRIFORME
	
	
	ILIOPSOAS
	
	
	ROMBÓIDES
	
	
	TRAPÉZIO
	
	
	BÍCEPS
	
	
	TRICEPS
	
	
	INFRAESPINHAL
	
	
	SUPRAESPINHAL
	
	
	TESTE DE FLEXIBILIDADE
	1
D
	2
D
	3
D
	4
D
	1
E
	2
E
	3
E
	4
E
	
1- NORMAL
2- LEVE
3- MODERADO
4- SEVERO
	ILIOPSOAS
	
	
	
	
	
	
	
	
	
	ISQUIOSTIBIAIS
	
	
	
	
	
	
	
	
	
	PIRIFORME
	
	
	
	
	
	
	
	
	
	QUADRICEPS
	
	
	
	
	
	
	
	
	
	ADUTORES DE QUADRIL
	
	
	
	
	
	
	
	
	
	AVALIAÇÃO POSTURAL
ANTERIOR
CABEÇA OMBROS PELVE JOELHOS 
( ) LINHA MÉDIA ( ) ALINHADO ( ) ALINHADA ( ) NORMAL
( ) RODADA P/ D ( ) ELEVADO ( ) ANTEVERSÃO ( ) VALGO
( ) RODADA P/ E ( ) DEPRIMDO ( ) RETROVERSÃO ( ) VARO
( ) INCLINADA P/ D 
( ) INCLINADA P/ E
LATERAL
CABEÇA OMBROS TORÁCICA LOMBAR JOELHOS
( ) ALINHADA ( ) NORMAL ( ) NORMAL ( ) NORMAL ( ) NORMAL
( ) PROTUSO ( ) PROTUSO ( ) HIPERCIFOSE ( ) HIPERLORDOSE ( ) HIPEREXTENSÃO
( ) RETRAÍDO ( ) RETRUSO ( ) RETIFICADA ( ) GENOFLEXO
POSTERIOR
ESCÁPULAS COLUNA 
( ) NORMAL ( ) ALINHADA
( ) ABDUZIDA ( ) ESCOLIOSE
( ) ADUZIDA 
( ) ALADA
( ) ELEVADA
( ) DEPRIMIDA
	INSPEÇÃO/PALPAÇÃO
	RITMO ESCÁPULOUMERAL
	MARCHA
	TESTES ESPECIAIS
	OBJETIVO
	PROPOSTA TERAPÊUTICA
____________________________________________
Isadora Fernanda Pinheiro
Fisioterapeuta 
CREFITTO 285314-F
EVOLUÇÃO DIÁRIA DE ATENDIMENTO
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