FICHA DE AVALIAO

IDENTIFICAO
Nome:__________________________________________________________________________________
Idade:________
sexo
___________Profisso:_______________________Estado
Civil__________________
Endereo:_______________________________________________Bairro_________________________
_
Cidade:__________________________________________UF:____________CEP:___________________
_
Fone:________________________ e-mail____________________________________________________
Cor da pele: ( ) branca ( ) parda ( ) negra ( ) amarela
Peso:_____________Altura_______________
ANAMNESE
Queixa
Princaipal:______________________________________________________________________________
_
J
fez
tratamento
esttico
anteriormente?
(
)
sim (
)no Porque?
_______________________________________________________________________________________
Antecedentes
cirrgicos:___________________________________________________________________
Antecedentes
alrgicos:____________________________________________________________________
Pratica
esportes?
(
)
sim
(
)no
.
Qual?
________________________Freqncia:______________________
Faz
algum
tratamento
mdico?
(
)
sim
(
)no.
Qual?
_____________________________________________
Portador de marca-passo? ( ) sim ( )no
Apresenta metais no corpo? ( ) sim ( )no
Faz uso de medicamentos: base de corticides ( ) anti-histamnico( ) esterides( )
Antiinflamatrios( ) outros( ) no faz uso de medicamentos
Qual
mtodo
anticoncepcional
usa?
_________________________________________________________
Tem
antecedentes
ontolgicos?
_____________________________________________________________
Bebe?
(
)
sim
(
)no
frequncia:_______________________________________________________________
Fuma:
(
)
sim
(
)no
Freqncia______________________________________________________________
Tipo de alimentao: ( ) Normal ( ) vegetariana
Freqncia
de
ingesta
de
liquido
por
dia:______________________________________________________
Transtorno
circulatrio
e
/e
ou
de
cicatrizao?
(
)
sim
(
)
no______________________________________
Diabetes: ( ) sim ( ) no
Hemofilia: ( ) sim ( ) no
Propenso a quelides: ( ) sim ( ) no
Apresenta
algun
tipo
de
disfuno
hormonal?
__________________________________________________
Alergia a: ( ) corrente eltrica ( ) produtos
Cuidas
dirios
e
uso
de
produtos
cosmticos:
__________________________________________________
__________________________________________ _____________________________________________

Usa
ou
j
usou
acido
na
pele?
(
)
sim
(
)no
Qual?
______________________________________________
Apresenta
algum
tipo
de
disfuno
hormonal:
_________________________________________________
Nmero
de
gestaes:________
_______
Nmero
de
filhos_______________________________________
Menstruao: ( ) regular
( )irregular
Funcionamento
do
intestino?
(
)regulara
(
)
irregular
freqncia___________________________________
hipertenso? ( ) sim
( ) no
De
0
a10
qual
seu
nvel
de
estresse?
__________________________________________________________
EXAME FSICO
Adiposidade localizada: ( )presente ( ) ausente
Regio:__________________________
Edema : ( )presente ( ) ausente
Regio:__________________________
Micro varizes: ( )presente ( ) ausente
Regio:__________________________
Estrias: ( )presente ( ) ausente
Regio:__________________________
Fibroedemegeloide: Grau ( ) 1 ( )2 ( )3
Regio:__________________________
Evoluo
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