Dados Pessoais

Nome CPF

Como chegou a Bel Col?

Histórico

□ Tratamento estético _____________________________________________________________________ □ Com ácidos: _______________________________________________

□ Cirurgia estética ____________________________________________________________________ □ Outras cirurgias: __________________________________________

□ Antecedentes alérgicos ___________________________________________________________________________________________________________________________________________

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

□ Patologia dermatológica ___________________________________________________________________________________________________________________________________________

□ Algum medicamento ___________________________________________________________________________________________________________________________________________

□ Método anticoncepcional ___________________________________________________________________________________________________________________________________________

□ Ciclo menstrual regular _______________________________________________________ Data do ultimo ciclo: ______________________________________________________

□ Reposição hormonal ___________________________________________________________________________________________________________________________________________

□ Gestante ___________________________________________________________________________________________________________________________________________

□ Filhos ___________________________________________________________________________________________________________________________________________

□ Dieta ___________________________________________________________________________________________________________________________________________

□ Ingere líquidos ___________________________________________________________________________________________________________________________________________

□ Esportes ________________________________________________________________________________________ Frequência: _________________________________

□ Fumante ___________________________________________________________________________________________________________________________________________

□ Etilista (bebida alcoólica) ___________________________________________________________________________________________________________________________________________

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

□ Problema nasal ou bucal ___________________________________________________________________________________________________________________________________________

□ Intestino regular ___________________________________________________________________________________________________________________________________________

□ Hereditariedade de acne ___________________________________________________________________________________________________________________________________________

□ Exposição ao sol _________________________________________________________________ □ Usa protetor solar: ____________________________________________

Queixa principal

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Ficha de Anamnese

Sistema Circulatório

□ Peso nas pernas □ Hematoma com facilidade □ Extremidades frias

□ Varises e/ou varicose □ Sensação de queimor

Hábito Alimentar

□ Legumes □ Verdura □ Fibras □ Carne vermelha

□ Frutas □ Refrigerante □ Doces/chocolates

Alterações vasculares

□ Petéquias □ Cianose □ Eritema □ Telangiectasia □ Hematoma

Manchas

□ Acromia □ Hipocromia □ Hipercromia

□ Efélides □ Cloasma □ Melasma

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? ___________________________________________________________________________________________________________________________

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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Assinatura do cliente Assinatura do ProfissionalData / /