FICHA DE AVALIAÇÃO NEUROLÓGICA GENÉRICA - ROGÉRIO SOUZA CANAL NEUROFUNCIONAL (1)

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Desenvolvido por Rogério Souza 
 
FICHA DE AVALIAÇÃO EM FISIOTERAPIA NEUROFUNCIONAL 
ANAMNESE 
Nome:____________________________________________________ Data de Nasc.: __/__/____ Idade: 
_____anos 
Sexo: ( ) M ( ) F Registro HU/RG: __________________ Estado civil:_______________ Religião: _______________ 
Raça:_____________________ Profissão: 
____________________________________________________________ Escolaridade:_____________________ 
Naturalidade: _________________ Procedência: ______________________ 
Endereço:________________________________________________________ Bairro: 
________________________ 
HMA: 
__________________________________________________________________________________________ 
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DIAGNÓSTICO:_________________________________________________________________________________ 
QP:__________________________________________________________________________________________ 
AP:__________________________________________________________________________________________ 
AF: __________________________________________________________________________________________ 
AC:__________________________________________________________________________________________ 
Medicamentos:________________________________________________________________________________ 
Exames Complementares: ________________________________________________________________________ 
_____________________________________________________________________________________________ 
EXAME FÍSICO 
1. DADOS VITAIS: FC_____ bpm FR: _____ rpm PA: ______/_______ 
2. INSPEÇÃO: 
_____________________________________________________________________________________________ 
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3. TROFISMO: 
 MMSS:_______________________________________________________________________________ 
 MMII:________________________________________________________________________________ 
4. TÔNUS: 
 MMSS: _________________________________________________________________________________ 
 MMII: __________________________________________________________________________________ 
5. ADM: 
_____________________________________________________________________________________________
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 6. MOTRICIDADE VOLUNTÁRIA: 
A. Solicitação de movimentos ativos: ______________________________________________________________ 
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B. Manobras deficitárias: 
 Braços estendidos: ( ) _______________________________________________________________________ 
 Raimiste:( ) _______________________________________________________________________________ 
 Mingazini:( ) ______________________________________________________________________________ 
 Queda de MMII em abdução: ( ) ______________________________________________________________ 
 Barré:( ) _________________________________________________________________________________ 
Desenvolvido por Rogério Souza 
C. Força Muscular (Medular): 
 Nível motor: D:____________ E: ___________________ 
MMSS D E 
C5 Flexores de cotovelo / Bíceps braquial 
C6 Extensores de punho / Ext. longo e curto 
C7 Extensores de cotovelo / tríceps braquial 
C8 Flexor profundo dos dedos / avalia 3º dedo 
T1 Abdutor do mínimo 
MMII D E 
L2 Flexores do quadril / iliopsoas 
L3 Extensores do joelho / quadríceps 
L4 Dorsiflexores do tornozelo / tibial anterior 
L5 Extensor longo do hálux 
S1 Plantiflexores do tornozelo / Gastronêmio e sóleo 
 
 7. MOTRICIDADE INVOLUNTÁRIA: 
( )Ausente ( ) Presente _____________________________________________ 
 8. REFLEXOS PROFUNDOS 
BICIPITAL D: E: 
TRICIPITAL D: E: 
ESTILORRADIAL D: E: 
CUBITOPRONADOR D: E: 
ADUTOR D: E: 
PATELAR D: E: 
AQUILEU D: E: 
Obs: ____________________________________________________________________________________________________ 
 
 9. REFLEXOS SUPERFICIAIS 
CUTÂNEO ABDOMINAL D: E: 
CUTÂNEO PLANTAR D: E: 
Obs: ____________________________________________________________________________________________________ 
 
 10. CLÔNUS 
PUNHO D: E: 
PATELAR D: E: 
AQUILEU D: E: 
 
 11. SENSIBILIDADE SUPERFICIAL 
A. Encefálico 
OMBRO D: E: 
BRAÇO D: E: 
ANTEBRAÇO D: E: 
MÃO D: E: 
TÓRAX D: E: 
COXA D: E: 
PERNA D: E: 
PÉ D: E: 
Obs: ____________________________________________________________________________________________________ 
 
