Académique Documents
Professionnel Documents
Culture Documents
Data de avaliao:___/____/____
1- Dados Pessoais
Nome:_____________________________________________________________________________
Data de nascimento:____/___/____
Idade:___________________________
Raa:____________________________
Escolaridade:___________________
Endereo:_______________________________________________________
Dispositivos auxiliares:
(
) cadeira de rodas (
) muletas axilar (
) muleta canadense
(
)Bengala (
) andador ( ) Outros:____________________________________________
2- Histria Clnica:
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3- Anamnese
HMA______________________________________________________________________________
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HMP______________________________________________________________________________
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Medicamentos em uso
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4- Exames complementares
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)Rx, ( )TAC, (
)RNM, (
)exames laboratoriais.
Resultados:______________________________________________________________________
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5- Exame fsico
a) Inspeo (estado geral, pele, deformidade, padres patologicos)
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b) Palpao (tnus, trofismo, clonus, edema)
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c) ADM: passiva e ativa
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6- Avaliao do tnus muscular
a) (
b) (
c) (
d) (
e) (
f) (
)Hipertonia (
) Leve (
)Hipotonia (
) Leve (
)Coria
)Atetose
)Mista
)Creo-atetose
) Moderada (
) Grave
) Grave
8- AVDs
Alimentao: (
) pastoso ( ) liquido ( ) auxiliado (
) independente
Lquidos: ( ) mamadeira ( ) copo ( ) auxiliado (
) independente
Higiene:
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9 Investigar
Viso: _____________________________________________________________________________
Audio:____________________________________________________________________________
Cirurgias:___________________________________________________________________________
Comunicao ( fala, gestos, uso dos olhos):
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10- Onde a criana esta? _______________________________________________________________
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b) Rolar:
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c) Sentar:_________________________________________________________________________
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PRONO
Postura Global:
a) Padres predominantes de atividade:
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b) Assimetrias:_____________________________________________________________________
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c) Alinhamento:
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Cabea
a) Linha mdia
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b) Vira E/D independentemente:
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Braos
a) Apoio nos antebraos:
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b) Suporte em braos estendidos:
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c) Suporte de peso mvel
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d) Libera um brao para o alcance
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Pernas
Movimentos independentes
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Sequencia de movimentos:
Rolar E/D:
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Pivotear E/D:
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Arrastar:
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Posio de quatro pontos com joelhos:
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Engatinhar:
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MANIPULAO:
Qualidade/ tipo de preenso
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Pegar/ soltar
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Sentada no cho
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Sentada na cadeira
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Ajoelhada
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Semi-ajoelhada
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a) Ps em paralelo
Padres de atividade
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b) Posio de passo
Alinhamento/ assimetria
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Balano
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c) Em p com apoio apenas em uma perna
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MARCHA
Padro
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Passos
Para frente
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Para os lados
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Para trs
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Dar o passo e parar
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Escadas
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CORRER:_______________________________________________________________________
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PULAR OBSTCULOS:
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SALTITAR:______________________________________________________________________
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13- REFLEXOS
Descrio das atividades reflexas.
1- Reflexo de voracidade ou dos quatro pontos cardeais (ou busca):
Inicio: RN
Termino: 1 ms
Estimulo: com um dos dedos na extremidade da rima bucal superior ou inferior dos lbios.
Resposta: a face se desloca ao agente estimulador.
2- Reflexo de extenso cruzada:
Inicio: RN
Trmino: 1 ms
Estmulo: na regio interna do MI, acima do malolo medial
Resposta: extenso com aduo de MMII.
3- Reflexo de socorro:
Inicio: RN
Trmino: 2 meses
Estmulo: colocar o RN em decbito ventral com a face numa superfcie
Resposta: o RN retira a face da superfcie procurando melhor posicionamento para respirar.
10-Reflexo de moro:
Inicio: RN
Termino: 4 meses
Estmulo: desestabilizao da cabea, cruzar os MMSS do RN e soltar bruscamente
Resposta: a criana responde com uma abduo, rotao dos braos, dos dedos e abertura da
boca.
11- Reflexo tnico cervical assimtrico (RTCA):
Inicio: o reflexo que marca o 2 ms
Trmino: 4 meses
Estmulo: vira a cabea da criana para um dos lados do corpo
Resposta: extenso dos MMSS para o lado em que a cabea foi virada e flexo dos MMSS
contra laterais.
12- Reflexo tnico cervical simtrico (RTCS):
Idade normal de resposta: 6 a 8 meses
Estmulo: posio da cabea em flexo e extenso
Resposta: quando a cabea esta em flexo, os MMSS so flexionados e os MMII estendidos.
Quando a cabea est em extenso os MMSS so estendidos e os MMII flexionados.