Anamnese Facial

Nome:______________________________________________________________________Data:___________ Indicação:___________________________________________________Contato:____________________________________________________________________Email:______________________________________________________________________

Queixa Principal:______________________________________________________________Lesões: ( ) Comedões ( ) Pústulas ( ) Pápulas ( ) Nódulos ( ) MilliumBiotipo Cutâneo: ( ) Normal ( ) Mista ( ) Seca ( ) OleosaAcne: ( ) Sim ( ) Não Grau:_______Cosméticos em uso:________________________________________________________________________________________________________________________________________Alergia: ( )sim ( ) Não Qual:_____________________________________________________Gravidez:___________ Diabetes:__________ Marca Passo:_____________________________Neoplasias:____________________________________________________________________Doenças de Pele:_______________________________________________________________Doenças Sistêmicas:_____________________________________________________________Epilepsia:__________ Pino ou Placa Metálica no Rosto: ________________________________Febre:________________________________________________________________________Tratamento Recente:____________________________________________________________Toma Medicamentos:___________________________________________________________Usa lentes de contato:______________ Aparelho dental:______________________________

Tratamento Indicado:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________ _____________________ Ass. Do Profissional Ass. do Cliente