Ficha de Anamnese

Dados Pessoais
Nome CPF

Como chegou a Bel Col?

Queixa principal

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Histórico

□ Tratamento estético □ Com ácidos:

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□ Cirurgia estética □ Outras cirurgias:

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□ Antecedentes alérgicos ___________________________________________________________________________________________________________________________________________

□ Alguma doença □ Diabete □ Pressão alta □ Outros: ____________________________________________________________________________

□ Patologia dermatológica ___________________________________________________________________________________________________________________________________________

□ Algum medicamento ___________________________________________________________________________________________________________________________________________

□ Método anticoncepcional ___________________________________________________________________________________________________________________________________________

□ Ciclo menstrual regular Data do ultimo ciclo:

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□ Reposição hormonal ___________________________________________________________________________________________________________________________________________

□ Gestante ___________________________________________________________________________________________________________________________________________

□ Filhos ___________________________________________________________________________________________________________________________________________

□ Dieta ___________________________________________________________________________________________________________________________________________

□ Ingere líquidos ___________________________________________________________________________________________________________________________________________

□ Esportes Frequência:
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□ Fumante ___________________________________________________________________________________________________________________________________________

□ Etilista (bebida alcoólica) ___________________________________________________________________________________________________________________________________________

□ Próteses □ Metalica □ Dentária □ Marcapasso □ Outros: ________________________________________________________

□ Problema nasal ou bucal ___________________________________________________________________________________________________________________________________________

□ Intestino regular ___________________________________________________________________________________________________________________________________________

□ Hereditariedade de acne ___________________________________________________________________________________________________________________________________________

□ Exposição ao sol □ Usa protetor solar:

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Hábito Alimentar
□ Legumes □ Verdura □ Fibras □ Carne vermelha
□ Frutas □ Refrigerante □ Doces/chocolates
Sistema Circulatório
□ Peso nas pernas □ Hematoma com facilidade □ Extremidades frias
□ Varises e/ou varicose □ Sensação de queimor
Alterações vasculares

□ Petéquias □ Cianose □ Eritema □ Telangiectasia □ Hematoma

Cuidados Diários com a Face:
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Com que sabonete costuma lavar a face? ____________________________________________________________________________________________________________

Usa filtro solar? Quantas vezes ao dia? _______________________________________________________________________________________________________________
Usa algum produto à noite? ___________________________________________________________________________________________________________________________

Manchas
□ Acromia □ Hipocromia □ Hipercromia
□ Efélides □ Cloasma □ Melasma
Formações sólidas

□ Pápula ____________________________________________________________________________________________________________________________________________________

□ Millium ____________________________________________________________________________________________________________________________________________________

□ Comedão aberto ____________________________________________________________________________________________________________________________________________________

□ Comedão fechado ____________________________________________________________________________________________________________________________________________________

□ Verruga ____________________________________________________________________________________________________________________________________________________

□ Nódulo ____________________________________________________________________________________________________________________________________________________

□ Sequela/Cicatriz ____________________________________________________________________________________________________________________________________________________

Características da Pele

Fototipo □ I □ II □ III □ IV □V □ VI
Flacidez □ Tissular □ Muscular
Acne □ Grau I □ Grau II □ Grau III □ Grau IV
Grau de oleosidade □ Normal □ Oleosa □ Mista □ Seca
Hidratação □ Hidratada □ Semi-hidratada □ Desidratada
Poros □ Dilatados □ Não dilatados
Espessura □ Fina □ Normal □ Espessa
Envelhecimento □ Leve □ Moderado □ Avançado □ Severo
Outros _______________________________________________________________________________________________________________________________________________________

Tratamento proposto/ Princípios Ativos

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Observações do Profissional

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Data / /
Assinatura do cliente Assinatura do Profissional