FACULDADE SÃO LUCAS

CLÍNICA DE FONOAUDIOLOGIA

CLÍNICA DE DISFAGIA – HOSPITALAR AACD

PROTOCOLO DE AVALIAÇÃO
Data: _______/_______/_______

1) Paciente: ______________________________________________________________________
RG: _________________________ D. N.: _____/_____/_____ Idade: ______________________
Diagnóstico: _____________________________________________________________________
Telefone: ________________________________________________________________________

2) Histórico: _____________________________________________________________________
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Linguagem: ______________________________________________________________________
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3) Já fez terapia fonaudiológica?

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Outras terapia: ___________________________________________________________________
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4) Entubação S( ) N( ) Tempo _______________________________

Tubo de alimento S( ) N( ) Tempo _______________________________
Traqueostomia S( ) N( ) Tempo _______________________________
Respiração artificial S( ) N( ) Tempo _______________________________
Coma S( ) N( ) Tempo _______________________________
5) Crises Convulsivas: _____________________________________________________________
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6) Cirurgia de Cabeça e Pescoço? ____________________________________________________

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7) Medicação Atual:
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8) Quadro Respiratório:
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8.1) Padrão:
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8.2) Asculta Pulmonar:

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8.3) Asculta Cerical:

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9) Hipóxia:
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10) Infecções:
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11) Refluxos:
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12) Dieta:
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Peso atual: _______________________________________________________________________

13) Tempo de refeição:

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14) Utensílios utilizados:

Chupeta: ________________________________________________________________________
Líquidos: ________________________________________________________________________
Pastosos: ________________________________________________________________________
Sólidos: _________________________________________________________________________

15) Manobras utilizadas:

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Parte II
1) Reflexos S( ) N( ) Exacerbado _______________________
Procura S( ) N( ) Exacerbado _______________________
Mastigação S( ) N( ) Exacerbado _______________________
Mordida S( ) N( ) Exacerbado _______________________
Tosse S( ) N( ) Exacerbado _______________________
Palatal S( ) N( ) Exacerbado _______________________
Vomito S( ) N( ) Exacerbado _______________________

2) Sensibilidade:
Toque e Pressão
- Facial: _________________________________________________________________________
- Intra oral: ______________________________________________________________________
- Língua: ________________________________________________________________________
Gustação
- Paladar: (doce, salgado,amargo e azedo) ______________________________________________
- Sensação do paciente: ____________________________________________________________
- Hipersensível ( ) - Hiposensível ( ) - Normal ( )

3) Aspecto Geral da Musculatura:

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- Paralisia Facial:
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4) Escape de sialorréia:
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5) Mobilidade:
- Língua: ________________________________________________________________________
- Mandíbula: _____________________________________________________________________
- Lábios: ________________________________________________________________________
- Palato: _________________________________________________________________________

6) Disartria:
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7) Dispraxia:
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8) Dentição:
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9) Mastigação
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10) Episódios de engasgos e sufocamentos:
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11) Triagem vocal:

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11.1) Tempo Máximo de Fonação:

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11.2) Relação S/Z:

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11.3) Qualidade vocal:

Na fala Seca ( ) Molhada ( )
Após alimentação Seca ( ) Molhada ( )
Hipernasal ( ) Hiponasal ( ) Normal ( )

11.4) Agudos:
- Incompetente ( ) - Competente ( )

PARTE III
Avaliação Funcional da Alimentação:

1) Pastoso:
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2) Líquido:
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3) Sólido:
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 4) Sucção:
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Comentários Conclusivos

1) Observações:
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2) Hipótese Diagnóstica:
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3) Conduta e Encaminhamentos Necessários:

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Examinador Responsável: __________________________________________________________

Inscrição no Conselho: ____________________________________________________________