Ficha Avaliativa Saúde da Mulher

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Clínica Integrada UNIVAG
Avaliação Clínica
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FICHA AVALIATIVA SAÚDE DA MULHER
Prontuário:_________________
NOME:_______________________________________________________________
IDADE: _______________________
DATA DA AVALIAÇÃO:____/____/____
ENDEREÇO:________________________________________________________________________________________________________________________________
TELEFONE: ___________________ ESTADO CIVIL: ______________
PROFISSÃO:__________________
NOME DO MÉDICO PRÉ-NATALISTA: _______________________ TELEFONE: ____________________
DUM: __/_____/______
DPP:_____/______/_____ G:___ P:___ A:____
IDADE GESTACIONAL: ______________
TELEFONE DE EMERGÊNCIA: ___________________________
_______________________________________________
RESPONSÁVEL
ASSINATURA/CARIMBO
QUEIXA PRINCIPAL
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OBJETIVOS E EXPECTATIVAS DO ATENDIMENTO: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ANAMNESE
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HGA: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SISTEMA DIGESTIVO
( ) CONSTIPAÇÃO
( ) ESFORÇO PARA EVACUAR
( ) AZIA
( ) PERDA DE FLATOS
OBS:__________________________________________________________________________________________________________________________
SISTEMA CARDIOVASCULAR
( ) HAS
( ) PROBLEMAS CARDÍACOS. QUAL? ______________________________
( ) HEMORRÍODA
( ) EDEMA
( ) VARIZES 
( ) HIPOTENSÃO POSTURAL
( ) ANEMIA
( ) HAIG
OBS:__________________________________________________________________________________________________________________________
SISTEMA GENITOURINÁRIO
( ) INFECCÇÃO URINÁRIA
( ) DISÚRIA
( ) SENS. ESVAZIAMENTO INCORRETO
( ) DOR ABDOMINAL / PÉLVICA
( ) INCONTINÊNCIA URINÁRIA
Obs:__________________________________________________________________________________________________________________________
SISTEMA MUSCULOESQUELÉTICO 
( ) FRATURAS
( ) PARESTESIA EM MMSS
( ) DOR
OBS:__________________________________________________________________________________________________________________________
DOR: 
O-INÍCIO:________________________________________________________
________________________________________________________________
L-LOCALIZAÇÃO:________________________________________________
_______________________________________________________________
D- DURAÇÃO: __________________________________________________
_______________________________________________________________
C- CARÁTER: ___________________________________________________
_______________________________________________________________
A- FATORES AGRAVANTES: ______________________________________
_______________________________________________________________
R- FATORES ATENUANTES: _______________________________________
________________________________________________________________
T- TRATAMENTOS APLICADOS:____________________________________
_______________________________________________________________
ESCALA EVA: _____________________
ATIVIDADE:____________________________________________________________________________________________________________________
PARTICIPAÇÃO:________________________________________________________________________________________________________________
SISTEMA NERVOSO
( ) LIPOTIMIA
( ) VERTIGEM 
( ) CONVULSÃO 
( ) PARESTESIA 
OBS:__________________________________________________________________________________________________________________________
MEDICAMENTOS
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EXAME FÍSICO
	SINAIS VITAIS: 
	PA: _____________ FC:_____________ 
	FR:_____________ SPO2: _____________ 
	Peso (Kg):_________________
	Ganho ponderal:____________ 
AVALIAÇÃO POSTURAL- EXAME ESTÁTICO EM ORTOSTATISMO
	VISTA ANTERIOR:
	CABEÇA: Alinhada ( ) Rodada = Direita ( ) Esquerda ( )
	OMBRO: Simétrico ( ) Elevado = Direito ( ) Esquerdo ( )
	CLAVÍCULA: Simétrica ( ) Elevada = Direito ( ) Esquerdo ( )
	TRIÂNGULO DE TALLES: Simétrico ( ) Aumentado = Direito ( ) Esquerdo ( )
	CRISTAS ILÍACAS: Simétrica ( ) Elevada = Direito ( ) Esquerdo ( )
	JOELHO: Simétrico ( ) Assimétrico = Genovaro ( ) Genovalgo ( )
	PATELAS: Simétrico ( ) Elevada = Direito ( ) Esquerdo ( )
	TORNOZELO: Normal ( ) Inversão ( ) Eversão ( )
	VISTA POSTERIOR:
	CABEÇA: Neutra ( ) Rodada = Direita ( ) Esquerda ( )
	COLUNA TORÁCICA: Alinhada ( ) Desalinhada = Direito ( ) Esquerdo( )
	COLUNA LOMBAR: Alinhada ( ) Desalinhada = Direito ( ) Esquerdo ( )
	ESCOLIOSE: Não possui ( ) S ( ) C ( )
	OMBRO: Neutro ( ) Elevado = Direito ( ) Esquerdo ( )
	ESCÁPULA (espinha): Simétricas ( ) Elevada= Direita ( ) Esquerda ( ) Alada = Direita ( ) Esquerda ( ) Aduzida = Direita ( ) Esquerda ( )
	TRIÂNGULO DE TALLES: Simétrico ( ) Aumentado = Direito ( ) Esquerdo ( )
	ESPINHAS ILÍACAS PÓSTERO-SUPERIORES (EIPS): Alinhadas ( ) Elevada = Direita ( ) Esquerda ( )
	ALTURA DAS CRISTAS ILÍACAS: Alinhadas ( ) Elevada = Direita ( ) Esquerda ( )
	JOELHO: Normal ( ) Varo ( ) Valgo ( )
	TORNOZELO: Normal ( ) Inversão ( ) Eversão ( )
	VISTA LATERAL DIREITA:
	CABEÇA: Alinhada ( ) Protusa ( ) Retraída ( )
	OMBRO: Normal ( ) Protusa ( ) Retraído ( )
	COLUNA CERVICAL: Normal ( ) Hiperlordose ( ) Retificada ( )
	COLUNA TORÁCICA: Normal ( ) Hipercifose ( ) Retificada ( )
	COLUNA LOMBAR: Normal ( ) Hiperlordose ( ) Retificada ( )
	
	CINTURA PÉLVICA: Normal ( ) Anteversão ( ) Retroversão ( )
	ARTICULAÇÃO DO QUADRIL: Alinhado ( ) Fletido ( ) Estendido ( )
	ARTICULAÇÃO DO COTOVELO: Alinhada ( ) Aumento da flexão ( ) hiperextensão ( )
