Anpolis, ______ de _____________________ de __________

AVALIAO FISIOTERAPUTICA
Paciente: __________________________________

Idade: _______

Queixa principal:
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Teste de risco de quedas:
Foi aplicado o TUG:
Valor de Referncia
< 20 seg baixo risco de quedas
20 a 29 seg mdio risco de quedas
>30 seg alto risco de quedas
Teste de alcance funcional:

Resultado

Valor de Referncia
Deslocamento < 15cm indicam fragilidade, risco
de quedas

Resultado

Teste de grau de fora:

Valor de referncia
0 paralisia total
1 esboo de contrao muscular
2 realiza o mov. sem a gravidade
3 realiza o mov. com a gravidade
4 mov. normal
com fora
diminuda
5 normal

Resultado MMSS (braos)

Resultado MMII (pernas)

Teste de Romberg
Equilbrio esttico

Resultado
Equilbrio dinmico

Teste de encurtamento muscular:

Resultado: _________________________________________________________________________
Reflexo patelar: _________________

Reflexo aquileu: _____________________________

Cordialmente,

Atendimento fisioteraputico
Paciente: __________________________________________________________________________
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