FICHA DE AVALIAÇÃO SAÚDE COMUNITARIA

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FICHA DE AVALIAÇÃO FISIOTERAPÊUTICO – IESPES
 UBS Vitória Régia 
Estagiário____________________________________________Data da avaliação___/___/___
Preceptor: Alexandre Oliveira 
IDENTIFICAÇÃO 
DADOS PESSOAIS 
Nome: _________________________________________________________Idade___________
Gênero F M Cor/Raça: ____________DN: ___/___/___ Nacionalidade_________________
Escolaridade:____________________________________________________________________
Profissão/Ocupação:___________________ Ativo Incapacidade Aposentado________tempo
Hobby:________________________________________________Lateralidade Destro Canhoto
Estado civil: solteiro (a) Casado Viúvo Divorciado Nome do cônjuge:___________________
____________________________________ Filhos: Sim Não n°________________________
Endereço Completo:_______________________________________________________________
Telefone: ( )_____________________________________________________________________
Médico__________________________________________________________________________
Agente Comunitário de Saúde_______________________ Grupão__________________________
Diagnóstico Clínico:_______________________________________________________________
Sinais Vitais: PA______mmHg, FC:__________bpm, SPO2:____________FR:_____________irpm
ANAMNESE
Queixa Principal:__________________________________________________________________
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História da doença Atual:____________________________________________________________
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História da doença progressa:_________________________________________________________
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História da doença Familiar:_________________________________________________________
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AVDs: ( ) Dependente ( ) Semidependente ; ( ) Independente;
Obs:______________________________________________________________________________
Locomoção:
 Deambula independente Deambula com supervisão Deambula com assistência
 Cadeirante independente Cadeirante dependente Restrito ao leito 
 Outros ________________________________________________________________________
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Uso de medicamentos:______________________________________________________________
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 EXAME FÍSICO 
Inspeção 
	( ) Locomoção independente
	( ) Hematoma;
	( ) Cadeira de roda;
	( ) Corado;
	( ) Muletas;
	( ) Cicatriz;
	( ) Andador ;
	( ) Escara: Profundidade; extensão;
	( ) Edema;
	( ) Infectada;
	( ) Calor;
	( ) Não infectada;
	( ) Rubor;
	
Palpação:
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Teste de força muscular:
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Goniômetria:____________________________________________________________________
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Teste reflexos 
 Patelar: Presente ( ) Ausente ( )
 Aquileu Presente ( ) Ausente ( )
Palpação Pulsos Arteriais:
 Pedioso: Presente ( ) Ausente ( ) Diminuído ( )
 Tibial Posterior: Presente ( ) Ausente ( ) Diminuído ( )
INFORMAÇÕES GERAIS DE SAÚDE:
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DIAGNÓSTICO CINÉTICO FUNCIONAL: 
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 OBJETIVOS DO TRATAMENTO:
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CONDUTAS:
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