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Ficha de avaliao

Data da avaliao: ____/___/____


Acadmica: ________________________________________________________________
Nome:_____________________________________________________________________
Idade:______ Sexo: ____ Peso: _____Altura: ______PA: ______________ Data de Nascimento:____/____/____
Profisso: ______________________ Funo:______________Tempo:____
Estado civil: ___________________
Endereo: _________________________________________________________
Naturalidade: _______________________________________________________
Telefone: _____________________
Diagnstico
Clnico:___________________________________________________________________________________________
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Dominncia: ( ) Destro ( ) Sinistro ( ) Ambidestro
Hbitos de vida: ______________________________________________________________
Quantas horas de sono: _____________.
Prtica de atividade fsica: _______________ Qual: ___________________ Frequncia: ___________________.
Algum dficit (visual, auditivo, outros): _____________________________________________.
Queixa principal: ___________________________________________________________________________________
Histria da Doena Atual:
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Historia da Doena Pregressa:
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Medicamentos em uso: ______________________________________________________________________________
Alguma patologia associada:_____________________________________________________
Realizou alguma cirurgia: _____________________________________________.
Faz algum tratamento conservador: _______________________________________________.

Quanto tempo sente dor: __________________________________________.


Irradiao: ( ) nega
( ) trapzio
( ) MSD ( ) MSE
( ) MID - acima do joelho
( ) MID - abaixo do joelho
( )MIE acima do joelho
( ) MIE abaixo do joelho
( ) outro: ___________________________________.
Horrio da dor: ( ) matutina ( ) vespertina ( ) noturna ( ) sem horrio
Estgio da dor: ( ) aguda
( ) crnica
Fatores de piora:
( ) esforo fsico
( ) repouso prolongado
( ) posio em p
( ) posio sentada
( ) deambulao
( ) tenso emocional
( ) esporte

( ) movimento
( ) outro: ______________________________.
Fatores que aliviam:
( ) repouso
( ) calor local
( ) fisioterapia
( ) medicao
( ) movimento
( ) exerccio/alongamento
( )outro: _____________________________.
Palpao:
Partes Moles:
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Partes sseas:
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Goniometria Membro Superior:

Ombro
Flexo
Extenso
Abduo
Aduo
Rotaes

Normalidade
0 - 180
180 - 0
0 - 90
0 - 40
0 - 90

Paciente

Cotovelo
Flexo
Extenso

Normalidade
0 - 145
145 - 0

Paciente

Radio Ulnar
Pronao
Supinao

Normalidade
0 - 80
0 - 90

Paciente

Punho
Flexo
Extenso
Desvio Ulnar

Normalidade
0 - 80
0 - 70
0 - 45

Paciente

Desvio Radial

0 - 15

Cervical
Flexo
Extenso
Rotao
Latero-flexo

Normalidade
0 - 65
0 - 50
0 - 55
0 - 40

Paciente

Joelho
Flexo
Extenso

Normalidade
0 - 140
140 - 0

Paciente

Quadril
Extenso
Flexo
Rotaes
Abduo
Aduo

Normalidade
0 - 10
0 - 125
0 - 45
0 - 45
0 - 15

Paciente

Goniometria Membros Inferiores:

Edema:____________ Local:________________Grau:______________________.
PERIMETRIA:
Brao

Direito

Esquerdo

Direito

Esquerdo

7cm
14cm
Antebrao
5cm
10cm
Punho

Local

Medida

Trax
Abdomen
Quadril

Coxa

Direita

Esquerda

7cm
14cm
21cm
Patela

Direita

Esquerda

7cm
14cm

GRAU DE FORA
Msculo

Grau 1

Grau 2

Grau 3

Grau 4

Grau 5

Flexibilidade (Banco de Wells) :


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Podoscpio:
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Teste especfico:
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Avaliao Postural :
Vista Anterior
Cabea: ( ) Alinhada

( ) Inclinada a D

( ) Inclinada a E ( ) Rodada a E ( ) Rodada a D

Ombros: ( ) Simtricos ( ) Direito + alto ( ) Esquero + alto


Rotao do tronco : ( ) esquerda ( ) direita ( ) Ausente
ngulo de tales: ( ) Simtrico ( ) Maior esquerda ( ) Maior a direita
Linha alba: ( ) Alinhada ( ) Desvio direita (

) Desvio esquerda

Altura das Crista ilacas: ( ) simtricos ( ) Direito + alto ( ) esquero + alto


Joelhos: ( ) Valgo ( ) Varo ( ) Normal
Tornozelos: ( ) Valgo ( ) Varo ( ) Normal
Ps: ( ) Normal ( ) Plano ( ) Cavo
Vista posterior
Altura da escapulas: ( ) Simtrico

( ) Direito + alto

( ) Esquero + alto

Escapula Alada: ( ) esquerda ( ) direita ( ) ausente


Gibosidade torcica: ( ) esquerda ( ) direita ( ) ausente
Prega gltea: ( ) simtrica ( ) direito + alto ( ) esquerdo + alto
Prega poplteas: ( ) simpetricos ( ) direito + alto ( ) esquerdo + alto
Joelhos: ( ) Valgo ( ) Varo ( ) Normal
Tornozelos: ( ) Valgo ( ) Varo ( ) Normal
Vista lateral Direita
Cabea: ( ) anteriorizada ( ) Posteriorizada ( ) Normal
Coluna cervival: ( ) hiperlordose ( ) retificada ( ) normal
Ombro: ( ) protuso ( ) retrados ( ) normal
Coluna torcica: ( ) hipercifose ( ) retificada ( ) normal
Abdomen: ( ) protuso ( ) retrado
Coluna lombar: ( ) hiperlordose ( ) retificada ( ) normal
Pelve: ( ) antevertida ( ) retrovertida ( ) normal
Joelho: ( ) hiperextenso ( ) semifletido
Vista lateral esquerda
Cabea: ( ) anteriorizada ( ) Posteriorizada ( ) Normal

Coluna cervival: ( ) hiperlordose ( ) retificada ( ) normal


Ombro: ( ) protuso ( ) retrados ( ) normal
Coluna torcica: ( ) hipercifose ( ) retificada ( ) normal
Abdomen: ( ) protuso ( ) retrado
Coluna lombar: ( ) hiperlordose ( ) retificada ( ) normal
Pelve: ( ) antevertida ( ) retrovertida ( ) normal
Joelho: ( ) hiperextenso ( ) semifletido

Diagnstico Fisioteraputico:
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Objetivo:
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TRATAMENTO:__________________________________________________________________________________
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