Documente Academic
Documente Profesional
Documente Cultură
ANTECEDENTES PERSONALES:
Nombre:_____________________________ Fecha Nacimiento:
____________________________
Edad Cronolgica: ______________________ Edad Corregida:
_____________________________
Direccin:
________________________________________________________________________
Telfono: _________________________________
Diagnstico Mdico:
________________________________________________________________________________
________________________________________________________________________________
ANTECEDENTES PERINATALES:
Parto: Normal ___ Cesrea ___ Uso Forcep ___Pre trmino ____ Trmino ____ Pos
trmino ____
Alimentacin: _________________________________________________________________
Fecha Evaluacin: __________________________ Evaluador:
_____________________________
Antecedentes Mrbidos:
____________________________________________________________
________________________________________________________________________________
Control de Esfnteres: Anal_____________ Vesical ____________ Uso de Sonda
_______________
Tratamiento Farmacolgico:
_________________________________________________________
________________________________________________________________________________
ANAMNESIS
Anamnesis Remota:
_______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________________________
Anamnesis Prxima:
_______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________________________
EVALUACIN INICIAL
Estado de Salud General del Paciente:
_________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Objetivo del Paciente:
______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN PSICOMOTORA
SUPINO
Cabeza (Gira, eleva contra la gravedad, logra lnea media, inclinada, Girada):
_________________
________________________________________________________________________________
________________________________________________________________________________
Extremidades Superiores (Logra lnea media, eleva, coje objetos, manipula,
traspasa, cruza lnea media):
_________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Tronco (Alineacin, transferencia de peso):
_____________________________________________
________________________________________________________________________________
________________________________________________________________________________
Pelvis (Anteversin, Retroversin):
___________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Extremidades Inferiores (Caderas, Rodillas, Pies, Movimientos espontneos,
disociados/bloques): _
________________________________________________________________________________
________________________________________________________________________________
GIRO
Secuencia (Bloque, Disociado, Caractersticas):
__________________________________________
________________________________________________________________________________
________________________________________________________________________________
PRONO
Cabeza (Gira, eleva contra la gravedad, logra lnea media, inclinada, Girada):
_________________
________________________________________________________________________________
________________________________________________________________________________
Praxias:
_________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVALUACIN DEL DOLOR:
Zona del Dolor:
___________________________________________________________________
Dolor reposo (EV) 0___ 1___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 7 ___ 8 ___ 9 ___ 10 ___
Dolor Movimiento (EV) 0___ 1___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 7 ___ 8 ___ 9 ___ 10
___
Caractersticas:
___________________________________________________________________
________________________________________________________________________________
REFLEJOS PERSISTENTES
Moro:
___________________________________________________________________________
Prehensin Palmar:
________________________________________________________________
Prehensin
Plantar_________________________________________________________________
Galant:_________________________________________________________________________
_
HALLAZGOS CLNICOS
Impedimentos Primarios:
___________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Impedimentos Secundarios:
_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
RAZONAMIENTO CLNICO (DIAGNSTICO KINSICO)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Clasificacin Internacional de Funcionalidad CIF
DETERIORO
ESTRUCTURAL:
LIMITACIN
ACTIVIDAD
RESTRICCIN
PARTICIPACIN
FUNCIONAL:
OBJETIVO GENERAL
________________________________________________________________________________
________________________________________________________________________________
OBJETIVOS ESPECFICOS
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
OBJETIVOS OPERACIONALES
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PRONOSTICO FUNCIONAL
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EVOLUCIN
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________