FICHA DE AVALIAÇÃO - NEUROSTUDENT

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FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
FICHA DE AVALIAÇÃO NEUROFUNCIONAL 
 
 
 
DADOS DO PACIENTE DATA: ____/____ /_______ 
Avaliação ( ) Reavaliação ( ) 
 
NOME:_________________________________________________________________________ 
TELEFONE: ________________ CELULAR:__________________ CELULAR (2):_________________ 
ENDEREÇO:______________________________________________________________________ 
DATA DE NASCIMENTO: ____ / ____ / ______ SEXO: _________ IDADE: __________________ 
ETNIA: _____________________ PROFISSÃO: _________________________________________ 
NATURALIDADE: _________________________________________________________________ 
DIAGNÓSTICO CLÍNICO:____________________________________________________________ 
 
SINAIS VITAIS 
 
P.A: _____________ mmH g F.C: ______________ bpm FR: ______________ irpm 
OBSERVAÇÕES: __________________________________________________________________ 
 
ANAMNESE 
 
QUEIXA PRINCIPAL (Q.P.) 
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HISTÓRIA DA DOENÇA ATUAL (H.D.A.) 
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FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
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HISTÓRIA PATOLÓGICA PREGRESSA (H.P.P.) 
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HISTÓRICO FAMILIAR (H.F.) 
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HISTÓRICO SOCIAL (H.S.) 
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OUTRAS OBSERVAÇÕES 
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FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
EXAME FÍSICO 
 
INSPEÇÃO 
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MOVIMENTOS INVOLUNTÁRIOS 
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REFLEXOS SUPERFICIAIS 
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REFLEXOS PROFUNDOS 
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 MANOBRAS DEFICITÁRIAS: 
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FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
TÔNUS MUSCULAR 
 
 
MEMBROS SUPERIORES: ____________________________________________________________ 
 
MEMBROS INFERIORES: _____________________________________________________________ 
 
 
COORDENAÇÃO: 
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FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
SENSIBILIDADE SUPERFICIAL 
 
SENSIBILIDADE SUBJETIVA: __________________________________________________________ 
 
SENSIBILIDADE SUPERFICIAL TATIL: ____________________________________________________ 
 
SENSIBILIDADE SUPERFICIAL DOLOROSA: _______________________________________________ 
 
SENSIBILIDADE PROFUNDA PALESTÉSICA: _______________________________________________ 
 
SENSIBILIDADE PROFUNDA 
 
SENSIBILIDADE PROFUNDA PROPIOCEPTIVA: ____________________________________________ 
 
DIADOCOCINESIA: _________________________________________________________________ 
 
EQUILÍBRIO 
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MARCHA 
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ESTADO MENTAL 
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FALA / LINGUAGEM 
_________________________________________________________________________________FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
NERVOS CRANIANOS 
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ATIVIDADES DE VIDA DIÁRIA 
I – INDEPENDENTE PD – PARCIALMENTE DEPENDENTE D – DEPENDENTE 
ALIMENTAÇÃO: ___________________________________________________________________ 
VESTUÁRIO (SUPERIOR): ____________________________________________________________ 
VESTUÁRIO (INFERIOR): _____________________________________________________________ 
BANHO (SENTADO): ________________________________________________________________ 
BANHO (EM PÉ): ___________________________________________________________________ 
HIGIENE GENITAL: _________________________________________________________________ 
LAVAR O ROSTO: __________________________________________________________________ 
LAVAR O CABELO: _________________________________________________________________ 
MAQUIAR-SE: _____________________________________________________________________ 
BARBEAR-SE: _____________________________________________________________________ 
PENTEAR O CABELO: _______________________________________________________________ 
LAVAR AS MÃOS: __________________________________________________________________ 
 
 
AMPLITUDE DE MOVIMENTO PASSIVA E ATIVA: 
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FORÇA MUSCULAR: 
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FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
EXAMES COMPLEMENTARES 
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CLASSIFICAÇÃO INTERNACIONAL DE FUNCIONALIDADE (CIF) 
 
FUNÇÕES E ESTRUTURAS CORPORAIS: 
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ATIVIDADE E PARTICIPAÇÃO 
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OBJETIVOS DE TRATAMENTO 
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FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
EVOLUÇÃO FISIOTERAPÊUTICA 
 
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FISIOTERAPIA NEUROFUNCIONAL @ NEUROSTUDENT 
DATA:____/_____/________ 
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