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Identificação do Paciente: Data da Avaliação: ____ /____ /______ Voluntário Número: ___________ Nome do Paciente: _____________________________________________________________________ Data de Nascimento: ____/____/ ______ Idade:_______________anos Lado Dominante: _____________

Dor: ( ) unilateral – ( )D ( )E ( ) bilateral

Anamnese: Queixa/Principal:_______________________________________________________ __ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ______ História da Dor: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ________ Local da Dor:

 Escala Visual Analógica (no último mês e no momento):

- Presença de dor na articulação patelofemoral no último mês?

( )sim ( )não ( ) difusa ( ) Localizada - Dor no joelho em atividades funcionais:

( ) Ao permanecer muito tempo sentada ( ) subir escadas ou descer escadas

( ) Agachar por tempo prolongado ( ) Correr

( ) ajoelhar-se ( ) contração isométrica de quadríceps

( ) praticar esportes

- História de Lesão ou Trauma: ( ) Sim ( ) Não Local: ______________________________________ Faz uso de Medicamentos: ( ) Sim ( ) Não

Qual (is):___________________________________ Realiza atividade Física: ( ) Sim ( ) Não

Modalidade: __________________________________ Frequência: __________dias/semana

Realizou alguma cirurgia: ( ) Sim ( ) Não

Local: _______________________________________ Realizou tratamento Fisioterapêutico: ( ) Sim ( ) Não Local: _______________________________________ Exame físico: Avaliação Antropométrica: Peso: _______Kg Altura: _______cm Testes Especiais Tibiofemoral

Joelho Direito Joelho Esquerdo

Stress Valgo ( ) S ( ) N ( ) S ( ) N

Stress Varo ( ) S ( ) N ( ) S ( ) N

Gaveta Anterior R, Neutra ( ) S ( ) N R, Neutra ( ) S ( )N Gaveta Posterior R, Neutra ( ) S ( ) N R, Neutra ( ) S ( )N Teste de Lackman ( ) S ( ) N ( ) S ( ) N Appley ( ) S ( ) N ( ) S ( ) N Patelofemoral Direita Esquerda Normal ( ) S ( ) N ( ) S ( ) N Hipermóvel ( ) S ( ) N ( ) S ( ) N Hipomóvel ( ) S ( ) N ( ) S ( ) N Presença de Crepitação ( ) S ( ) N ( ) S ( ) N Alta ( ) S ( ) N ( ) S ( ) N Medializada ( ) S ( ) N ( ) S ( ) N Lateralizada ( ) S ( ) N ( ) S ( ) N

Palpação das facetas Apreensão/ deslocamento

Teste de Clarke (resistir o mov, da patela ao solicitar a contração do quadríceps) Teste de Compressão de Noble ( TIT)

Avaliação do alinhamento postural Medidas do Ângulo Q (deitada):

 MI Direito: _________graus MI Esquerdo: ________graus Anteversão Femoral  Direita: ________ graus  Esquerda: _______ graus Avaliação da flexibilidade MI Direito MI Esquerdo Quadriceps ( Ely) Isquiotibiais

Banda trato/ilio ( Ober)

Avaliação da força muscular

1ª Repetição 2ª repetição Extensão do quadril

Abdução do quadril Rotadores Laterais

Anexo 4

Escala de Atividades de Vida Diária (EAVD)

Paciente: _______________________________________________________

Diagnóstico: _____________________________________Data: ___

Instruções:

O seguinte questionário foi formulado para que você possa demonstrar, os sintomas e limitações que apresenta no joelho enquanto você faz atividades de vida diária, Por favor, assinale uma única resposta, ou seja, a que melhor descreve

esses sintomas e limitações nos últimos um ou dois dias (1 ou 2 dias), Para uma

mesma pergunta, mais de uma resposta poderia servir, no entanto, assinale apenas aquela que melhor represente as dificuldades sentidas em sua atividade de vida diária,

Sintomas

O quanto cada um desses sintomas afeta sua atividade de vida diária? Marque uma resposta em cada linha,

Eu não tenho o sintoma Tenho o sintoma porém não afeta minhas atividades O sintoma afeta levemente minhas atividades O sintoma afeta moderadamente minhas atividades O sintoma afeta extremament e minhas atividades O sintoma impede realizar qualquer das minhas atividades diárias Dor Rigidez / Travamento Inchaço Instabilidade (falta de firmeza) Fraqueza Mancar

Limitações Funcionais nas Atividades Diárias

Como o seu joelho afeta sua capacidade de ,,,, (marque uma resposta em cada linha)

Não

dificulta minimamente Dificulta às vezes Dificulta moderadamente Dificulta Dificulta muito Impede de realizar Andar? Subir escadas? Descer escadas? Ficar em pé? Ajoelhar? Agachar-se? Sentar com os joelhos dobrados a 90°? Levantar de uma cadeira?

Que nota você daria para a atual função de seu joelho durante suas atividades de vida diária numa escala de 0 a 100? Considere a nota 100 a medida de seu joelho antes da lesão / trauma, e a nota 0 a total incapacidade de realizar qualquer atividade de sua rotina diária,

Nota:

Qual das seguintes alternativas melhor descreve as funções gerais de seu joelho durante sua atividade de vida diária? (marcar apenas uma resposta)

( ) Normal

( ) Quase Normal ( ) Anormal

( ) Extremamente Anormal

Sua lesão / trauma no joelho afeta sua atividade durante as atividades de vida diária? Classifique seu atual nível de atividade: (marcar apenas uma resposta)

( ) Normal

( ) Quase Normal ( ) Anormal

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