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Faculdade Pitágoras Betim

AVALIAÇÃO FISIOTERAPÊUTIA !E RESPIRAT"RIAA#BULATORIAL

$ % !ados Pessoais&

'ome& _________________________________________________________ 

!ata 'ascime(to)& __/__/____   Idade& ____ Ra*a& __________  

Estado i+il& __________ Peso& ____ ,gAltura& _____ m I#& _______  

'aturalidade& ________________ Pro-iss.o/ocu0a*.o& _________________

E(dere*o& ______________________________________  EP& _______-____  Tele-o(es& (__)_____-______ / (__)_____-______ / (__)_____-______  

#1dico Res0)& __________________  !iag(2stico m1dico& ______________  

!iag(2stico Fisiotera03utico& ______________________________  

!ata a+alia*.o atual& ____/____/____ 

4 % A(am(ese&

5uei6a

Pri(ci0al:_________________________________________________

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7ist2ria da #ol1stia Atual:________________________________________

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 _______________________________________________________________ 

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8rau de !is0(eia de acordo com a Escala de !is0(eia de #R :_______________ 

Medicamentos em uso

Medicamento Dosagem Posologia

7ist2ria da #ol1stia Pregressa:____________________________________

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7ist2ria Familiar& ________________________________________________

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7ist2ria Psicossocial: ____________________________________________

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 _______________________________________________________________ 

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9 : #a(i-esta*;es Res0irat2rias Primárias&

Tosse:_________________________________________________________

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Expectoração:____________________________________________________ 

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Hemoptise:______________________________________________________ 

Dor Torcica:____________________________________________________ 

!"ieira Torcica:_________________________________________________

!ianose:________________________________________________________ 

Dispneia:_______________________________________________________ 

#utros:_________________________________________________________ 

9)$ : #a(i-esta*;es Res0irat2rias Secu(dárias&

$erais:_________________________________________________________ 

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Extratorcica:____________________________________________________ 

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< % E6ame F=sico&

%inais &itais: '!:____pmP:____*___mmHg '+:____irpm %p#,:____

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0ndice cintura-1uadril:______________________ 

.nspeção Esttica:

Torx:__________________________________________________________ 

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.nspeção Din2mica:

Padrão +espirat3rio:______________________________________________ _______________________________________________________________ 

+itmo:__________________________________________________________ 

 mplitude:_______________________________________________________ 

Es4orço:_________________________________________________________ 

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Data do exame: __/__/____ 

>)4 Radiogra-ia& _________________________________________________

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Data do exame: __/__/____ 

>)<

Es0irometria& _________________________________________________

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Data do exame: __/__/____ 

>)> Outros:______________________________________________________ 

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Data do exame: __/__/____

? % O@eti+os do tratame(to&  _______________________________________ 

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% o(duta Fisiotera03utica&

!urto PraBo:_____________________________________________________

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MCdio PraBo:____________________________________________________

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ongo PraBo:_____________________________________________________ 

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A+alia*.o Postural&

Vista A(terior& Vista Posterior&

Vista Lateral EsCuerda& Vista Lateral !ireita&

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E60a(si@ilidade Torácica&

Lo@os Su0eriores&

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Lo@o #1dio e l=(gula&

Lo@os I(-eriores&

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E6ames om0leme(tares&

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Tomogra-ia om0utadoriDada

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