Dra.

Nome do Fisioterapeuta
CREFITO:

Ficha de avaliação Fisioterapêutica Pediátrica

IDENTIFICAÇÃO:

Nome:________________________________________________________________
Data de nascimento: ____/_____/_____ Sexo: F( ) M ( )
Idade:________ raça:_______________ peso: ________ altura:_________
Naturalidade:__________________ Procedência:____________________________
Nome do responsável_____________________________________________________
Endereço:_____________________________________________________________
Data da admissão: ____/_____/_____ Data da avaliação: ____/_____/_____

ANAMNESE
QP:____________________________________________________________________

HDA:__________________________________________________________________
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HPP/
HF:____________________________________________________________________
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História do parto, gestação e pós-parto:______________________________________

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História do desenvolvimento:_______________________________________________
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ALimentação:__________________________________________________________________
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EXAME FÍSICO
SINAIS VITAIS

FC: ________ bpm FR:________ irpm Tax: ______° C

INSPEÇÃO______________________________________________________________
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PALPAÇÃO______________________________________________________________
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OBS:___________________________________________________________________
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AVALIAÇÃO RESPIRATÓRIA

AP:____________________________________________________________________
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TIPO DE TÓRAX:__________________________________________________________
PADRÃO RESPIRATÓRIO:___________________________________________________
SINAIS DE DESCONFORTO RESPIRATÓRIO:_____________________________________
PERCUSSÃO DO TÓRAX:___________________________________________________
OBS:___________________________________________________________________
_______________________________________________________________________

AVALIAÇÃO NEUROLÓGICA

Tônus Muscular:_________________________________________________________
Coordenação e equilíbrio__________________________________________________
Sensibilidade:___________________________________________________________
Reflexos superficiais:______________________________________________________
Reflexos profundos:______________________________________________________
Outras Informações:______________________________________________________
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AVALIAÇÃO TRAUMATO-ORTOPÉDICA______________________________________________

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Exames complementares
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DIAGNÓSTICO CLÍNICO:__________________________________________________________
DIAGNÓSTICO FISIOTERAPÊUTICO:________________________________________________
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CONDUTA TERAPEUTICA:
_____________________________________________________________________________
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Cidade,________/__________/_______

Assinatura e carimbo do profissional

_______________________

Nome do profissional

CREFITO-4/ 00.000F