FICHA DE AVALIAO ORTOPDICA

Estagirio______________________________ Data da Avaliao: ____/_____/_____

Nome:_________________________________________________________ Idade:_________________

Data de nascimento:___________ Sexo:_________________ Estado civil:_________________________

Profisso:__________________________________________Telefone:____________________________Endereo:___________________________________________ Cidade:___________________________

Diagnstico Clnico:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Queixa Principal:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HMA:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Possui Antecedentes Familiares:___________________________________________________________Possui alterao de sensibilidade? _________________________________________________________

Possui alteraes viscerais? Bronquite, pneumonia, clculo renal, clculo na vescula, infeces, problemas intestinais, etc_________________________________________________________________

_____________________________________________________________________________________

J sofreu traumas? Acidentes de carro,Toro de tornozelo, quedas, etc. __________________________

_____________________________________________________________________________________

Altura:__________Peso:_______Sinais Vitais: FC:______ Presso:___________ FR:______________

Medicamentos Utilizados:____________________________________________________________________________________________________________________________________________________Utiliza andador, muleta ou cadeira de rodas?_______________________________________________

H quanto tempo est com dor? Local da dor? ______________________________________________________________________________________________________________________________

A dor irradiada? Para onde?_____________________________________________________________Algum movimento/posio piora ou melhora a dor?____________________________________________Possui patologias associadas, cirurgias, fraturas, pinos ou placas metlicas?________________________

_____________________________________________________________________________________

Exame Fsico:

Inspeo local:_________________________________________________________________________ _____________________________________________________________________________________Palpao:__________________________________________________________________________________________________________________________________________________________________ADM e Fora Muscular:

MEMBRO SUPERIORMEMBRO INFERIOR

AtivaPassivaForaAtivaPassivaFora

MdiaDEDEDEMdiaDEDEDE

OmbroExtenso45QuadrilExtenso10

Flexo180Flexo125

Abduo180Abduo45

Aduo40Aduo10

Rotao Lat.90Rotao Lat.45

Rotao Med.70Rotao Med.45

CotoveloExtenso0JoelhoExtenso0

Flexo145Flexo140

AntebraoSupinao90TornozeloFlexo Plantar45

Pronao90Dorsiflexo20

PunhoExtenso70PInverso40

Flexo80Everso20

Desvio Ulnar45

Desvio Radial20

Apresenta dor em algum movimento? Qual ngulo da dor? ___________________________________________________________________________________________________________________________

Possui encurtamentos musculares? Quais msculos?__________________________________________

_____________________________________________________________________________________

Avaliao Postural:DE

Calcneo valgo

Calcneo varo

P plano

P cavo

Joelho valgo

Joelho varo

EIAS mais elevada

Ombro anteriorizado

Cabea anteriorizada

Anteverso plvica

Retroverso plvica

Hipercifose

Mobilidade de TroncoDE

Inclinao lateral

Rotao

Flexo

Extenso

DE

Mobilidade Cervical

Inclinao lateral

Rotao

Flexo

Extenso

Testes Especiais:

TesteResultado

Alteraes em Exames Complementares:____________________________________________________

_____________________________________________________________________________________Diagnstico Fisioteraputico:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Objetivos do Tratamento Fisioteraputico (enumerar):

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Conduta / Recurso Fisioteraputico com Parmetros e Srie____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________

Nome do Acadmico Supervisor de Estgio