FICHA DE AVALIAÇÃO FISIOTERAPÊUTICA – NEUROMUSCULAR II
Data da avaliação: ____/____/____
Aluno: ________________________________________________________________________________________
DADOS PESSOAIS:
Nome: _______________________________________________________________________________________
Gênero: ( ) F ( ) M
Idade:__________________ Escolaridade: _________________________________
Nome do acompanhante:__________________________________________________________________________
INFORMAÇÕES CLÍNICAS:
Diagnóstico clínico: _____________________________________________________________________________
Diagnóstico fisioterapêutico: ______________________________________________________________________
Uso de medicamento: ( ) Não
( ) Sim...........Qual? ______________________________________________
Terapias concomitantes: ( ) Não
( ) Sim...........Qual? ______________________________________________
H.M.A.:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
QUEIXA PRINCIPAL:___________________________________________________________________________
DESENVOLVIMENTO MOTOR NORMAL:
Marcar todas as habilidades que o paciente apresenta:
( ) controle de cabeça ( ) controle de tronco
( ) senta
( ) ajoelhado
( ) semi-ajoelhado
( ) em pé
( ) arrasta
( ) marcha com apoio
( ) engatinha
( ) marcha sem apoio
AVALIAÇÃO DO TÔNUS:
( ) Normotonia ( ) Hipotonia
( ) Ataxia (hipotonia proximal)
( ) Atetose
( ) Espasticidade Graus
Classificação da espasticidade (Escala de Ashworth Modificada)
0
Sem aumento do tônus muscular
1
Leve aumento do tônus muscular (mínima resistência ao final do arco de movimento)
1+
Leve aumento do tônus muscular (leve resistência em aproximadamente 50 % do arco de movimento)
2
Moderado aumento do tônus muscular (em todo o arco de movimento e os segmentos comprometidos têm
fácil movimentação)
3
Considerável aumento do tônus muscular e difícil movimentação passiva dos segmentos comprometidos
4
Rigidez em flexão ou extensão
( ) MS direito
( ) MS esquerdo
( ) MI direito
( ) MI esquerdo
TROFISMO:
( ) Normotrofia
( ) Hipotrofia
Local: _________________________________________________________________________
( ) Hipertrofia
Local: _________________________________________________________________________
ALTERAÇÕES POSTURAIS:
Anterior
Lateral
Posterior
CONDIÇÕES MUSCULARES:
Força
Músculos
Tríceps sural
Tibial anterior
Isquiotibiais
Quadríceps
Abdutores de quadril
Adutor de quadril
Íliopsoas
Glúteo máximo
Rombóides
Quadrado lombar
Peitoral maior
Peitoral menor
Grande dorsal
Trapézio superior
Escalenos
ECM
Deltóide anterior
Deltóide médio
Deltóide posterior
Bíceps braquial
Tríceps braquial
Pronadores
Supinadores
Flexores de punho
Extensores de punho
Flexores de dedos
Extensores de dedos
Reto abdominal
Paravertebrais
Graduação
0
1
2
3
4
5
DIREITO
Classificação da FORÇA MUSCULAR
Ausência de contração
Esboço de contração
Contração a favor da gravidade
Contração contra a gravidade
Movimento contra a gravidade e
resistência moderada
Movimento contra a gravidade e
resistência acentuada
ESQUERDO
Graduação
+
++
+++
Alongamento
DIREITO
ESQUERDO
Classificação do ALONGAMENTO
MUSCULAR
Ausência de encurtamento
Encurtamento de até 25% do arco de
movimento (leve)
Encurtamento de até 50% do arco de
movimento (moderado)
Encurtamento de mais de 50% do arco de
movimento (grave)
SENSIBILIDADE:
( ) Normoestesia
( ) Hiperestesia Local: __________________________________________________________________________
( ) Hipoestesia Local: __________________________________________________________________________
( ) Anestesia
Local: __________________________________________________________________________
EQUILÍBRIO: (Graduação: 1 = Presente; 2 = Alterado; 3 = Ausente)
Estático: ( ) Dois pés
( ) Um pé
( ) Romberg
Dinâmico: Marcha ( )
COORDENAÇÃO: (Graduação: 1 = Presente; 2 = Alterado; 3 = Ausente)
( ) Index-index
( ) Index-nariz
( ) Calcanhar-joelho
( ) Diadococinesia
( ) Eumetria
REFLEXOS TENDINOSOS: (Graduação: 1 = Presente; 2 = Hiporreflexia; 3 = Hiperreflexia; 4 = Ausente)
( ) Bicipital
( ) Tricipital
( ) Patelar
( ) Aquileu
MARCHA:
( ) Ceifante
( ) Atáxica
( ) Tesoura
( ) Escarvante
( ) Anserina
( ) Estepante
( ) Festinante
( ) Digitígrada
( ) Outra: _________________
Descrição da marcha: (descrever somente os padrões que estiverem alterados nas respectivas fases da marcha):
Fase de apoio:
Inicial: _____________________________________________________________________________________
Médio: _____________________________________________________________________________________
Final: ______________________________________________________________________________________
Fase de balanço:
Inicial: _____________________________________________________________________________________
Médio: _____________________________________________________________________________________
Final: ______________________________________________________________________________________
ATIVIDADES DE VIDA DIÁRIA QUE O PACIENTE REALIZA:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
LIMITAÇÕES FUNCIONAIS DE MAIOR RELEVÂNCIA:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
USO DE ÓRTESES E EQUIPAMENTOS AUXILIARES:
( ) Não
( ) Sim - Quais? _____________________________________________________________________
INFORMAÇÕES COMPLEMENTARES:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
OBJETIVOS DE TRATAMENTO:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
CONDUTA:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Assinatura do aluno: ______________________________________________________________________________
Assinatura do supervisor: __________________________________________________________________________