	JOELHOS: Normal ( ) Genurecurvatum ( ) Genuflexo ( )
	ARTICULAÇÃO DO TORNOZELO (Ângulo tíbio-társico): Normal ( ) Aumentado ( ) Diminuído ( )
	VISTA LATERAL ESQUERDA:
	CABEÇA: Alinhada () Protusa (x) Retraída ( )
	OMBRO: Normal ( ) Protusa (x) Retraído ( )
	COLUNA CERVICAL: Normal ( ) Hiperlordose ( ) Retificada ( )
	COLUNA TORÁCICA: Normal ( ) Hipercifose (x) Retificada ( )
	COLUNA LOMBAR: Normal ( ) Hiperlordose (x) Retificada ( )
	COLUNA SACRAL: Normal ( ) Hipercifose ( ) Retificada ( )
	CINTURA PÉLVICA: Normal ( ) Anteversão (x) Retroversão ( )
	ARTICULAÇÃO DO QUADRIL: Alinhado ( ) Fletido ( ) Estendido ( )
	ARTICULAÇÃO DO COTOVELO: Alinhada ( ) Aumento da flexão ( ) hiperextensão ( )
	JOELHOS: Normal ( ) Genurecurvatum ( ) Genuflexo ( )
	ARTICULAÇÃO DO TORNOZELO (Ângulo tíbio-társico): Normal ( ) Aumentado ( ) Diminuído ( )
OBS.:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
EXAME DINÂMICO EM ORTOSTATISMO
	Flexão anterior:____________________________________________
	Flexão lateral:_____________________________________________
	Extensão:_________________________________________________
	Rotação:_________________________________________________
EXAME EM DECÚBITO DORSAL – AVALIAÇÃO DA DIÁSTASE
_____cm acima da cicatriz umbilical:_______
Acima da cicatriz umbilical:_______
_____cm abaixo da cicatriz umbilical:_______
AVALIAÇÃO DO ASSOALHO PÉLVICO
	INSPEÇÃO
SENSIBILIDADE: 
_______________________________________________________________________________________________________________________________________________________________________________________________________________
	COLORAÇÃO: ( ) Normocorada ( ) Hipocoada ( ) Hipercorada
_______________________________________________________________________________________________________________________________________________________________________________________________________________
	SECREÇÃO: ( ) Secreção fisiológica ( ) Secreção não fisiológica
__________________________________________________________________________________________________________________________________________
HEMORROIDA: ( ) Presente ( ) Ausente
_______________________________________________________________________________________________________________________________________________________________________________________________________________
PERÍNEO: 
_______________________________________________________________________________________________________________________________________________________________________________________________________________
REFLEXO DE TOSSE: ( ) Preservado ( ) Ausente
_______________________________________________________________________________________________________________________________________________________________________________________________________________
REFLEXO (CUTANEO-ANAL / CLITORIANO):
_______________________________________________________________________________________________________________________________________________________________________________________________________________
VALSALVA: PERDA DE URINA / PROLAPSO
( ) Ausente ( ) Presente 
Se presente: ( ) Prolapso da parede anterior ( ) Prolapso da parede posterior ( ) Prolapso apical
_______________________________________________________________________________________________________________________________________________________________________________________________________________
CONTRAÇÃO VISÍVEL: ( ) Preservado ( ) Ausente
_______________________________________________________________________________________________________________________________________________________________________________________________________________
CICATRIZES:
_______________________________________________________________________________________________________________________________________________________________________________________________________________
DISTÂNCIA ANO-VULVAR: 
_______________________________________________________________________________________________________________________________________________________________________________________________________________
TÔNUS (ESCALA DE DIETZ):
_______________________________________________________________________________________________________________________________________________________________________________________________________________
RESISTÊNCIA:
_______________________________________________________________________________________________________________________________________________________________________________________________________________
COORDENAÇÃO: 
_______________________________________________________________________________________________________________________________________________________________________________________________________________
CONTROLE MOTOR:
_______________________________________________________________________________________________________________________________________________________________________________________________________________
FORÇA:
_______________________________________________________________________________________________________________________________________________________________________________________________________________
ORIENTAÇÕES
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DIAGNÓSTICO FISIOTERAPÊUTICO
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OBJETIVO DE TRATAMENTO 
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________OBERVAÇÕES
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
11 - CONDUTAS FISIOTERAPÊUTOCAS
Paciente:______________________________________ Nº ____________________
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