CLINICAL AND ESTHETIC RECORD

Reason for consultation: ...............................................................

Diagnosis: ..........................................................................

Treatment: .........................................................................

Sessions: ........................................Session No.: ......................

PERSONAL BACKGROUND:

Name: ..............................................File number:.....................

Address: ............................................................................

Contact phone: ...........................email:...........................

Date of birth: ...........................Edad...........................

Occupation or trade: ................................................................

Number of children: ..........................................Type of

delivery: .....................

MEDICAL HISTORY:

Diseases: ......................................................................

Medications you are currently taking: .......................................

History of chronic diseases: .......................................

Surgical history: .......................................................

Use of Implants or devices.................Type: .........................

Allergies: ..............................................................................
 OTHER DATA

Hobbies: ..............................................................................

Physical activity or sport: ........................... Frequency: ............

Feeding: ........................................................................

Harmful Habits:

Cigar consumption: .............................................................

Alcohol Consumption: .............................................................

Drug use: .....................................................................

Sleeping hours........................Sleep type: .........................

Remarks: .....................................................................

SIGNATURE..................................

REDUCTIVE TREATMENT MEASURES (CMS)

DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8

HIGH
ABDOMEN

WAIST

ABDOMEN
UNDER

HIPS