Valoración Fisioterapéutica

Datos del Paciente:

Nombres y apellidos: _____________________________________________

Edad: ___________Representante:___________________________________

Ocupación: ___________________________C.I:________________________

Dirección: _______________________________________________________

Teléfono: ________________Fecha:________________________________

Diagnóstico Medico:_______________________________________________

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Antecedentes:

Personales:____________________________________________________________

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_____________________________Familiares:________________________________

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Estudios Complementarios:

RX:___________________________________________________________________

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_________________________________________________RMN:________________

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________________________________________________________EMG:_________

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DENSITOMETRIA OSEA:__________________________________________

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OTROS:_______________________________________________________________

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Medicamentos:_________________________________________________________

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Anamnesis:

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Dolor:

Escala de caras (niños)

Observaciones:

Ubicación:_____________________________________________________________

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Características: _________________________________________________

Desencadenantes:______________________________________________________

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Atenuantes:____________________________________________________________

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 Exploración Física:

Observación general:
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Inspección y Palpación:
Estado de la piel y anexos:
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Movilidad del tejido:
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Cicatriz:
Dimensiones:____________________________________________________
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Temperatura de la zona:
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Edema:
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Medición de Perímetros :
Longitudinales
Miembros Superiores Aparentes Reales
MSD

MSI

Miembros Inferiores Aparentes Reales

MID

MII

Circunferenciales
Miembros Superiores Brazo Antebrazo
 MSD

MSI

Miembros Inferiores Muslo

Pierna
20 cmts. 10 cmts. 5 cmts.

MID

MII

Conclusiones:____________________________________________________
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Rangos Articulares (AMA)

Miembros Superiores

Miembro Flex. Ext. Abd. Ad. Rot Rot Supinación Pronación Desviación Desviación
Superior Int. Int. Radial Cubital

Hombro

Codo

Antebrazo

Muñeca
 MCF
II-V

IFP
II-V

IFD
II-V

CM Pulgar

MCF
Pulgar

IF
Pulgar

Miembros Inferiores

Miembro Flex. Ext. Abd. Ad. Rot. Rot. Inversión Eversión

Inferior Int. Int.

Cadera

Rodilla

Tobillo

MTF
Hallux

IF
Hallux
MTF
Pie

IFP
Pie

IFD
Pie

Observaciones:___________________________________________________
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Fuerza Muscular (FM) Gradación convencional

Grados Descripción en letras Amplitud del movimiento

N (Normal) Amplitud completa del móv. contra

5 gravedad y contra resistencia máxima

Amplitud completa del móv. contra

4 B (Bueno) gravedad y contra resistencia
moderada

Mas de la mitad de la amplitud del

4- B- móv. contra gravedad y contra
resistencia moderada.

Menos de la mitad de la amplitud del

móv. contra gravedad y contra
3+ R+ resistencia moderada
 Amplitud completa del móv. Contra la
3 R (Regular) gravedad

Mas de la mitad de la amplitud del

3- R-
móv. contra la gravedad.

M+ Menos de la mitad de la amplitud del

2+ móv. contra la gravedad

La amplitud completa del móv. sin

2 M (Malo) gravedad

Mas de la mitad de la amplitud del

2- M- movimiento sin gravedad

1+ T+ Menos de la amplitud del móv. Sin

gravedad

1 T (trazas o residual) Ninguna amplitud del móv. sin

gravedad y con una contracción
palpable o visible
Ninguna amplitud del móv. sin
0 0 (cero o nulo) contracción muscular palpable o visible

Miembros Superiores
Miembro
Superior Musc. Musc. Musc. Musc. Musc. Musc. Musc. Musc. Musc. Musc.
Flex. Ext. Abd. Ad. Rot. Rot. Supin. Prona. Desv. Desv.
Int. Ext. Radial Cubital

Hombro

Codo

Antebrazo

Muñeca

MCF
II-V
 IFP
II-V

IFD
II-V

CM
Pulgar

MCF
Pulgar

IF
Pulgar

Miembros Inferiores

Miembro Musc. Musc. Musc Musc. Musc. Musc. Musc. Musc.

Inversión Eversión
Inferior Flex. Ext. Abd. Ad. Rot. Rot.
Int. Int.

Cadera

Rodilla

Tobillo

MTF
Hallux
 IF
Hallux

MTF
Pie

IFP
Pie

IFD
Pie

Observaciones:___________________________________________________
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Región Cervical

Musculatura: FM

Flexora

Extensora

Rotadores Der.

Rotadores Izq.
Inclinadores Laterales Der.

Inclinadores Laterales Izq.

Tronco

Musculatura: FM

Flexora

Extensora

Rotadores Der.

Rotadores Izq.

Inclinadores Laterales Der.

Inclinadores Laterales Izq.

Postura
Vista anterior:
Cabeza: ______________________________________________________
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Hombros:_______________________________________________________
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Torax:__________________________________________________________
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Abdomen:_______________________________________________________
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Triangulo de la talla:_______________________________________________
EIAS:___________________________________________________________
Pelvis:__________________________________________________________
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Rodillas:________________________________________________________
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Pies:___________________________________________________________
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Vista Lateral:
Cabeza:_________________________________________________________
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Hombros:_______________________________________________________
Lordosis Cervical:_________________________________________________
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Cifosis Dorsal:____________________________________________________
Lordosis Lumbar:_________________________________________________
Torax:__________________________________________________________
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Abdomen:_______________________________________________________
Pelvis:__________________________________________________________
Rodillas:________________________________________________________
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Pie:____________________________________________________________

Vista Posterior:
Cabeza: ______________________________________________________
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Escapulas:______________________________________________________
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Columna:________________________________________________________
_______________________________________________________________:
Triangulo de la talla:_______________________________________________
EIPS:___________________________________________________________
Pelvis:__________________________________________________________
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Pliegues Glúteos:_________________________________________________
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Rodillas:________________________________________________________
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Pies:___________________________________________________________
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Pruebas Especiales:
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Deambulación y Marcha:

Observaciones:
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ABC:
Vestido: ________________________________________________________
Aseo: __________________________________________________________
Alimentación:____________________________________________________
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Sueño:__________________________________________________________
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Recreación:______________________________________________________
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Diagnóstico Fisioterapéutico: ________________________________________

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Pronostico:

Objetivos:
General:
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Específicos:
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 Plan de Tratamiento:
Indicado:
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Sugerido:
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 Evolución:

Fecha:______________________

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Firma del Ft.