EVALUACIN NEURO-REHABILITACIN INFANTIL

ANTECEDENTES PERSONALES:
Nombre:_____________________________ Fecha Nacimiento: ____________________________
Edad Cronolgica: ______________________ Edad Corregida: __________________________
Direccin: ____________________________ __________________________________________
Telfono: _________________________________
Diagnstico: ______________________________________________________________________
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Parto: Normal ___ Cesrea ___ Uso Forcep ___Pre trmino ____ Trmino ____ Pos trmino ____
Alimentacin: _________________________________________________________________
Fecha Evaluacin: __________________________ Evaluador: _____________________________
Antecedentes Mrbidos: ____________________________________________________________
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Control de Esfnteres: Anal_____________ Vesical ____________ Uso de Sonda _____________
Tratamiento Farmacolgico: _________________________________________________________
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ANAMNESIS
Anamnesis Remota: _______________________________________________________________
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Anamnesis Prxima: _______________________________________________________________
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IMPRESIN GENERAL DEL PACIENTE
Uso de ayuda tcnica:
Silla de ruedas: _____ Andador:_____ Bastn: _____ No usa: _____ Otra: __________________
Elementos de ortopedia: ________________________________________________________
Estado del paciente:
Vigil: ________ Obnubilado: ________ Somnolencia: ________ Sopor: ________ Coma: ________
EVALUACIN ESTADO CONCIENCIA
Conexin: ________________________________________________________________________
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Respuesta a estmulos visuales: ______________________________________________________
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Respuesta a estmulos auditivos: _____________________________________________________
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Respuesta a rdenes simples y complejas: ______________________________________________
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ENTORNO SOCIAL
(Vivienda, accesibilidad, barreras arquitectnicas de su domicilio, locomocin colectiva, etc)
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EVALUACIN INICIAL
Estado de Salud General del Paciente: _________________________________________________
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Objetivo del Paciente: ______________________________________________________________
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EVALUACIN PSICOMOTORA
SUPINO
Cabeza (Gira, eleva contra la gravedad, logra lnea media, inclinada, Girada): _________________
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Extremidades Superiores (Logra lnea media, eleva, coje objetos, manipula, traspasa, cruza lnea
media): _________________________________________________________________________
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Tronco (Alineacin, transferencia de peso): _____________________________________________
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Pelvis (Anteversin, Retroversin): ___________________________________________________
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Extremidades Inferiores (Caderas, Rodillas, Pies, Movimientos espontneos, disociados/bloques): _
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GIRO
Secuencia (Bloque, Disociado, Caractersticas): __________________________________________
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PRONO
Cabeza (Gira, eleva contra la gravedad, logra lnea media, inclinada, Girada): _________________
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Apoyo de Extremidades Superiores (Caractersticas, Simetra)______________________________
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Tronco (Alineacin, transferencia de peso, centro de gravedad, superficie de apoyo, base de
sustentacin, carga de peso): ________________________________________________________

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Pelvis (Anteversin, Retroversin): ___________________________________________________
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Extremidades Inferiores (Caderas, Rodillas, Pies, Movimientos espontneos, disociados/bloques): _
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SEDENTE
(Logra por si slo, mantiene posicin, control de cabeza, tronco, carga de peso, posicin EESS, EEII,
Reacciones de proteccin, traccin a sedente; incluir sedente piernas extendidas y/o sobre banco)
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CUATRO APOYOS
(Logra por s solo, caracterstica de la posicin)
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GATEO
(Maduro, inmaduro, coordinado, simetra)
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TRASPASO A BPEDO
(Logra por si slo, uso de EESS, EEII, Transferencia de peso, etc)
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BPEDO
(Logra por s solo, mantiene, reacciones equilibrio, enderezamiento, proteccin)
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MARCHA
(Independiente, dependiente, Caractersticas de patrn segn fases)
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EVALUACIN ARTICULAR
(Limitaciones articulares, rango de movilidad pasiva, articulaciones inestables, riesgo de
deformidades, etc.)
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EVALUACIN DE LA SENSIBILIDAD SENSORIALIDAD PERCEPCIN
Sensibilidad Superficial: ____________________________________________________________
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Sensibilidad Profunda: _____________________________________________________________
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Visin: __________________________________________________________________________
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Audicin: ________________________________________________________________________
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Gnosias: _________________________________________________________________________
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Praxias: _________________________________________________________________________
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EVALUACIN DEL TONO:
(Incluir pruebas de Holding /Placing, Presencia de reacciones asociadas, descripcin de patrn,
Hipotona/ Hipertona, escala de Asworth)
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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: ___________________________________________________________________
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REFLEJOS PERSISTENTES
Moro: ___________________________________________________________________________
Prehensin Palmar: ________________________________________________________________
Prehensin Plantar_________________________________________________________________
Galant:__________________________________________________________________________

HALLASGOS CLNICOS
Impedimentos Primarios: ___________________________________________________________
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Impedimentos Secundarios: _________________________________________________________
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RAZONAMIENTO CLNICO (DIAGNSTICO KINSICO)
(Incluir Clasificacin Internacional de Funcionalidad CIF)
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OBJETIVO GENERAL
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OBJETIVOS ESPECFICOS
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OBJETIVOS OPERACIONALES
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PRONOSTICO FUNCIONAL
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EVOLUCIN
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Colaboracin: Profesor, Klgo. Juan Salas