anamnese facial

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Nome:

DATA: ____/____/______ HORA: ___:___

Endereo: ________________________________________________________________

______________________________ Bairro _____________________________________

N__________ Cidade ________________________________ UF ___________________

Complemento _____________________________________________________________

__________________________________ E-mail _________________________________

Telefone: (___) _________________________ Celular: (___)________________________

DADOS DO CLIENTE

Estado Civil: Casado(a) Solteiro(a) Possui Filhos? Sim No ________________

Data de nascimento: ____/____/_____ Data da ltima menstruao: ___/____/______

Ciclo Menstrual: Regular Irregular H suspeita de gravidez? Sim No _____

Usa mtodos contraceptivos? Sim No Possui ovrios policsticos? Sim No

Faz reposio hormonal? Sim No Alguma disfuno da tireide? Sim No

Visita regularmente o ginecologista? Sim No Possui bons hbitos alimentaresfaz

alimentao balanceada? Sim No Alimentao: Hipercalrica Hiperglicmica

Hiperlipdica Hipersdica Funcionamento do Intestino Regular Irregular ___

Costuma dormir aps se alimentar? Sim No Caso afirmativo, qual tempo e a

frequncia? _______________________________________________________________

Ingesto diria de gua: Nenhuma Muito pouca Pouca Menos que 8 copos/dia

Mais que 8 copos/dia Ingesto de outros lquidos: Sucos Refrigerantes Chs

Caf Quantas vezes urina por dia? _____________________________ No sei

Faz uso de algum diurtico? Sim No Possui problemas renais? Sim No ____

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FICHA N _____________

CADASTRO N

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Possui problemas cardacos? Sim No Caso afirmativo, identifique quais a seguir:

Presso arterial: Alta Baixa Normal Obs.: _______________________________

Possui marca-passo? Sim No Obs.: _____________________________________

Apresenta algum problema circulatrio? Sim No Obs.: ____________________

Tem diabetes? Sim No Fez algum tratamento esttico anterior? Sim No

Em caso positivo, qual foi o tratamento e em qual data? ___________________________

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______________________________________________________Data: ____/____/_____

Costuma tomar sol? Sim No Usa prtese dentria? Sim No Utiliza algum

produto cosmtico? _______________________________________________________

Pratica alguma atividade fsica Sim No Caracterize a atividade fsica em: Leve

Moderada Intensa Quanto tempo dorme por dia? 8h/dia Menos de 8h/dia

Mais de 8h/dia Obs.: ___________________________________________________

Utiliza ou j utilizou algum cido? Sim No Qual: ________________________

Faz uso de algum psicotrpico? Sim No Usa lentes de contato? Sim No

Tabagismo: Sim No Frequncia: ______________________________________

J passou por interveno cirrgica? Sim No Caso afirmativo, quais e em qual pe-

rodo da vida: ______________________________________________________________

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Faz algum tratamento mdico no momento? Sim No Caso afirmativo, informe o

tratamento: _______________________________________________________________

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Possui antecedentes oncolgicos? Sim No Obs.: __________________________

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Alguma doena no mencionada? _____________________________________________

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AVALIAO DA PELE

CARACTERSTICAS CUTNEAS

MANCHAS PIGMENTARES RELACIONADAS MELANINA

MANCHAS POR ALTERAES VASCULARES

FORMAES SLIDAS

FORMAES COM CONTEDO LIQUDO

LESES DE PELE

SEQUELAS

PELOS

ALTERAES DE QUERATINIZAO

CLASSIFICAO DO FOTOTIPO CUTNEO

QUANTO HIDRATAO

QUANTO AO GRAU DE OLEOSIDADE

QUANTO ESPESSURA

PRESENA

ACROMIA CLOASMA EFLIDES HIPERCROMIA

HIPOCROMIA

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ANGIOMA CIANOSE ERITEMA HEMATOMA

TELEANGECTASIAS

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CERATOSE PPULAS NDULOS VERRUGAS

MILLIUM NECROSE COMEDO

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BOLHA PSTULA VESCULA

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CROSTA DESCAMAO ESCARA FISSURA FSTULA

ESCORIAO ULCERAO

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ATROFIA CICATRIZ

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HIPERTRICOSE HIRSUTISMO

ECZEMA HIPERQUERATOSE PSORASE

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FOTOTIPO I FOTOTIPO II FOTOTIPO III FOTOTIPO IV

FOTOTIPO V FOTOTIPO VI

DESIDRATADA NORMAL

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ALPICA LIPDICA NORMAL SEBORREICA

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ESPESSA FINA MUITO FINA

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TRATAMENTOS E DETALHAMENTO CALENDRIO

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SEG TER QUA QUI SEX SB DOM

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PLANO DE TRATAMENTOS

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OBSERVAES DO PROFISSIONAL ESTETICISTA

OBSERVAES: ____________________________________________________________

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ASSINATURAS

CIDADE:__________________________________________UF______ DATA: ____/____/______

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CLIENTEN DO RG________________________

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PROFISSIONAL ESTETICISTA

anamnese facial

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