domingo, 10 de março de 2013

Olá pessoal do 2o ano. Colei aqui um esboço de uma ficha de avaliação. Repito: É um esboço. Podem utilizar a vontade, mas saibam que não é a melhor, nem está completamente "fechada".

Até mais.

Andrey.




 
      Ficha de Avaliação em Ortopedia e Traumatologia
      Estágio Supervisionado – Curso de Fisioterapia                   
      Docente Responsável: Prof. Andrey Golias

1. Dados Pessoais
Nome:_______________________________ Idade:________ Sexo: F(  ) M(  )
Raça:_________________Profissão:_________________________________
Avaliação Médica:____________________ Data da Avaliação:____/____/____

2. Exame Subjetivo
2.1. QP:________________________________________________________
______________________________________________________________
2.2. HMA:_______________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
2.3. HMP:_______________________________________________________
______________________________________________________________
2.4. Tratamento Medicamentoso:_____________________________________
______________________________________________________________

3. Exame Objetivo
3.1. Inspeção geral:_______________________________________________
______________________________________________________________
3.2. Avaliação postural:____________________________________________
____________________________________________________________________________________________________________________________
3.3. Palpação:___________________________________________________
____________________________________________________________________________________________________________________________
3.4. Mobilidade (ADM):_____________________________________________
______________________________________________________________
____________________________________________________________________________________________________________________________
3.5. Extensibilidade/ flexibilidade:_____________________________________
____________________________________________________________________________________________________________________________
3.6. Força Muscular:______________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
3.7. Perimetria:__________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
3.8. Exame Neurológico:___________________________________________
______________________________________________________________
3.9. Avaliação Funcional:___________________________________________
____________________________________________________________________________________________________________________________
3.10. Avaliação da marcha:_________________________________________
____________________________________________________________________________________________________________________________
3.11. Testes Específicos:__________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
3.12. Laudos Clínicos e Exames:_____________________________________
______________________________________________________________
____________________________________________________________________________________________________________________________

4. Diagnósticos
4.1. Diagnóstico Clínico (transcrito do encaminhamento médico):____________
______________________________________________________________
4.2. Diagnóstico Fisioterapêutico:____________________________________
____________________________________________________________________________________________________________________________

5. Planejamento
5.1. Objetivos:___________________________________________________
______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5.2 Condutas:___________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5.3. Freqüência:__________________________________________________
______________________________________________________________
5.4. Prognóstico:_________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________

Acadêmico:_______________________________________________

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