1. FICHA DE AVALIAÇÃO FISIOTERÁPICA EM UROGINECOLOGIA
Prontuário:___________________________ Data: ______________________
Nome:____________________________________________________ Idade: ______________
Data do nascimento: _______/_______/______ Estado civil: ____________________________
Peso: _________________ Altura: _______________ IMC: ____________________________
Profissão: _____________________________________________________________________
Endereço: _____________________________________________________________________
Bairro: _______________________________ Cidade: __________________________________
Estado:______________________________________ CEP: _____________________________
Telefones: _____________________________________________________________________
Diagnóstico Medico: _____________________________________________________________
Médico responsável: _____________________________________________________________
Diagnóstico Fisioterapêutico: ______________________________________________________
Exames complementares:
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Medicamentos em uso:
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Queixa principal:
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HMA/HMP:
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Antecedentes Pessoais:
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2. ______________________________________________________________________________
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Sintomas Urinários:
Perda urinaria:
( ) ao tossir ( ) ao espirrar ( ) erguer peso ( ) agachar
( ) ao caminhar ( ) ao esforço ( ) outras circunstâncias
Quais:_________________________________________________________________________
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Quando iniciou: _________________________________________________________________
Frequência urinária: _____________________________________________________________
Proteção utilizada: ( ) absorvente ( ) fralda ( ) outro
Qual: _________________________________________________________________________
Frequência de troca: _____________________________________________________________
Cirurgias: ______________________________________________________________________
Função intestinal: ( ) Incontinência Anal ( )Hemorroidas ( )Normal ( ) Outro
Qual:__________________________________________________________________________
Cirurgias:______________________________________________________________________
Antecedentes Ginecológicos:
DUM:__________________________ Menarca: ______________________________________
Menopausa:____________________________________________________________________
Tipos de parto: _________________________________________________________________
Cirugia ginecológica:_____________________________________________________________
DST: _________________________________________________________________________
Tipo de contraceptivo: ___________________________________________________________
Tempo: _______________________________________________________________________

3. INSPEÇÃO FÍSICA
Cicatrizes: _____________________________________________________________________
Trofismo vaginal: ________________________________________________________________
Força muscular: _________________________________________________________________
Sensibilidade: __________________________________________________________________
Testes especiais:
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Outros dados relevantes:
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Fisioterapeuta Responsável