Anamnese Facial
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Transcript of Anamnese Facial
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