FICHA DE ANAMNESE FACIAL

DADOS PESSOAIS:

NOME:_____________________________________________________________

ENDEREÇO:____________________________________________________________________
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TELEFONE:___________________________

PROFISSÃO:__________________________

EMAIL:______________________________

TELEFONE DE EMERGÊNCIA:_________________________

ANAMNESE

QUEIXA
PRINCIPAL:____________________________________________________________________
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HISTÓRICO DA DOENÇA
ATUAL:_______________________________________________________________________
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HISTÓRICO DA DOENÇA
PREGRESSA:___________________________________________________________________
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HISTÓRICO FAMILIAR:___________________________________________________________

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HÁBITOS:_____________________________________________________________________

Possui algum tipo de alergia?_________

Você costuma tomar sol?_________

Fez tratamento estético anterior?_______

Usa método anticoncepcional?__________

EXAME FÍSICO

A PELE APRESENTA PONTOS DE INFLAMAÇÃO?___________

POSSUI ACNE? EM QUE GRAU?_________________

LESÕES ACNEICAS AUTO MANIPULADAS PELO CLIENTE? ________________

CICATRIZES DE ACNE? ONDE?____________________

TEM PONTOS DE DESCAMAÇÃO OU RESSECAMENTO?

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PRESENÇA DE RUGAS E LINHAS?_______________________________________

FLACIDEZ? EM QUE AREAS:__________________________________________________

TRATAMENTO PROPOSTO
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TRATAMENTO HOME CARE PROPOSTO:

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RECOMENDAÇÕES ESPECIAIS:
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