Marcia Adrio-Briz

PROTOCOLO EVALUACIN PARLISIS FACIAL

Fecha:____/____/________

IDENTIFICACIN

Nombre:___________________________________________________________________

FN:____/____/_________ Edad:__________

Direccin:__________________________________________________________________
_____________________________________________________________________

Telfono:______________ Mvil:______________

Profesin:________________________________________________________________

DATOS MDICOS

Tipo PF:_________________________________________________________________

Etiologa:_____________________________________________________________

Escala House:__________________________________________________________

Exmenes
complementarios:___________________________________________________________
__________________________________________________________________________
_______________________________________________________________________

Tratamiento: ( ) Ciruga ( ) Farmacolgico ( ) Teraputico

Comentarios_______________________________________________________________
__________________________________________________________________________
_____________________________________________________________________
 Marcia Adrio-Briz

QUEJA

Inicio PF:______________________________________________________________

( ) Sbito ( ) Gradual

Sntomas:__________________________________________________________________
_____________________________________________________________________

Providencias:_______________________________________________________________
__________________________________________________________________________
______________________________________________________________________

SITUACIN ACTUAL

Mejora:________________________________________________________________

Oclusin ocular:_____________________________________________________________

Dificultad alimentacin:______________________________________________________

Alteracin gusto:__________________________________________________________

Datos
complementarios:___________________________________________________________
__________________________________________________________________________
______________________________________________________________________

OBSERVACIN EN REPOSO

Signos Total Parcial Normal

Abolicin arrugas frontales
Cejas cadas
Ojo cado
Desvo de nariz
Abolicin surco nasolabial
Desvo/depresin comisura labial
Labio superior cado
Labio inferior cado
Mejilla flcida
 Marcia Adrio-Briz

EVALUACIN MOVILIDAD

Msculo Grado Tono Sincinesia

Occiptofrontal
Corrugador
Procero, nasal y ELS
Orbicular ojos (parp)
Orbicular ojos (orb)
ELS, cigomticos
Risorio
Buccinador
Mirtiforme
Depresor labio inf
Depresor angulo
Mentoniano
Platisma

MENSURACIN

Medida Reposo Movimiento

Gap de ojo
Comisura labial-tragus
Ojo ext-comisura labial
Ojo int-comisura labial
Desvo labio derecho
Desvo labio izquierdo
Filtro nasal-filtro labial

CONCLUSIN:______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
______________________________________________________________________

EVALUADOR:_______________________________________________________________