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Nome Completo:____________________________________________________________

Data de Nascimento:_________________ Idade: _________

Sexo:___________________________

Motivo da consulta: _______________________________________

Queixa principal

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Motivo

⃝ Dermatológica ⃝ Estética ⃝ Ambas

História da doença atual

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História familiar

⃝ HAS ⃝ DM ⃝ Tireoidopatia ⃝ Dislipidemia ⃝ Doenças de pele

⃝ Tumores de pele ⃝ Dislipdemia ⃝ Outros


História paolófica pregressa

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Tratamentos estéticos anteriores

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Alergias

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Exame dermatológico

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Tratamentos sugeridos

⃝ Limpeza de pele ⃝ Peeling

⃝ Toxina Botulínica ⃝ Trat. estético corporal

⃝ Preenchimento ⃝ Trat. facial

⃝ Sculptra ⃝ Criolipólise

⃝ Depilação a laser ⃝ Cirurgia plástica

⃝ Rejuv.a laser ⃝ Freezer

⃝ Trat. facial ⃝ Outros

⃝ Laser CO2

⃝ Led

⃝ Cirurgia dermatológica
Diagnóstico

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Observações

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Conduta

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