Desenvolvido por Rogério Souza 
B. Medular 
DERMÁTOMOS D E 
C2 Protuberância Occipital 
C3 Fossa clavicular 
C4 Ápice da articulação acromioclavicular 
C5 Face lateral da fossa antecubital 
C6 Região dorsal do POLEGAR 
C7 Região dorsal do dedo MÉDIO 
C8 Região dorsal do Dedo MÍNIMO 
T1 Face medial da fossa antecubital (epic. Medial) 
T2 Ápice da axila 
T3 3º Espaço intercostal 
T4 Linha do mamilo 
T5 5º Espaço intercostal 
T6 Apêndice xifoide 
T7 7º Espaço intercostal 
T8 Rebordo Costal 
T9 9º Espaço intercostal 
T10 Cicatriz umbilical 
T11 Região abaixo da cicatriz 
T12 Ligamento inguinal (médio) 
L1 Região inguinal (virilha) 
L2 Face anterior de coxa 
L3 Côndilo femofal medial 
L4 Maléolo medial 
L5 Região dorsal do pé 
S1 Face lateral do calcanhar 
S2 Face poplítea 
S3 Tuberosidade Isquiática 
S4 Região perianal 
S5 Região perianal 
 
C. Lesão Nervosa Periférica 
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Desenvolvido por Rogério Souza 
12. SENSIBILIDADE PROFUNDA (Cinética-postural) 
Ombro: D:_________________________________________; E:_________________________________________; 
Cotovelo: D:_______________________________________; E:_________________________________________; 
Punho: D:_________________________________________; E:________________________________________; 
Quadril: D:________________________________________; E:_________________________________________; 
Joelho: D:_________________________________________; E:________________________________________; 
Tornozelo: D:______________________________________; E:_________________________________________; 
Hálux: D:_________________________________________; E:_________________________________________; 
 
13. ATIVIDADES FUNCIONAIS 
DD  DL’s:____________________________________________________________________________________ 
_____________________________________________________________________________________________ 
DD  Sentado: ________________________________________________________________________________ 
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DL DV: _____________________________________________________________________________________ 
_____________________________________________________________________________________________ 
DV  Gato:________________________________________________________________________________________________________________________________________________________________________________ 
Gato  Sentado:_______________________________________________________________________________ 
_____________________________________________________________________________________________ 
 
14. TRANSFERÊNCIAS (Medular) 
 Cadeira – leito: ( ) Sim/independente; ( ) Sim/dependente; ( )não/dependente; 
______________________________________________________________________________________ 
 Para o chão: ( ) Sim/independente; ( ) Sim/dependente; ( )não/dependente; 
______________________________________________________________________________________ 
 Para o automóvel: ( ) Sim/independente; ( ) Sim/dependente; ( )não/dependente; 
______________________________________________________________________________________ 
 Cadeira para em pé: ( ) Sim/independente; ( ) Sim/dependente; ( )não/dependente; 
______________________________________________________________________________________ 
 Para o vaso sanitário: ( ) Sim/independente; ( ) Sim/dependente; ( )não/dependente; 
______________________________________________________________________________________ 
 Em pé (órtese)– automóvel: ( ) Sim/independente; ( ) Sim/dependente; ( )não/dependente; 
______________________________________________________________________________________ 
 
15. LOCOMOÇÃO (Medular): ( ) Cadeira de rodas ( ) Órtese 
 ( ) Independente ( ) Semi dependente ( ) Dependente 
 _____________________________________________________________________ 
 
16. AVD (Dependente, semi-dependente ou independente); 
 Alimentação:____________________________________________________________________________ 
 Vestuário:______________________________________________________________________________ 
 Higiene:________________________________________________________________________________ 
 
17. EQUILÍBRIO: 
 Encefálico 
 Romberg: OA: _______________________________ OF: ______________________________________ 
 Tandem: OA: _______________________________ OF: ______________________________________ 
 Unipodal: OA: _______________________________ OF: ______________________________________ 
 Medular 
 Sentado: ____________________________________________________________________________ 
 Gato: ______________________________________________________________________________ 
 
Desenvolvido por Rogério Souza 
 
18. COORDENAÇÃO 
 Index-index ( ) _________________________________________________________________________ 
 Index-Nariz ( ) _________________________________________________________________________ 
 ndex-Index-Nariz ( ) _____________________________________________________________________ 
 Calcanhar-joelho ( ) _____________________________________________________________________ 
 Rechaço ( ) ____________________________________________________________________________ 
 Diadococinesia ( ) _______________________________________________________________________ 
 
19. ANÁLISE DA MARCHA: 
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20. AVALIAÇÃO POSTURAL: 
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DIAGNÓSTICO CINETICO-FUNCIONAL 
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OBJETIVOS FISIOTERÁPICOS 
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Avaliado por: _____________________________________ .