Escolar Documentos
Profissional Documentos
Cultura Documentos
INDENTIFICAO
Nome: ____________________________________________Idade_______ sexo: ( ) F ( ) M
Estado civil:
____________________________Profisso:___________________________________________
Data da avaliao: _____/______/______
ANAMNESE
Q.P.:_________________________________________________________________________
Consome bebida alcolica: ( ) No ( ) Sim, ( ) Diariamente ( ) Frequentemente ( )
ocasionalmente.
Fuma: ( ) No ( ) Sim. ( )1 5 dia ( ) 5 a 10 dia ( ) mais de 10 ao dia
Gravidez: ( ) No ( ) Sim Est em acompanhamento medico ?
______________________________________
Distrbios endcrino-metablico: ( )No ( )Sim,
qual(is):__________________________________________
Uso de medic amentos: ( )No ( )Sim, qual (is):________________________Tempo de
uso:____________
Histrico cirrgico
___________________________________________________________________________
ANALISE CAPILAR:
Comprimento: ___________________tipos de cabelos:
_____________________________________________
Textura: ________________________ Densidade:
_________________________________________________
Porosidade: _____________________Elasticidade:
_________________________________________________
Curvatura: ______________________ Origem:
____________________________________________________
Patologias do couro cabeludo: ( ) Pitriase Capites ( )Dermatite Seborreica ( )
Psorase ( )Pediculose
( ) alopecia areata
Tricoses: ( ) pili annulati ( ) Moniletrix ( ) pilitorti ( ) tricorrexe nodosa ( )
tricoptlose ( ) outros
Porcentagem de cancie:
______________________________________________________________________
Cor natural:
___________________________Extenso:______________________________________________
Cor
cosmtica:__________________________Exteso:_____________________________________________
_
Alisamento: ( )Sim ( )No Tempo de uso?
_____________________________________________________
Descolorao: ( )sim ( )No ( )parcial ( )Total
HISTRICO QUIMICO:
Tratamento
Alteraes de cor
Alteraes de forma
Manuteno utilizada:
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________
Faz algum tratamento capilar: ( )Sim ( )No qual
(is ):____________________________________________
Faz uso de condicionador: ( )Sim ( )No
Faz uso de leving: ( )Sim ( )No Frequncia?
___________________________________________________
DIAGNOSTICO:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________
OBJETIVO, PROCEDIMENTO, TERAPUTICA DE TRATAMENTO E PRESCRIO DOMICILIAR:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________Aluno(a)
Responsavel:________________________________________________________________________
FICHA DE EVOLUO
DATA:
DATA:
( )RETORNO /
( )RETORNO /
DATA:
( )RETORNO /
DATA:
ASSINATURA DO CLIENTE:
RBRICA DAS(OS) ALUNAS(OS):
PROCEDIMENTO