Ficha de Avaliao Fisioteraputica

1. Anamnese
Nome:_________________________________________________________
Data de Nascimento:__/__/__ Idade: _____________ Sexo:_______________
Estado Civil:_____________________________________________________
Nvel de Escolariadade:____________________________________________
Profisso:_______________________________________________________
Endereo:_______________________________________________________
Telefone:________________________________________________________
Data da avaliao:__/__/__ Termino do tratamento:__/__/__
2.Histria Clinica
Diagnstico Clnico:_______________________________________________
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Nome do Mdico:_________________________________________________
Telefone:________________________________________________________
Exames Complementares:__________________________________________
Queixa Principal:__________________________________________________
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HMA:___________________________________________________________
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HMP:___________________________________________________________
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Antecedente Familiar:______________________________________________
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Antecedente Pessoais:____________________________________________
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Histria Social:
( )Etilismo ( )Tabagismo ( )Atividade fsica ( )Sedentarismo
OBS:___________________________________________________________
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Patologias associadas:_____________________________________________

3. Antropometria:
Peso:_________________________ Altura:____________________________
4.Sinais Vitais:
PA:___________________ FC:_________________ FR:__________________
Temperatura Corporal:_____________________________________________
Estado Geral:____________________________________________________
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5.Independncia/ Locomoo:_____________________________________
6.Exame Fsico
Inspeo:
a.Vista Anterior:
CABEA:
( ) Alinhada ( ) Rodada D ( ) Rodada E ( ) Inclinada E ( ) Inclinada D.
ALTURA DOS OMBROS:
( ) Nivelados ( ) Esquerdo mais elevado ( ) Direito mais elevado
CLAVCULA:
( ) Simtricas ( ) Oblquas para baixo
LINHA ALBA
( ) Retilnea ( ) Desvio E ( ) Desvio D
TRINGULO DE TALLES
( ) Simtricos ( ) Maior D ( ) Maior E
TESTE DE ADAMS
( ) Sem giba ( ) Gibosidade E ( ) Gibosidade D
ALTURA DAS MOS
( ) Simtricos ( ) D mais alta ( ) E mais alta
CRISTA ILACAS
( ) Simtricas ( ) D mais alta ( ) E mais alta
ESPINHA ILACA ANTERO-SUPERIOR (EIAS)
( ) Simtricas ( ) D mais alta ( ) E mais alta
JOELHOS
( ) Valgo ( ) Varo ( ) Normal

PATELAS
( ) Convergentes ( ) Divergentes ( ) Normais
PS
( ) Planos ( ) Cavos ( ) Normais
HLUX
( ) Hlux Valgus ( ) Alinhado

b.Vista Lateral
CABEA:
( ) Anteriorizada ( ) Posteriorizada ( ) Normal
CERVICAL:
( ) Hiperlordose ( ) Retificada ( ) Normal
OMBRO:
( ) Protusos ( ) Anteriorizado ( ) Posteriorizados ( ) Normais
MOS:
( ) Anterior Coxa ( ) Posterior Coxa ( ) Alinhadas

DORSO:
( ) Curvo ( ) Plano ( ) Normal
ABDOMEN:
( ) Protuso ( ) Ptose ( ) Normal
LOMBAR:
( ) Hiperlordose ( ) Retificada ( ) Normal
PELVE:
( ) Anteverso ( ) Retroverso ( ) Normal

TRONCO:
( ) Antepulso ( ) Retropulso ( ) Normal
JOELHOS:
( ) Recurvatum ( ) Fletidos ( ) Normal

c.Vista Posterior
CABEA:
( ) Alinhada ( ) Rodada D ( ) Rodada E ( ) Inclinada E( ) Inclinada D.
ALTURA DOS OMBROS:
( ) Nivelados ( ) Esquerdo mais elevado ( ) Direito mais elevado
ESCPULAS:
( ) D mais alta ( ) E mais alta ( ) Rotao Superior D( ) Rotao Superior E
( ) Rotao Inferior D ( ) Rotao Inferior E( ) Escpulas Abduzidas
( ) Escpulas Aduzidas ( ) Escpula Alada D ( ) Escpula Alada E
( )Simtricas.
TESTE DE ADAMS:
( ) Convexidade D ( ) Convexidade E
Local: ( ) LOMBAR ( ) TORCICA ( ) CERVICAL ( ) EM s
EIPIs:
Simtricas ( ) D mais alta ( ) E mais alta
PREGA GLTEA:
( ) Simtricas ( ) D mais alta ( ) E mais alta
LINHA POPLTEA: ( ) Simtricas ( ) D mais alta ( ) E mais alta
CALCNEO:
( ) Simtricos ( ) Valgo ( ) Varo
Marcha:_________________________________________________________
Cintura Escapular:________________________________________________
Orteses:________________________________________________________
Assimetria:______________________________________________________

Edema:
( ) 1cruz ( ) 2 Cruz ( ) 3 Cruz ( ) 4 Cruz
Cicatrizes:_______________________________________________________
Feridas:_________________________________________________________
Trofismo:
( ) Hipotrofismo ( ) Hipertrofismo
Equimose:_______________________________________________________
Cor do Membro:__________________________________________________

Palpao:
Ponto doloroso:___________________________________________________
Ndulos:________________________________________________________
Contratura:______________________________________________________
Crepitaes:_____________________________________________________
Edema:
( ) Cacifo ( ) Sem cacifo
Espasmo:_______________________________________________________
Cicatrizes ou aderncia:____________________________________________
Sinais flogstico:_________________________________________________
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Tnus Muscular:
( )Hipotnia ( )Hipertnia ( )Normotnia
OBS:___________________________________________________________
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Mensurao:_____________________________________________________
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Perimetria:_______________________________________________________
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7.Teste Funcionais:
Membro Superior
Ativo
Extenso
Flexo
Ombro
Abduo
Aduo
Rotao
Externa
Rotao
Interna
Cotovelo Extenso
Flexo
Antebrao Supinao
Pronao
Extenso
Punho
Flexo
Desvio
Ulnar
Desvio
Radial

Mdia
45
180
180
40

Passivo
D
E

Contra
Resistncia
Sim
No

90
70
0
145
90
90
70
80
45
20

Membro Inferior

Quadril

Joelho
Tornozelo

Extenso
Flexo
Abduo
Aduo
Rotao
Externa
Rotao
Interna
Extenso
Flexo
Flexo
Plantar
Dorsiflexo
Inverso
Everso

Mdia
10
125
45
10
45
45
0
45
45
20
40
20

Ativo
D
E

Passivo
D
E

Contra
Resistncia
Sim
No

OBS:___________________________________________________________
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8. Testes Especficos
Testes

Positivo

Negativo

Hiperrreflexo

Normal

9. Teste de Reflexos
Reflexos
Bicipital
Tricipital
Estilo-Radial
Patelar
Tendo Calcano

Hiporeflexo

10. Auscuta:
Cardaca/Pulmonar:_______________________________________________
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11. Passagem e transferncia: _____________________________________

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12. Observaes (cirurgias, cicatrizes, placas metlicas, vlvulas, convulses,

etc):____________________________________________________________
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13. Diagnostico Fisioterapeutico: ___________________________________

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14. Objetivo do Tratamento: ______________________________________

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15. Plano do Tratamento: _________________________________________

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Nome do acadmico (a)