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FICHA DE AVALIAO FACIAL

BIOTIPO CUTNEO
( ) Eudrmica ( ) Lipdica (
ESTADO CUTNEO
( ) Normal
( ) Desidratado

) Alpica

) Mista

) Sensibilizado

) Acneico

) Seborreico

TEXTURA
(

) Lisa

) spera

ESPESSURA
( ) Fina ( ) Muito Fina

) Espessa

STIOS
(
) Dilatados na zona T

) Dilatados em toda Face

ACNE
(
) Grau I (

) Grau III

) Grau II

) Grau IV (

) Contrados

) Grau V

INVOLUO CUTNEA
(
) Linhas (
) Sulcos (
) Rugas (
) Elastose (
) Ptose
Local: ________________________________________________________________________
FOTOTIPO CUTNEO FITZPATRICK
(
) TIPO I (
) II (
) III (
) IV (

)V

FOTOENVELHECIMENTO ESCALA DE GLOGAU


(

) I (

) II

) III

) IV (

)V

Obs: ________________________________________________________________________

MANCHAS PIGMENTARES (MELANINA)


(
) Acromia (
) Eflides (
) Hipocromia (
) Melanose (
) Hipercromia (
) Melanose Solar
(
) Outros: _________________________________________________________________
ALTERAES VASCULARES
(
) Equimose (
) Petquias (
) Telangectasias (
) Eritrma
rubi (
) Roscea Outros:
_________________________________________________________________
LESES DE PELE

) /nevo

( ) Comedes (
) Ppula (
) Pstula ( ) Millium (
) Cisto ( ) Ndulo
(
) Siringoma
(
) Nevo Melanoctico ( ) Xantelasma (
) Dermatite ( ) Ulcerao (
)
Hiperqueratose
( ) Psorase ( ) Outros:__________________________________________________________
CICATRIZ
( ) Hipertrfica (
) Atrfica ( ) Queloideana (
) Retrtil ( ) Hipercrmica
(
) Hipocrmica
PELOS
( ) Hirsutismo (
) Hipertricose ( ) Alopcia (
) Foliculite
Objetivos: ___________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Tratamento Proposto:
__________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Observaes: ________________________________________________________________________
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