AVALIAÇÃO NEUROLOGIA ADULTO:

DATA:____/___/______

1.Dados Pessoais:
Nome:__________________________________________________________________
Data de nascimento: ____/____/____
Idade:__________________________________
Diagnóstico Clínico:____________________________________________Data da
lesão:________________________

[Digite o nome da empresa]

Diagnóstico
Fisioterápico:______________________________________________________________________
_____
Escolaridade:________________________________________Profissão:______________________
______________
Responsável:__________________________________________________Telefone:_____________

2. H.M.A:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

3. QUEIXA
PRINCIPAL:_______________________________________________________________________
_________________________________________________________________________________

4. Doenças Associadas e Medicamentos :

_________________________________________________________________________________
_________________________________________________________________________________

5. Exames
Complementares:__________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________

6. Cirurgias e Complicações (sondas, gastro, etc):

 _________________________________________________________________________________
_________________________________________________________________________________

7.Tratamento
Multiprofissional:__________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

8. AVP: Atividades de Vida Prática (Hobby e Rotina):

_________________________________________________________________________________
_________________________________________________________________________________

9. Órteses/Dispositivos de Marcha/Cadeira rodas:

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
[Digite o nome da empresa]

10.
OBS:_____________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

11. Avaliação Física: PA:___________________

Inspeção:______________________________________________________________________
______________________________________________________________________________
____________________________
______________________________________________________________________________
______________

Tônus Muscular: Escala Modificada de Ashworth ( graduação da espasticidade )

MMSS:________________________________________________________________________
______________________________________________________________________________
MMII:_________________________________________________________________________
______________________________________________________________________________

Trofismo
Muscular:_____________________________________________________________________
2
ADM:
MMSS:________________________________________________________________________
______________________________________________________________________________
 MMII:_________________________________________________________________________
______________________________________________________________________________

Reflexos:______________________________________________________________________
______________________________________________________________________________

Força Muscular:

Pescoço:_________________________________________________________________________

Tronco:__________________________________________________________________________

_________________________________________________________________________________

[Digite o nome da empresa]

Grupos Musculares D E

MMSS

MMII

Encurtamentos musculares, retrações, deformidades e alterações posturais:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Movimentos
Involuntários:___________________________________________________________________

3
 Atividades Motoras:
a) Supino:
_________________________________________________________________________________
_________________________________________________________________________________
b) Rolar:
_________________________________________________________________________________
_________________________________________________________________________________
c) Prono:
_________________________________________________________________________________
_________________________________________________________________________________
d) Sentar:
_________________________________________________________________________________
_________________________________________________________________________________
e) Gato/Ajoelhado/Semi-ajoelhado:
_________________________________________________________________________________
_________________________________________________________________________________
f) Bípede:
_________________________________________________________________________________
[Digite o nome da empresa]

_________________________________________________________________________________

g) Marcha:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

h) Rampas e escadas:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Coordenação:

MMSS:___________________________________________________________________________

_________________________________________________________________________________

MMII:_____________________________________________________________________________

_________________________________________________________________________________

Equilibrio:

Estático:__________________________________________________________________________

_________________________________________________________________________________

Dinâmico:________________________________________________________________________
4 _________________________________________________________________________________

Sensibilidade:
Térmica: _________________________________________________________________

Dolorosa:_________________________________________________________________

Tátil:_____________________________________________________________________

Avaliação
Respiratória:______________________________________________________________________

_________________________________________________________________________________

AVD's (Alimentação, Higiene, Vestuário, Locomoção):

[Digite o nome da empresa]

_________________________________________________________________________________
_________

_________________________________________________________________________________
_________

_________________________________________________________________________________
_________

Observações Gerais (cognitivo, visão, audição, linguagem):

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

11- Programa de Tratamento:

Objetivos:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5

Condutas:
_________________________________________________________________________________
 _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
[Digite o nome da empresa]