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Nome Completo:____________________________________________________________ Data de Nascimento:_________________ Idade: _________ Sexo:____________________________ Encaminhado por: _____________________________________________________________________________ Queixas (sintomas, duração, história pregressa de queixa) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Avaliação Oromiofacial (lábios: sensibilidade, postura, mobilidade, tônus) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Avaliação da Disfagia Dificuldade para se alimentar: ⃝ SIM ⃝ NÃO Via Oral: ⃝ SIM ⃝ NÃO Sonda Nasoenteral: ⃝ SIM ⃝ NÃO Observações: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Qualidade Vocal ⃝ Adequada ⃝ Alta ⃝ Aspirado ⃝ Compensação Nasal ⃝ Gudizado ⃝ Gutural ⃝ Inadequada ⃝ Monótona ⃝ Pastosa ⃝ Rouca ⃝ Soprosa ⃝ Aspirado ⃝ Tensa ⃝ Trêmula Ritmo ⃝ Adequado à intenção do discurso ⃝ Inadequado à intenção do discurso Ataque Vocal ⃝ Adequado ⃝ Aspirado ⃝ Brusco Observações ___________________________________________________________________________________________________________________________________________________ Avaliação de Linguagem (Aspectos linguísticos – sintaxe, semântica, pragmática, fonética, fonologia) Linguagem Oral _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Linguagem Escrita _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Internações, Medicamentos em uso Exames Realizados _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Hipótese Diagnóstica _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Conduta _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
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