Ficha de Avaliação de Neurologia

FICHA DE AVALIAÇÃO

Nome do Responsável:_____________________________________________________________________

Data da Avaliação:_______________________________   Local da Avaliação:_________________________

Identificação do(a) Paciente:

Nome:___________________________________________________________________   N° sessões:_____

Data de Nascimento:______________  Idade:___________   Sexo:________________   Raça:____________

Estado Civil:_______________________   Profissão:______________________________________________

Endereço:________________________________________________________________________________

Cidade:__________________________________________________________________________________

Telefone Resid:____________________________   Telefone Cel:____________________________________

Médico Responsável:_______________________________________________________________________

Diagnóstico clinico:________________________________________________________________________

Queixa Principal:__________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

História da Doença Pregressa(HDP):____________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

História da Doença Atual(HDA):_______________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

História Familiar:___________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

História Psicossocial:________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Medicação Administrada:____________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Sinais Vitais:  FC:____________________        FR:_____________________        PA:______________________

 -  Tipo Corporal:     (    ) Normal            (    ) Obeso            (    )  Sobrepeso         (    )  Caquético

 

Avaliação Funcional:

Exame Físico:

-  Inspeção Estática: ________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Inspeção Dinâmica: __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________

Palpação Óssea: ___________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Palpação de Tecidos Moles: __________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Testes Específicos do Segmento a ser Tratado: ___________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Testes de Mobilidade: ______________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dados Complementares:

Deformidades Instaladas: ____________________________________________________________________ _________________________________________________________________________________________

Uso de Órtese/Prótese: _____________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Exames Complementares (raio x, ECG, EMG, etc.): ________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________

Analise da Postura e da Marcha: ______________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Prova de Função Muscular: __________________________________________________________________  ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________