Ficha de avaliação Geronto Fisioterapia PDF

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Ficha de avaliação do estágio de Geronto...

Description

Estágio Supervisionado Fisioterapia Gerontológica e Reumatológica I e II

Ficha de Avaliação Data da avaliação:_____/_____/_____. Dados pessoais: Nome:____________________________________________________________________ Gênero ( ) M ( ) F

DN: ____/____/___

Idade: _____

Estado civil: _________________

Endereço: _________________________________ Telefone: ______________________ Profissão (anterior/atual): ___________________________________________________ Hipótese diagnóstica, se houver: ___________________________________________________ Profissional solicitante/ contato:______________________________________________________ Anamnese: Queixa (s) principal (is) / funcional (is): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ______________________________________________________________________. HMA:___________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ________________________________________________________________. HPP:___________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________ Cirurgias/internações:____________________________________________________________ _______________________________________________________________________________ HF:_______________________________________________________________________________ ____________________________________________________________________________ Doenças associadas: ____________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________. Medicamentos em uso/posologia: __________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________. Exames de imagens e laboratoriais: ________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________. Hábitos de vida: _________________________________________________________________ _______________________________________________________________________________.

Estágio Supervisionado Fisioterapia Gerontológica e Reumatológica I e II Escalas e/ou testes funcionais:_________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ Quedas no último ano: Não: _____ Sim: ____: ___________________________________ Fatores de Risco identificados para quedas:______________________________________ ____________________________________________________________________________ Exame físico IMC _______________ Peso: _______ Estatura _______ Sinais Vitais: PA: ____________ FC: _____________ FR: ___________ SatO2:_________ AP: ________________________________________________________________________ Inspeção:_______________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________ Palpação:______________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ Intensidade da dor (0 -10): ______ Local anatômico: ________ Irradia? ( ) Sim ( ) Não Tipo de dor: O que piora a dor:____________________ ___________________________________ ___________________________________ O que melhora a dor: _________________ ___________________________________ ___________________________________

Sensibilidade (tipo/local) / Reflexo (local):__________________________________________ ____________________________________________________________________________ Propriocepção (sentido de posição/ cinestesia): ______________________________________ ____________________________________________________________________________ Coordenação motora:__________________________________________________________ Equilíbrio:____________________________________________________________________ Postura:________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________

Estágio Supervisionado Fisioterapia Gerontológica e Reumatológica I e II Amplitude de Movimento (ADM) e Força Muscular (FM): ADM Movimento

( ) Passiva D

( ) Ativa E

FM D

E

Marcha: _____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Testes especiais (ortopédicos):___________________________________________________ ______________________________________________________________________________ __________________________________________________________________________ DIAGNÓSTICO FISIOTERAPÊUTICO: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________. PROGNÓSTICO:______________________________________________________________ OBJETIVOS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________ PLANO DE TRATAMENTO: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ _______________________________ Carimbo e assinatura do estagiário

_____________________________ Carimbo e assinatura do supervisor...